Monday, June 28, 1999
Money stacked against HMO bill
Liability big concern for business
COLUMBUS — Gov. Bob Taft promised to give Ohioans the power to sue their HMOs if denied medical care, but opponents had the power of money on their side.
Business and insurance interests that successfully led efforts to torpedo Mr. Taft's proposal contributed four times as much as proponents did to Republican legislative leaders between 1994 and 1998, according to a computer-assisted analysis of campaign contributions by The Cincinnati Enquirer.
The disparity was even more dramatic among members of a Senate committee that rejected an attempt to revive the idea last week. Opponents gave 14 times the amount proponents did to Republican members of the panel that beat back the amendment on a party-line vote.
Doctors, trial lawyers, labor leaders and consumer groups say opinion polls show Americans want laws ensuring HMOs put patients before profits, including the right to sue insurers that refuse to approve medical treatments.
But it's easier to make a campaign ad than a law.
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HMO APPEALS
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Under a bill state senators are to consider this week, patients who have been denied coverage could first appeal to their HMO. If they aren't satisfied, they could ask the state Department of Insurance to determine whether the recommended treatment is covered under their insurance plan.
Disputes over the medical necessity of treatments would be sent to randomly selected panels of medical experts, certified by the Insurance Department, that would review the cases and make binding determinations about whether the procedures should be covered.
Life-threatening cases would be decided within seven days and all others within 30 days. The bill also requires the reviewers to have clinical experience within the previous three years with the treatment in question.
The measure also would allow women to see their obstetrician or gynecologist without a referral and authorizes new tax breaks for medical expenses.
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“We had a process that didn't represent the people,” said Rep. Jeff Jacobson, R-Brookville, who lost an attempt to restore the liability provision on the House floor earlier this month. “No matter how well-intentioned people were, the lobbyists for the health insurance industry controlled the outcome”
State senators this week are to consider a bill that would instead enable Ohioans to appeal denials of coverage to outside medical experts, a process known as “external review.”
“This bill was written by and for the insurance industry and its allies,” said Cathy Levine, policy director of the Universal Health Care Action Network of Ohio, a consumer group. “Any appeals process means little unless backed up with meaningful enforcement, which includes the right to sue.”
Even before Mr. Taft introduced his bill and persuaded a bipartisan majority of House members to co-sponsor it, Republicans who control the General Assembly made it clear they opposed giving patients an explicit right to haul their HMOs — health maintenance organizations — into court.
Business and insurance industries mobilized and formed the Coalition for Quality Health Care, a group whose sole mission was to block the idea from becoming law.
When the dust cleared from months of debate, much of which took place in private, Mr. Taft's campaign promise was in shambles. For GOP leaders, the outcome of the health-care debate had more to do with their philosophical objections to liability lawsuits than money pumped into their campaign machines.
They contend the bill setting up an independent appeals process will achieve Mr. Taft's goal — getting patients prompt treatment when they need it — without pushing disputes about insurance coverage into court.
“The other side just isn't going to give money to Republican candidates,” said Senate President Richard Finan, R-Evendale. “We've tried for years to limit liability. It doesn't make sense to me that we were going to create a new form of it.”
While opponents clearly were worried about Mr. Taft's adding his voice to those clamoring for HMO lawsuits, Mr. Finan argued the bill did not rise to the level of an issue that would spur interest groups to ante up more money to legislative campaign committees.
Business and insurance interests battled trial lawyers and unions even more fiercely over previous GOP-sponsored measures that limited liability lawsuits and curbed workers' compensation benefits, Mr. Finan said.
“After struggling through tort (lawsuit) reform, I think it was natural to have concerns about going back and restating some liability provisions,” said House Speaker Jo Ann Davidson, R-Reynoldsburg. “Money had nothing to do with our position.”
Lobbyists for corporations, insurance companies and interest groups such as the Ohio Chamber of Commerce always have tried to cultivate relationships with people in both parties who write state laws. But most of their campaign contributions go to Republicans.
Since 1994, when the GOP took control of the General Assembly and promised a pro-business agenda, corporations and interest groups involved in the debate over HMO lawsuits have given $1.8 million to campaign committees controlled by Ms. Davidson.
Proponents — doctors, nurses, unions and trial lawyers — gave $323,313.
During the same period, Mr. Finan's political fund and the Republican Senate Campaign Committee collected just over $1 million from members of the Coalition for Quality Health Care, the anti-HMO lawsuit group.
Proponents contributed $322,345.
Lobbyists rejected suggestions from Mr. Jacobson and other critics that their contributions were attempts to buy influence. Asked why they give money to politicians, most said they were supporting “good government.”
“I've never linked or directed any contribution based on one issue,” said Mark Davidson, a lobbyist for Columbus-based Nationwide Insurance. “All we can ask is that at least our position will be listened to by members of both parties in both houses.”
Tom Froehle, a lobbyist for the Ohio Manufacturing Association, said opponents of HMO lawsuits won the debate by persuading legislators that explicitly granting such a right would drive up health care costs and force employers to drop insurance for their workers.
“I didn't have anything to do with the more cynical side of government, meaning fund-raising,” Mr. Froehle said. “We weren't roaming the halls with dollar bills. We were armed with information.”
When it became clear Republican leaders wouldn't advance a bill that contained the right to sue HMOs, lawsuit proponents lost one of their key allies: the Ohio State Medical Association.
Many doctors contend that if they can be sued for malpractice, so should an HMO. They say an HMO is practicing medicine when it denies a type of treatment or declares the treatment isn't necessary for a particular patient.
But Tim Maglione, a lobbyist for the physicians' group, said he is satisfied with the legislation as it stands now.
“We got what we wanted in terms of patient protection with the external review process,” Mr. Maglione said. “I think this should give the public confidence that their health-care system works.”
Lobbyists for insurers and business groups hashed out the new appeals process with Mr. Maglione in closed-door negotiating sessions led by Rep. Dale Van Vyven, a Sharonville Republican who chairs the House Health, Retirement and Aging Committee.
Mr. Van Vyven, who also is an insurance agent, said business and insurance lobbyists refused to discuss the bill until he agreed to strip out the liability provision. He promptly did so.
Opponents of HMO liability have contributed $104,994 to Mr. Van Vyven's campaign committee since 1994, while proponents have given $44,115.
“In my particular case, that may be true due to my closeness to the insurance industry,” he said of the disparity in contributions. “It's just a philosophical thing. Why in the world should we have attorneys benefit from this when the idea is to get the patient benefits?”
Sen. Grace Drake, R-Solon, chair of the Senate Health, Human Services and Aging Committee, said she refused to consider HMO liability because “the courts already are filled with enough frivolous lawsuits.”
“I've never done a special-interest thing knowingly since I've been here,” Ms. Drake said. “My goal is to improve the quality of health care in this state.”
Proponents said insurers and business groups exaggerated the potential cost of litigation against HMOs. They cited a nonpartisan Congressional Budget Office study that estimated a similar bill pending in Congress would increase premiums by 1.2 percent.
The self-described “poster child” for reforming Ohio's health care system doubts the appeals process established by Ohio lawmakers will work as well as its supporters claim.
Linda Smrdel Kerns spent $150,000 for a bone marrow transplant while fighting her insurance company's refusal to pay for the procedure her physician recommended. Without the treatment, the Columbus woman said, she would have died from breast cancer, the same disease that killed her mother, sister, aunt and great-grandmother.
Ms. Kerns fought her insurance company for 11 months before it agreed to pay for the procedure.
“Nobody seems to be listening to the patients now that the (election) campaign is over,” she said. “My insurer had an appeals process, too. But I had to hammer and hammer and hammer at them before I got the treatment I needed.”
Insurance companies and business groups argued that court decisions already are opening the door to HMO lawsuits. But they pulled out the stops to prevent the House and Senate from adding specific liability language to the bill.
When the measure was headed to the House floor, for instance, the Ohio Chamber of Commerce financed campaign-style radio ads intended to drum up opposition. “Call Rep. Jacobson. Tell him to lose the sue-everybody amendment so you don't lose your health care,” the ad said.
Mr. Taft, meanwhile, said he still supports giving patients an explicit right to sue their HMOs. But he plans to sign the bill anyway.
Other supporters of the liability provision say the governor's position is another example of the influence business and insurance interests wield over the lawmaking process.
“I don't think there's any reality to that perception,” said Rep. Randy Gardner, R-Bowling Green, the bill's chief sponsor. “Too much of the debate in the House was about process. The process worked quite well.”
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