Hoping to win broad support for their cause, opponents of managed care are taking their fight to the ballot box this November. Voters in two western states — California and Oregon — will be asked to vote yes or no on several anti-managed care ballot initiatives.

When it's not possible to get controversial issues through the legislature, the next step is to take them to the people with state ballot initiatives, says Salem, Ore., political consultant Tom Mann, who has been instrumental in getting an initiative on the Oregon ballot.

In California, two separate "patient protection" initiatives will be before the voters. One is sponsored by the California Nurses Association (CNA) and the Foundation for Taxpayer and Consumer Rights, and the other is being offered by the Service Employees International Union.

Both initiatives contain provisions limiting physician compensation arrangements, setting minimum staffing levels at hospitals and other health facilities, restricting circumstances under which providers can be removed from a plan's network, and requiring disclosure of certain health plan operational data.

The Service Employees initiative would require that physicians, nurses and other caregivers be discharged only for just cause. The CNA initiative would prohibit mandatory arbitration and impose new taxes on health care organizations and their executives. The taxes would be levied in situations such as the downsizing or closing of private hospitals, the conversion of not-for-profit health plans to for-profit status, or the granting of stock or compensation worth more than $2 million to executives of health care businesses or to their families.

Opponents argue that if they're approved, the measures will have a very detrimental effect on health care. Taxpayers Against the Government Takeover (TAGT), a "coalition of business, insurance and hospitals" set up to defeat the initiative drive in California, claims the initiatives would mean significantly higher costs for virtually every taxpayer, local government entity, business and nonprofit group in the state. They would "require dozens of new rules and regulations to be administered by the state, creating additional layers of bureaucracy and costs," says Duane Dauner, president of the California Healthcare Association and co-chair of TAGT.

In Oregon, voters will be asked to decide whether to ban capitation as a method of provider payment. That state's initiative was launched by Gordon Miller, a Salem ophthalmologist, who strongly opposes capitation.

If approved, it would allow just five forms of reimbursement: payment for work performed, hourly wages, prearranged salary/benefits, bon- uses, and expense reimbursement. Providers accepting payment on any other basis would be subject to loss of their professional licenses.

In Florida, supporters of an anti-managed care initiative tried unsuccessfully to gather the necessary signatures to place their measure on the ballot. It would have added a guarantee of provider choice to the state constitution, which would have effectively eliminated network-based health care in Florida.

Opponents and critics of managed care will be watching the outcomes in California and Oregon with great interest, and so will managed care organizations themselves. Approximately 26 states allow laws or state constitutional amendments to be proposed by ballot initiative. "At least five other states are interested in what we are doing on capitation in Oregon," says political consultant Mann.

"Getting these issues on the ballot has proved to other states that this is something that is doable."

— Joan Szabo

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