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by Vicki Lens ********** Over the past several years the judiciary has become a major venue for challenging managed care. This article examines the present and potential effect of such litigation, focusing on the recent Supreme Court decision in Pegram v. Herd rich and class action litigation filed under the Racketeer Influenced and Corrupt Organizations Act. The author concludes that although court-based reforms are a necessary and pragmatic response to managed care, they can result in only incremental changes. Litigation also cannot resolve the larger conflicts that result when a social welfare service such as health care is provided through a corporate model. Social workers need to look beyond the "next best" reform of managed care and advocate for more fundamental solutions to the inequities and inefficiencies in the provision of health care. Keywords advocacy health care judicial reform managed care With the advent of managed care, the provision of health care has been transformed from "a purely professional undertaking to a business providing professionals services" (Abraham & Weiler, 1994, p. 395). The infusion of commercial and marketing principles into the provision of health services has changed the terms of the health care debate. What business model works best, and not whether a business model works at all, has frequently become the focus as social workers and other health care professionals attempt to tame, transform, or accommodate managed care, often all at the same time. "Managing managed care" has become an art unto itself as social workers and others are advised how to negotiate business contracts with managed care companies (MCOs) (Gibelman & Whiting, 1999), use conflict resolution techniques to resolve managed care disputes (Strom-Gottfried, 1998), or implement agency-based administrative practices that ensure quality service delivery within a managed care context (Galambos, 1999). Such t echniques and strategies are a necessary and pragmatic response to managed care. At the same time, the larger issue of the desirability of treating health care as a commodity rather than a social service must be addressed. Although the fee-for-service system that preceded managed care was not without its faults or its own preoccupation with profit, managed care has raised the "corporatization" of health care to new and unprecedented heights (Schamess, 1998). Complaints abound that profit-driven health care has resulted in reduced access to care, especially for vulnerable groups, and the denial of necessary medical services to patients in general, causing physical harm and even death. These complaints and others have generated a different response to managed care, one that seeks not to accommodate it but reform it. One of the prime venues where this challenge is taking place is the judicial system. Within the past few years, lawsuits have been filed against nearly every major managed care company. Litigation strategies have undergone a transformation, from suits that focus narrowly on individual cases of patient harm to dozens of nationwide class actions that challenge such basic managed care business practices as linking medical decisions to financial considerations. In June 2000, the Supreme Court entered the fray, issuing a decision in Pegram v. Herdrich that provides a glimpse of how the judicial system is likely to view efforts to reform managed care. The judiciary has a rich tradition of playing a role--often a radical one--in shaping social welfare policy. From such diverse areas as civil rights, child welfare, education, and abortion, the judiciary has had a major influence on many of our institutions and policies. Whether or not it is having a similar effect on health care policy, and in particular managed care, is the subject of this article. Also addressed is the role of the social worker in judicial-based reforms. Both health care professionals and consumers have engaged in extensive litigation covering a wide range of managed care practices (Trueman, 2000). This article focuses on two of the most recent and significant lawsuits: the 2000 Supreme Court decision in Pegram interpreting the Employee Retirement Income Security Act of 1974 (ERISA) (P.L. 93-406), the federal law regulating the vast majority of MCOs, and recent class actions filed against the major managed care companies under the Racketeer Influenced and Corrupt Organizations Act (RICO) (P.L. 91-452). I chose Pegram because it is the most significant case decided by the Supreme Court on the issue of managed care. The RICO cases were selected as representative of the types of broad-based litigation now being filed against MCOs. THE PEGRAM DECISION: THE ERISA BARRIER AND MANAGED CARE Managed care can be defined as a "reimbursement framework combined with a health care delivery system" (Furrow, Greaney, Johnson, Jost, & Schwartz, 1995, p.398). It also has been described as a structure for "marshalling appropriate clinical and financial resources to insure needed care" (Segal, 1999, p. 47). One industry definition for managed care is" a system of health care delivery that influences utilization and cost of services and measures performance. The goal is a system that delivers value by giving people access to quality, cost effective health care" (United Health Care Corporation, cited in Davis, 1998, p. 410). Thus, in its most neutral form managed care is a mechanism for attending to cost and care together. Some contend that combining the two has several advantages, including permitting the efficient, flexible, and integrated delivery of necessary health services (Segal, 1999). Although rationing of medical resources is inevitable, under this view managed care is seen as a structured and effective response for accomplishing this. Others assert that there is an inherent conflict in trying to contain the cost of health care while maintaining the quality of care (Cornelius, 1994). That is because the methods used to control costs, such as utilization review, provider selection, fee setting, and financial incentives that encourage rationing of medical care, can clash with the medical needs of patients (Havas, 1998; Orentlicher, 1995; Schamess, 1998). In this view, treating health care as a business rather than a social service is both inappropriate and ineffective (Schamess). Managed care was a response to the excesses of the old fee-for-service system. Under that system, medical providers set their fees for services limited only by the usual and customary charge for such services. Thus, providers had an incentive to increase costs, not contain them (Schamess, 1998). Patients, the majority of whom had insurance, often through an employer, also had no incentive to minimize health costs (Randall, 1993). The result was skyrocketing medical costs; with medical care consuming 14 percent of the gross national product by 1993 (Levit, Cowan, Lazenby, & McDonnell, 1994). Charges of unnecessary services, excess profits, and denial of access for uninsured and poor people were levied against the fee-for-service system, helping to usher in the era of managed care. Managed care promised to contain costs and ensure the quality of care by integrating health care services, monitoring the services provided, and setting limits on fees. Managed care, however, brought in a new class of complaints against the health care industry. The emphasis on cost containment and the intervention of managed care entities in crucial decisions about medical care created new risks and harms for patients. Preauthorization procedures that ended up denying or delaying patients access to such things as diagnostic tests or medical procedures increasingly became the focus of disputes (Mariner, 2000; Ross, 2000). The result of such denials or delays can be death or prolonged illness, as for example when a patient's case of lung cancer remains undetected because his physicians request for a lung x-ray is denied by the MCO. Suing the treating physician for malpractice, a common remedy in the past, was no longer sufficient, or sometimes even appropriate. Rather it is the MCO who denied the test that is more properly the target. However, because of the federal law governing managed care, ERISA, it is these disputes that present the most difficult legal challenges. ERISA was passed in 1974 to protect employee's pension and welfare benefits. It regulates such things as eligibility determinations for benefits, the calculation and payment of benefits, record keeping, and monitoring of funds. ERISA also applies to employer sponsored (that is, self-funded) plans that provide health benefits, an increasingly popular way for many employers to provide health benefits (Ross, 2000). To simplify the offering of such plans and promote nationwide uniformity, ERISA preempts all state laws that relate to the activities regulated under ERISA, such as eligibility determinations (Glodt, 2000). Hence MCOs are shielded from being sued under state law for denying or delaying medical care because such determinations relate to eligibility. The legal recourse in an ERISA plan is ERISA. And the remedies available under ERISA are decidedly limited--the cost of the disputed service. Thus, the HMO patient described would only receive the cost of the x-ray and nothing for his pain and suffering and other damages resulting from the late diagnosed illness (Glodt). In contrast, patients who have individual insurance policies are able to sue their plan and its administrators for making negligent eligibility decisions. One way around this, attempted by the plaintiff in Pegram v. Herdrich, was to argue for an interpretation of ERISA that would require MCOs to make health care decisions based solely on medical need. In Pegram a patient of an HMO that was owned by its physicians was required to wait eight days to undergo an ultrasound for an inflamed abdomen so that the procedure could be performed more cheaply at one of the HMO's facilities, over 50 miles away, rather than at a local hospital. Before the eight days, the patient's appendix ruptured, causing peritonitis and requiring emergency surgery. Using language in ERISA that said plan administrators are fiduciaries who must discharge their duties solely in the interests of the participants and beneficiaries, the plaintiff contended that the physician-controlled HMO as a fiduciary must act in the patient's best interest, regardless of the cost. Incentive plans that rewarded physicians at the end of the year for reducing expenses, by such tactics as using only their facilities to conduct diagnostic tests, interfered with their fiduciary obligation to patients by placing the physicians' well-being above that of their patients. As a remedy, the plaintiff requested that the physician's profits be returned to the HMO to be used for the benefit of plan participants. The Supreme Court rejected this argument, holding that the HMO was not acting in the role of a fiduciary when it ordered that the test be conducted at the HMO's facility rather than at a local hospital. The Court construed the word "fiduciary" as relating not to medical decisions, but to financial transactions, such as eligibility determinations. Thus, whether a plan covered a particular illness or test would be a fiduciary act under ERISA, whereas medical decisions about how to diagnose and treat a patient's condition would not. The Court then characterized the decision to delay the plaintiff's diagnostic test as a mixed eligibility and treatment decision, because it involved both a determination of what tests the plan covered and the physician's medical judgment that the patient was not in danger and did not require an immediate test. According to the Court, because such mixed decisions involved medical judgments they could not be considered a fiduciary decision that could be challenged under ERISA. Although the question posed by Pegram was a narrow one--whether financial incentives violated ERISA's fiduciary requirements--underlying the case was the basic dilemma inherent in managed care: how to reconcile cost effectiveness with a duty of care. An added twist in Pegram was that it involved a decision by a physician-owned HMO and not a distant administrator, perhaps making it easier for the Court to reconcile medical decisions with financial ones. Although it could be argued that the two hats held by the physician--plan administrator and treating physician--raises serious conflict of interest and ethical issues for the medical profession the Court should have addressed (Bloche, 2000). In fact, the Court's response was to candidly admit what HMOs are all about--the rationing of medical care--and to state clearly that mixing profits and medicine was entirely acceptable and in accord with Congress's wishes. As the Court stated, "for over 27 years the Congress of the United States has promoted the formation of HMO practices" (Pegram v. Herdrich, 2000, p.2 156) and it "would be acting contrary to the Congressional policy of allowing HMO organizations if it were to entertain an ERISA fiduciary claim portending wholesale attacks on HMOs solely because of their structure" (Pegram v. Herdrich, p. 2157). According to the Court, financial incentives to ration treatment were essential to that structure. As legal commentator Gregg Bloche (2000) noted, the "Court accepted the industry's doomsday stories about the potential impact" on MCOs of patients challenging physician incentive schemes (p.3).As Bloche pointed out, the Court could have found a way to acknowledge the need for cost containment while at the same time giving physicians a certain zone within which to exercise their professional judgment without undue pressure from incentive schemes. The Court's refusal to interpret ERISA's provisions more broadly is instructive on two levels. First, it highlights the insufficiencies of ERISA, a law passed to protect employee pension plans very different in structure than present day managed care plans. Second, and perhaps more significant, the decision also reflects the limits of using judicial strategies for addressing the basic conflicts at the core of managed care. The Court made it clear that it was up to Congress, not the judiciary, to grapple with the issues underlying the distribution of health care reso urces (Bloche, 2000). Notwithstanding the result, Pegram did provide some clues as to what changes can be made under ERISA and hence to managed care. In a footnote the Court noted that the fiduciary standard may apply when it came to disclosing the characteristics of a plan. Thus, although financial incentives that led to rationing of services are entirely appropriate, failing to disclose them to the beneficiaries--the patients--may not be. A requirement that MCOs clearly disclose their financial incentive schemes, rationing policies, and other cost containment measures may be the one protection available to consumers under ERISA. That the Court left the door open for the one protection--disclosure--that often is used to prevent abuses in the commercial world is revealing in itself. It is indicative of just how far we have traveled along the road of the commercialization of health care. Telling a consumer about a particular practice, rather than changing that practice, is a frequently used remedy to complaints of overreaching and unfairness in the financial and consumer sectors. Although the duty to disclose is an improvement over the past business rule of caveat emptor, it still often is a way to avoid the restructuring of basic business practices. To be sure, disclosure can lead to change. In the commercial world, it is assumed that informed consumers use such information to pick and choose among businesses, who in turn modify their practices to satisfy consumer choice. However, this analogy may have less usefulness in the health care industry; where there are fewer and fewer choices as managed care companies consolidate (Schamess, 1998). Moreover, most consumers get their health insurance through their employer; consequently they have little or no choice but to accept the terms of the medical care presented to them (Mariner, 2000). However, the usefulness of a disclosure requirement should not be discounted. If MCOs are forced to routinely make certain disclosures it may effect the way they market and advertise their plans, and ultimately even some of the contents of the plans themselves. As more consumers (and their employers) become aware of the way in which financial considerations are affecting health care decisions, pressure may be applied on MCOs to alter some of these practices. MCOs are not immune from such pressures; one major HMO decided, partly in response to public pressure, that it would no longer require preauthorization for certain medical procedures (Steinhauer & Freudenheim, 1999). USING CLASS ACTIONS AND RICO TO REFORM MANAGED CARE It is not surprising, given the legal track record under ERISA, that other legal strategies have emerged. One of the most inventive and wide ranging is the attempt to use RICO to directly challenge some of the basic business practices used by MCOs. RICO, passed as part of the Organized Crime Control Act of 1970, was designed to combat organized crime, especially where it had infiltrated legitimate business activities. It is aimed primarily at racketeering activity, broadly defined to include violent crimes, such as murder and kidnapping, and white-collar crime activities, such as mail and wire fraud. The activity must occur with enough frequency to be considered a "regular way of doing business" (Ross, 2000). Although primarily a criminal statute, private individuals can use RICO to file civil suits against an offending company or individual. Civil remedies include treble damages and attorney's fees. They also can include remedies that require a business to reorganize, dissolve, or divest themselves of funds to prevent it from engaging in certain activities. In short, RICO is a potent tool that can radically alter the way an entity does business. It is the existence of civil remedies and the fact that mail and wire fraud can be applied to a wide variety of business activities that has transformed RICO into an instrument for challenging a wide variety of businesses and business practices, many of which are unrelated to organized crime activities. Any business that uses telephones and the mail to conduct business (which is virtually all businesses) and uses fraudulent business practices in the regular course of business, is a proper target under RICO (Ross, 2000). The ability to use RICO against MCOs was only recently established by the Supreme Court in 1999, in the case of Forsyth v. Humana (1999). The case involved a hidden agreement between an MCO, Humana Health Insurance, and its providers to discount its rates to providers to less than the 80 percent provided for in their written contract. As a result patients ended up paying co-payments higher than their contractual obligation of 20 percent. The patients sued, alleging that Humana had violated RICO by engaging in a scheme to defraud. In defense, the MCO claimed that a federal law, the McCarran-Ferguson Act (U.S.C. 15 [section]1011- 1015), giving states the primary responsibility for regulating insurance, preempted the use of RICO. The Supreme Court rejected this argument, opening the door to RICO lawsuits against MCOs. Within months of the Court's decision class action lawsuits based on RICO were filed in judicial districts across the country against nearly every major managed care company, including Humana, Prud ential, Cigna, Pacificare Health Systems and Foundation Health Systems, and Aetna ("Class Actions," 1999). These lawsuits go to the very heart of managed care practices, alleging that the insurers have "engaged in a pattern of fraudulent and heavy-handed extortionate conduct" ("Class Actions" 1999, p. 10) by advertising, through the print, broadcast, and the Internet media that they provide quality health care and then delivering inadequate health care to increase corporate profits. Using representations made by the MCOs and their own marketing materials, the complaints, here excerpted from the case against Aetna, describe the following conduct: Aetna has engaged in a massive nationwide fraudulent advertising campaign designed to induce people to enroll in its HMO by representing that Aetna affirmatively manages its members' health care so as to, inter alia, raise the quality of care to a "level of health care never available under the old fee-for-service system" when in fact, Aetna designed undisclosed internal policies to improve defendants' profitability at the expense of quality of care. (Maio v. Aetna, 2000, p. 474) Aetna has further "fail(ed) to disclose its restrictive and coercive internal policies and practices, which render its advertising, marketing and membership materials false and misleading in violation of RICO. (Maio v. Aetna, 2000, p.474). Virtually all of an MCO's standard practices for reducing costs, including financial incentives, limiting access to specialists, preauthorization decisions and capitation arrangements, are linked to the alleged fraudulent activity because they are used to deny patients the health benefits they were promised. The extortionate conduct alleged in these lawsuits affects both patients, who are denied necessary care, and providers, who are forced by MCOs to consider factors other than the patient's health when deciding treatment, and in addition, are prevented from discussing with their patients the financial incentives behind their treatment decisions. The remedies requested are as broad as the allegations, including punitive and compensatory damages, injunctive relief prohibiting certain business practices, and the creation of a trust to benefit patients. In short, as stated by the lead attorney for these lawsuits, they seek nothing short of transforming the entire industry, by "ensure(ing) that MDs, not MBAs or CPAs determine patient treatment" ("Class Actions", 1999, p. 10). However, it is doubtful that these cases will ultimately result in a major reform of managed care. Like the disclosure argument described earlier, these cases follow a commercial mode of attack. They borrow heavily from the traditional tools for challenging commercial ventures, for example, by alleging false advertising and deceptive business practices. But the problems of managed care go beyond promising quality health care (or care better than the old fee-for-service system) and then not delivering the same. Even assuming one could prove these allegations, the answers do not get to the heart of the problem: whether a profit-making entity such as an MCO should be providing health services at all. Indeed, despite the RICO complaints' sweeping language, even the complaints state that they are" [n]ot a challenge to the legitimacy or wisdom of managed care" (Nahra, 2000). It is likely that these courts will view these cases as the Supreme Court did--as business arrangements involving complex issues of risk allocation and profit-making incentives--despite the fact that the "product" being provided is health services. One appellate court already has rejected the use of RICO (Maio v. Aetna, 2000), finding that advertising "quality care" was too vague a standard to base a fraud action. Relying on the language in the Pegram decision, the court also made it clear that it was not the province of the judicial system to decide the efficacy or desirability of HMOs as a structure for delivering health care. However, these cases, filed as class actions, have a potential for reform notwithstanding negative decisions. The RICO cases have been strategically filed around the country to exert the maximum amount of pressure on the largest MCOs. Such cases are time consuming and expensive for defendants, making settlements a possibility even where the law is unclear (Cerminara, 1998). Settlement negotiations are already under way, although the outcome cannot be predicted at this time (Freudenheim, 2001). Although this article focuses on the Pegram and RICO cases, other lawsuits challenging managed care also need mention. These cases--and there are scores of them--challenge an array of practices by MCOs, including delaying payments to health care professionals, arbitrarily denying necessary medical care and interfering with treatment decisions, misleading patients about benefits available under their contracts, as well as antitrust actions against companies for conspiring to set fees (National Association of Social Workers [NASW],1997; Rabasca, 2000; Zielbauer, 2001). Some of the lawsuits do result in reforms. For example a lawsuit filed by the California Psychological Association against Aetna recently resulted in an agreement not to mislead consumers about the number of therapy visits they were entitled to (Rabasca, 2000). Another lawsuit, Holstein v. Magellan (NASW, 2000b), which NASW was involved in, resulted in a settlement with Magellan agreeing not to terminate mental health professionals from managed c are panels for challenging treatment decisions. These and the RICO lawsuits will undeniably do some good, blunting some of the harshest and harmful practices of MCOs, either through court decisions or settlements. But although they may chip away at the margins of managed care, its basic structure remains. Legal strategies that focus on health care as a business venture result in business like remedies, requiring some changes in business practices, such as a greater degree of independence for providers and more flexibility in fee setting, but leaving the overall profit-making structure, including incentive schemes, intact. However, many of these cases, filed as class actions, have a potential for "extralegal" reform. That health care litigation is increasingly using the mechanism of class actions is itself significant. Traditionally, health care claims were litigated individually, primarily because health care revolved around the individual relationships between provider and patients. This relationship has been overshadowed by large business entities, the uniform standards and business practices of which can hurt great numbers of patients in similar ways, thus lending itself to group, rather than individual, legal challenges (Cerminara, 1998). As explained earlier, a corporate model of health care also means a corporate model of litigation; with patients transformed into consumers using the same mechanisms of redress--the class action--that have been used in other consumer-based industries such as credit and financial services (Cerminara). The increasing use of class actions in health care litigation can help create a climate for reform that can reverberate beyond the judicial system. Class actions can act as an antidote to the powerlessness experienced by consumers under our present health care delivery system. As increasingly remote and large MCOs, rather than the patients and their physicians, make crucial decisions, patient autonomy and self-determination are being eroded. One way to reverse this trend is to empower consumers, and class actions are a classic form of empowerment (Cerminara, 1998). Consumers who feel powerless to challenge their MCOs on their own, and who do not have the resources or time, can join other consumers to press their claims. An added benefit is the publicity such cases attract, educating even more consumers and policymakers about the problems in the managed care industry. Class actions can thus yield benefits beyond the legal case, helping to generate political reform movements and legislative reforms while empow ering individual consumers. In sum, recent health care litigation, and specifically Pegram and the RICO class actions, demonstrate that the courts have become a significant arena for the reform of managed care. The judiciary is expanding beyond its traditional role of resolving individual disputes between doctor and patient; it is being asked to resolve the larger conflicts that result when a social welfare service such as health care is provided through a corporate model rather than a social services model. On the whole, the courts have refrained from resolving this underlying dispute, focusing instead on incremental changes. In this way court-based reforms are very similar to federal and state legislative proposals, which seek merely to modify the behavior of MCOs, not to radically alter or eliminate them as a mechanism for providing health care. Thus, like legislative reforms, judicial-based remedies are a pragmatic and necessary response to managed care, although not the final answer. THE ROLE OF THE SOCIAL WORKER IN JUDICIAL BASED REFORMS Since the advent of managed care, social workers have taken an active role in advocating for changes that would protect consumers and the profession from its worst abuses. As direct providers under managed care plans and even as administrators of those plans, social workers have sought to humanize managed care while at the same time adapting to its demands. Through its professional organizations, such as NASW and the Clinical Social Work Federation, social workers have engaged in political advocacy, vigorously joining in the national debate over managed care (Phillips, 1998). Advocacy about managed care issues can take several paths. One approach is to work to reform managed care and advocate for changes that provide more protection for patients and better care. Under this approach, participating in judicial-based reforms is essential, because they likely result in at least some reforms of the system. NASW has been involved to some extent in these cases, as have other professional associations such as the American Medical Association and the American Psychological Association. However, many of these cases are being driven by attorneys outside the traditional groups of legal reformers such as nonprofit organizations and legal aid attorneys with close ties to the social welfare community. For example, the RICO cases involve a coordinated, nationwide effort by a group called the REPAIR team, which stands for RICO and ERISA Prosecutors for Insurance Industry Reform ("Class Actions," 1999). The REPAIR team consists of attorneys from the private bar who were previously involved in highly successful litigation against the major tobacco companies. But reforming managed care is a social welfare issue and requires input from that community, including social workers. Thus, it is important for social workers and their professional organizations to provide input into any settlements that may be reached with managed care companies. This is especially true where, as in the RICO lawsuits, virtually all of the major managed care companies have been sued. It is primarily social workers that can expand any settlements beyond such issues as who gets to make medical decisions and how profit incentives should be structured and disclosed. Social workers, who are ethically required to protect the most needy and vulnerable populations, including poor people and people with disabilities, especially need to make sure that the interests of these groups are represented (NASW, 2000a). For social workers and their professional organizations, this means forming alliances with such groups as the REPAIR team and others involved in major litigation against MCOs. Social workers also can encourage their clients to participate in class action lawsuits. As the largest group of mental health practitioners (Segal, 1999), social workers are in a position to encourage many clients to join in lawsuits. By so doing, social workers are fostering client empowerment, one of the most potent and basic tools of all in bringing about change and one greatly needed in the managed care arena. This means as a practical matter that practitioners should closely monitor the status of major court cases. Information about various lawsuits is available on the Internet through such Web sites as NASW (www.socialworkers.org) and the American Psychological Association (www.apa.org). This information also can be helpful to individual practitioners in other ways. Becoming conversant in these legal lines of attack can be as important to practitioners as knowing the contents of their managed care contracts. On a practical level, these court cases may change the very content of those contracts. In addition, they may be of help to social workers when negotiating contract terms with managed care companies, which may be more sensitive to certain issues and more receptive to negotiation because of the pressure being applied in the legal arena. But however desirable judicial-based reforms of managed care may be, other approaches that incorporate more radical changes are needed. For most of the 20th century, the provision of health care was a commercial endeavor with the pursuit of profit underlying both the old fee-for-service system and managed care. Businesses--through our employer-based system of health care--are the biggest purchasers of health insurance, and now Businesses--through managed care organizations--are the biggest providers of it. The result has been inequities. For 18 percent of the population, or roughly 43.9 million people, it means going without health insurance (Employee Benefit Research Institute, 2000). For others who have insurance it can mean health care denied or delayed, or substandard health care, when profits interfere with good medical judgment. Thus, social workers need to look beyond the "next best" reform of managed care and advocate for a more fundamental solution, such as a universal, single-payer system or a variation thereof, that addresses these inequities. (For a more complete discussion of these alternatives, which is beyond the scope of this article, see Belcher & Palley, 1991; Mizrahi, 1992; Scuka, 1994). To be sure, social workers will be bucking the recent trend to commercialize through privatization nearly all types of social services, not just health care. And many social workers and others recall too vividly the defeat of Clinton's health plan in 1994 that at least held the promise of more fundamental reforms despite some of its flaws. But the lessons of judicial-based reforms, and parallel reform efforts in the legislature is that incremental changes, while pragmatic, useful and worth pursuing, ultimately are not enough to address the basic inequities of a profit-driven health care system. Of the many professions involved in health care, social workers, as both providers of services and the traditional champions of disenfranchised people, have a unique contribution to make in fashioning a more equitable health care system. 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