A conservative think tank's new book on health care in Maryland is drawing fire from liberal activists. But with health care costs putting the pressure on the state's budget, some Democratic leaders are voicing some of the same concerns as the book's authors.

"Health Care in Maryland: A Diagnosis" offers critical looks at Maryland's approach to pressing issues such as Medicaid, prescription drug costs and medical malpractice tort reform. The Maryland Public Policy Institute, a Germantown group that supports limited government and market-driven public policy, published the 91-page paperback in April.

While longer on discussion than solutions, the book offers several remedies:

*Convert Medicaid to a funding stream for personal health savings accounts, "allowing patients to access the health care system in the best way they see fit," up to the amount of aid they receive.

*Reduce or eliminate the state's health care mandates on insurance policies sold in Maryland.

*Eliminate the new "reinsurance fund" created by the legislature to subsidize the rising costs of medical malpractice insurance with revenues derived from an HMO premium tax.

*Eliminate the state's regulation of where and when hospitals can build new facilities.

*Resist proposals to import prescription drugs from Canada.

*Eliminate the state's existing "all-payer" system of regulating hospital rates.

"We're trying to push this realization in Maryland that this Annapolis-down, Baltimore-down management style of health care has actually caused problems in and of itself," said Thomas A. Firey, a fellow of the Maryland Public Policy Institute and a contributor to the book.

"In Maryland, there is a lot of need for change because we are caught in this Nixonian, 1970s-era approach to health care policy," said Firey, who describes himself as a libertarian and Maryland as a bastion of regulations run amok.

Taking a hard look
 
Senate Minority Whip Andrew P. Harris wrote the book's introduction, in which he argues that increasing regulation has made it impossible to provide low-cost health insurance, which has in turn contributed to the problem of a rising uninsured population.

"What the book did is, it provided a different blueprint for ensuring care of Marylanders and taking care of Marylanders, other than what we've been hearing from Health Care For All," said Harris (R-Dist. 7) of Cockeysville, referring to the coalition that led this year's campaign to make large employers spend 8 percent of their payroll on health care benefits. The bill awaits the governor's veto.

If liberal activists want to extend health insurance to more people, said Harris, an anesthesiologist, they should take a hard look at the cost of health insurance mandates for small businesses. Mandates drive up costs, he said, discouraging businesses from offering any insurance to their employees.

Glenn Schneider, executive director of Health Care For All, said such libertarian, business-minded approaches are the true dinosaurs in the health care debate.

"If you're a fan of stale bread, eight-track tapes and bad health policy, this book's for you," said Schneider, who took particular issue with the book's assessment of Medicaid.

"We've heard these same reruns before in the business community," he said. "Blame the doctors, blame the patients, and then come up with an unworkable system like health savings accounts. I'd love for anyone to tell me how HSAs are going to work for anyone who is chronically ill, disabled or in a nursing home. What happens when the money is expended? Do we kick them out of the nursing homes?"

But with Medicaid costs soaring, conservatives are not the only ones talking about cutting costs.

Speaking as director of the National Conference of State Legislatures, Del. John Adams Hurson told The New York Times on Monday that Medicaid enrollees need to accept more "responsibility" for their health care and recognize that it is "not free."

The Times report said NCSL is working on a proposal to allow states to make Medicaid enrollees pay more for the care they receive.

The concept of health savings accounts is worth discussing, as well as looking at charging more premiums for some higher-earning enrollees,which Maryland already does in some cases, said Hurson (D-Dist. 18) of Chevy Chase.

Mixed reception  

Sen. Thomas McLain Middleton shares some concerns about the cost of insurance mandates. "I do have some concerns about the regulatory processes we have in place," said Middleton (D-Dist. 28) of Waldorf, speaking Tuesday after Gov. Robert L. Ehrlich Jr. signed a health care reform that Middleton and Hurson worked to pass.

Rather than expand insurance coverage, their initiative expands a network of community clinics to serve the poor and uninsured.

"As a matter of fact, the Finance Committee is going to be undertaking an effort this interim to look closely at mandates in the health insurance statute," Middleton said. "Not necessarily to do away with them, but to see if there is a way to streamline them and make them more cost-effective."

Middleton said he believes in the all-payer system of regulating hospital rates because it ensures that people can receive emergency care regardless of income or insurance.

"But I believe we need to be on guard with it, to make sure it is workable," he said. "To say it is enough is short-sighted. Emergency room care is the most expensive health care we can provide, and ultimately, consumers pay the cost for uncompensated care."

Sean Dobson, deputy director of the social advocacy group Progressive Maryland, praised Firey's tort reform chapter for looking at the role the insurance industry plays in raising doctors' malpractice insurance premiums, as well as for raising concerns about legitimately injured patients who fail to receive compensation.

"There is such a thing as enlightened conservative thinking," he said. "I found Firey's article about medmal quite enlightening ... when it comes to medical malpractice, I think the libertarians are on more solid ground."

But Dobson said he rejects the libertarian approach to health care delivery on its face.

"I would challenge them to show any country in the whole world that has a market-driven approach and also has near-universal coverage and high-quality coverage," he said. "That is the elephant in room that these guys never want to deal with."

Staff Writer Steven T. Dennis contributed to this report.