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Patients First, a coalition of four health-care unions based in Newark, New Jersey, is trying a different tack. In February it ran arresting ads on drive-time radio that opened with the beeping of a heart monitor ("This used to be the sound that mattered in determining your health care") and was followed by the ringing of a cash register ("Today this is the sound that matters"). The ads urged listeners to call a toll-free number "if you've been a victim of when profits come before patients." The coalition mainly wanted to recruit such victims to testify before New Jersey legislators considering an HMO regulatory bill.
PATIENTS
With help from consumer advocates, patients are organizing to make their voices heard. California, not surprisingly, is in the lead: 75% of its insured citizens are in managed-care plans, more than in any other state. Health Access, a coalition of 215 consumer organizations, is drafting a very comprehensive state bill of rights for HMO members. It would set legal standards on everything from when HMOs can deny care to how long they can keep patients waiting on the telephone.
The coalition is apparently heartened rather than daunted by the fate of two propositions to regulate HMOs that appeared on last November's ballot. Both lost but drew about 40% of the vote--even though supporters of one measure were outspent nearly 50 to 1 by their foes. The more restrictive of the two measures, significantly, was drafted largely by the California Nurses Association. Nurses fear that HMOs want to squeeze them out of many jobs and replace them with low-paid technicians.
A major goal of many patients' groups is to compile report cards showing how HMOs stack up against one another. The patients are getting some help from employers such as the 33 giants that have formed the San Francisco-based Pacific Business Group on Health. P.B.G.H. has set up an online facility, on which the nearly 3 million employees of its member companies can swap stories about how well or how badly they have been treated by managed-care plans.
GOVERNMENT
Voters roared approval last November for President Clinton and members of Congress who boasted about a new law forcing insurers to pay for at least two days in the hospital for women giving birth. That response has opened the floodgates to a much broader effort to force reform. Though Republicans are so far cool to any sweeping legislation, some more narrowly targeted proposals are picking up bipartisan support. One such bill, introduced in February, would set a "prudent layperson" standard for emergency-room treatment: an insurer must pay for any condition a layman reasonably fears is an emergency, even if it turns out to be a false alarm.
The Clinton Administration is issuing a stream of thou-shalt-not orders to HMOs that sign up Medicare patients. The latest prohibits quick in-and-out mastectomies. Others forbid HMOs to limit what doctors can tell Medicare patients and restrict their ability to pay bonuses to doctors as a reward for keeping costs down. This regulatory club has power, since HMOs rate signing up Medicare and Medicaid patients as their best prospect for expansion.