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The backlash against managed care and some of its practices remains the hottest health care-related issue for state legislators.

Bills requiring health care plans to offer hospital coverage to women undergoing mastectomies was introduced in more than 30 states and passed by 10. Typical of these are bills passed in Rhode Island and Maine that require managed care plans and insurers to offer at least 48 hours of hospitalization after a mastectomy and coverage of at least 24 hours after an axillary lymph node dissection.

Those proposals are a direct response to public anger after reports surfaced that managed care plans in some cases were attempting to force women to undergo mastectomies on an outpatient basis.

States also are moving to stop other practices associated with managed care. For example, seven states have passed measures mandating coverage for emergency room services that a "prudent" user believes are necessary.

In addition, states are trying to force employers to give employees in health maintenance organizations an alternative to providers in the HMOs' networks.

For example, Oklahoma and Iowa have enacted legislation that requires employers with at least 50 employees that only offer an HMO to offer a point-of-service option also. That requirement, though, may violate the pre-emption provisions of the Employee Retirement Income Security Act, some benefit experts say.

Under a POS, enrollees can go outside the HMO network each time they need to use health care services. But HMOs impose more cost-sharing requirements for services delivered outside the network. Other states are requiring HMOs to offer POS options, with the District of Columbia, Idaho, Montana and New Jersey considering such legislation.

States are taking other approaches to improve services delivered by managed care plans. For example, a new Virginia law requires HMOs to offer enrollees 24-hour telephone access to a physician or licensed health care professional.

The wave of bills aimed at curbing what the public perceives as managed care abuses isn't surprising given the dominant role managed care has assumed in delivering health care services.

"Managed care is now the establishment. It is not the alternative delivery system," says Susan Laudicina, director of research in the Washington office of the Blue Cross & Blue Shield Assn.

Other legislative measures appear intended as a way for specialists to maintain their revenue base as managed care grows.

For example, 10 states have enacted measures that give patients direct access to specialists without first having to see an HMO's gatekeeper. A Minnesota measure, for instance, gives managed care enrollees direct access to obstetricians and gynecologists, while a new Florida law lets enrollees see a dermatologist directly, without a referral from a primary care physician.

"Every licensed medical group is trying to get a direct stream of patients. Ultimately, you lose coordinated care, because there will be nothing left to coordinate," Ms. Laudicina noted.

Meanwhile, states continue to follow the decades-long practice of requiring insurers and managed care plans-typically in response to special-interest pro-vider groups-to offer specific benefits, such as coverage for diabetes.

Following is a roundup of state health care reform activity, based on reports by Business Insurance staff and coordinated by Editor-at-Large Jerry Geisel. (continued in part two)