摘要：The federal Employee Retirement Income Security Act of 1974 (ERISA) supersedes state laws as they relate to employer-based health care plans. Thus, cases brought under ERISA are heard in federal courts. We examined the intent, scope, and impact of recent laws passed in 10 states attempting to expand the legal rights of health plan enrollees to sue their plans. In June 2004, the US Supreme Court ruled that state-law causes of action brought under the Texas Health Care Liability Act involving coverage decisions by Aetna Health Inc and CIGNA Health Care of Texas were preempted by ERISA. The full implications of this decision are not evident at present. THE US HEALTH CARE DELIVERY system is regulated through a maze of overlapping state and federal laws and regulations. In recent years there has been a steady stream of state legislation affecting the way in which managed care plans conduct their business. 1– 4 For example, states have passed physician antitrust exemption laws (the law passed in Texas allows independent physicians to join together under certain circumstances to negotiate reimbursement rates with managed care plans), 5 any-willing-provider laws (which require a health plan to accept any qualified provider willing to abide by the terms and conditions of the plan), 6 freedom of choice laws, laws mandating minimum lengths of stay for maternity admissions, 7 other mandated benefit laws, and, most recently, laws that permit enrollees to sue their employee health benefit plans for negligence in state courts. In large part, these laws have been enacted in response to the rapid growth of managed care plans and concerns about the impact these plans have on quality of care. 8 In 1977, only 4% of American workers were enrolled in a managed care health plan and the remaining 96% were enrolled in an indemnity plan. 9 In 2001, 93% of American workers were enrolled in a managed care health plan and 7% were enrolled in an indemnity plan. 10 Because enrollees in managed care plans often must receive plan approval before obtaining a particular type of care (as opposed to workers in indemnity plans, who receive medical services and then file a claim with the insurer), a great deal of attention has been focused on the rights of enrollees in such plans. Cases in which individuals have suffered grievous harm as a result of being refused access to a specific health care service have garnered significant publicity and have focused attention on the limited legal recourse available to such individuals as a result of the preemption of state laws relating to employee health benefit plans. The most recent state legislative initiatives concerning managed care plans reflect the belief that federal laws unfairly prevent enrollees from suing their plans for wrongful denial or delay in treatment. 11 Here we examine the intent, scope, and impact of state laws designed to expand the legal rights of enrollees to sue their health plans. 12 Texas passed the first such law in 1997, and 9 other states subsequently have passed similar laws. 8, 13, 14
