HMOs are enrolling 14,000 Americans a day in a revolution that's finally taming inflation in the world's most expensive health-care system. But cautionary tales of shabby hospital care and doctors opting for the cheapest treatment, rather than the most appropriate, have spawned backlash legislation in at least 40 states.

Some 400 bills have been proposed this year, compared with 239 in all of 1995. Taken together, they represent an enormous threat to health maintenance organizations and other managed care programs.Insured Americans, long accustomed to total freedom in choosing doctors and ample reimbursement for any test or surgery, chafed at HMO restrictions from the outset. But this time, the grousing has commitment, a core, potentially backed by the power of law.

Many proposals would undermine the very premise of managed care, that costs can be controlled by restricting how and where people seek medical attention.

They would force managed care programs to pay any doctor or hospital a client uses or allow clients to see specialists without pre-approval or pay for emergency room care even if the emergency was imagined.

The proposed restrictions are worrying corporations, who fear lawmakers' meddling will allow the costs of employee benefit packages to soar again. Some companies, while staunchly supportive of HMOs, are working behind the scenes to force poor-performing HMOs to shape up and thus avoid new laws.

Managed care's defenders express confidence they'll survive the backlash. So far, they've been successful. While 33 states have anti-HMO laws on the books, most are narrowly worded or contain loopholes, according to the American Association of Health Plans, an industry trade group.

Nonetheless, they're taking the threat seriously, in part due to the fierce conviction of the backlash leaders. Many are patients or relatives who feel victimized by what they consider a cruel industry that exalts profits.

Take Linda Ross of Yucaipa, Calif., who's collecting signatures for an anti-HMO referendum in the state with the most concentrated HMO care.

She blames negligence at an HMO-owned hospital for letting her 61-year-old mother languish four hours in an emergency room while a blood clot starved her body of oxygen.

"They parked her and let her die," said Ross, who owns a construction supply company. "She had no call button. She had no monitors, nothing, and this is the level of care they want to foist on the rest of the country."

The "Patient Protection Act" that Ross supports is one of the most sweeping. The California bill would ban HMOs from paying doctors bonuses for withholding treatments; outlaw "gag clauses" that prohibit doctors from disclosing to patients HMO policies that limit care; and stop HMOs from firing doctors who speak out against policies they feel endanger patients.

For Wanda Peake, the crusade against HMOs is deeply personal. The former teacher's aide from Lugoff, S.C., told her Legislature an HMO almost stopped an orthopedist from mending her broken, infected leg because it would cost too much. She eventually persuaded the HMO to approve the procedure.

"Managed care wanted to amputate my leg," said Peake, 30. "My doctor wanted to save my leg. I've got two kids who need me; one is handicapped. I was in the hospital for a month. I was in fear, and angry."

Peake backs legislation that would force HMOs to pay for care by any doctor or hospital in her state.

Another group in vehement opposition to HMOs is that of specialist physicians, who resent restrictions on their income by what they call a cut-rate medical system. Doctors' average pay fell in 1994 for the first time in the 14 years that the American Medical Association has tracked it.

"As a colon cancer specialist, I'm seeing people getting the second-, third- and fourth-best test, then showing up sicker and with their disease more advanced," complained Dr. Michael Klein, a suburban Los Angeles gastroenterologist. "I'm seeing people waiting six to 10 weeks for authorization to see specialists or get CAT scans."

The backlash faces formidable odds. Despite the frightful stories, many HMOs enjoy good reputations and earn praise for trimming costs and providing quality medicine.

"Managed care satisfaction surveys show that the vast majority of HMO members are very pleased with the care they get," said Kathleen Murphy, a vice president for Connecticut-based Aetna Health Plans Inc.

HMOs contend they offer patients a better package than traditional health insurance systems because a single primary care doctor must approve and coordinate all medical treatment. The unfettered traditional system gave doctors the financial incentive to overtreat, they say.

They're supported by a Dartmouth study that shows wide differences in care around the country, indicating many patients outside managed care are undergoing unnecessary mastectomies, heart bypasses and prostate surgeries.

Because corporations champion managed systems, it's no surprise that more than 70 percent of Americans who get care through their employers belong to such systems. Last year, thanks to managed care, health-care premiums rose just 2 percent, one study showed. Through the 1980s, double-digit inflation in health care costs was common.

Despite their enthusiasm, however, several big companies, including Xerox, American Express and GTE Corp., are instituting measures to make HMOs more accountable.

GTE, for example, now ranks each of the 130 HMOs it uses around the country, then discounts monthly premiums for workers who choose the best ones.

Other companies are demanding that HMOs measure how well they treat ailments such as asthma, diabetes, breast cancer and depression.

The proposed anti-HMO legislation could hurt businesses in several ways, company officers say.

"They not only affect the bottom line, but the ability of American industry to compete, and that's jobs we're talking about," said Lanny Aselton, of Devro-Teepak, a Lexington, S.C. sausage casings company.

Murphy, of Aetna Health Plans, predicted that legislated changes to managed care could push health premiums up by 5 percent to 15 percent and force some employers to drop coverage altogether.

Health economists agree there's no way to reverse the managed care revolution, especially with a big spike in demand approaching as baby boomers age.

Still, corporate executives are realizing they may have been hasty in embracing managed care as a magic solution, said Michael Sparer, a professor of health policy at Columbia University in New York.

"People are beginning to recognize it's not magic," Sparer said. "It's not going to solve all the problems and will create some problems of its own, which legislatures are going to have to deal with."



The major anti-HMO proposals:

FREEDOM OF CHOICE - ANY WILLING PROVIDER: Most HMOs require patients to see doctors on a restricted list. Those doctors often get financial bonuses to limit care deemed unnecessary. These bills outlaw such bonuses, and some would allow patients to see almost any doctor. HMOs say this negates their power to ensure quality care.

DIRECT ACCESS: HMOs often require a "primary care" physician to approve all care by specialists. These bills allow patients direct access to gynecologists, dermatologists, dentists, optometrists, psychologists and others. HMOs say this prevents them from rejecting unqualified or wasteful specialists.

GAG CLAUSES: Some HMOs ban doctors from disclosing money they receive to restrict care or from discussing treatments the HMO doesn't cover. Others ban doctors from criticizing the HMOs. These bills would abolish such rules, but HMOs say doctors speaking freely about payment disputes or disallowed treatments would alarm patients.

EMERGENCY SERVICES: HMOs often reject claims for emergency room care for non-emergencies, such as chest pains that turn out to be heartburn. The bills would require coverage as long as the patient had a reasonable belief the emergency was real. HMOs say this encourages the use of expensive ER care when a visit to the doctor would do.

DRIVE-THROUGH DELIVERIES: HMOs commonly urge new mothers to leave hospital after 24 hours. The bills allow coverage for 48 hours, 96 hours for a Caesarean birth, allowing doctors to spot complications. HMOs say evidence is overwhelming that most mothers and babies need only 24 hours.

GRIEVANCE PROCESS: Critics complain some HMOs allow clerks with no medical training to deny crucial care, then delay appeals for months. The bills require a speedy, simple appeals process, governed by doctors. HMOs say most states already require adequate procedures.