Maryland Gov. Robert L. Ehrlich Jr. (R) waded into a crowd of more than 200 restless doctors on a recent evening and issued a call to arms: Your help is desperately needed in Annapolis, he said, to persuade "a tough legislature" to confront rising medical malpractice insurance rates.
"I know it's a pain. I know it's horrible. It's not why you went to medical school," Ehrlich told the gathering at Greater Baltimore Medical Center. "But you have the ultimate resolution of this issue in your hands."
The hour-long visit was part of a flurry of recent appearances by Ehrlich, all designed to shine a bright light on his battle with lawmakers over how to head off a potential health care crisis. Last week, Ehrlich called it "the number one issue in Maryland right now."
Yet, for all the attention he has generated, Ehrlich faces widespread skepticism among Democrats and even some doctors over whether he is serious about finding a workable solution.
The governor already has rejected one costly proposal that would slow malpractice insurance increases right away. He is pushing instead for a longer-term approach that was discarded by the Democrat-controlled General Assembly in the past legislative session.
Since coming to office 18 months ago, the state's first elected Republican governor in a generation has confounded his critics by turning defeats into victories. His failure to win approval for slot machine gambling, for instance, has become ammunition against the Democrats he blames for thwarting his plan.
The debate over doctors' insurance "has all the hallmarks of that strategy," said Sen. Brian E. Frosh (D-Montgomery), chairman of the Judicial Proceedings Committee, which has jurisdiction over medical malpractice legislation. "I don't want to foreclose the possibility that something can be worked out, but it's mostly rhetoric from the administration and not much work."
Paul E. Schurick, Ehrlich's communications director, dismissed the Democrats' talk as "whining" and said the governor is "dead serious" about seeing a bill passed before more Maryland doctors are forced from the profession.
The state's largest malpractice insurer, Medical Mutual Liability Insurance Society of Maryland, raised premiums by 28 percent for this year. The company has proposed a 41 percent increase for next year. A growing number of doctors, particularly those in such high-risk specialties as obstetrics, say rate increases are making it too costly to practice.
Ehrlich recently floated the idea of a special legislative session on the issue before the General Assembly reconvenes in January, but aides acknowledge that there is no consensus on how to proceed. In the past, Ehrlich has called for tighter caps on payouts to people harmed by medical mistakes, while Democrats generally have advocated insurance reforms and better policing of the medical profession.
The three interest groups pitted against one another in the debate -- doctors, trial lawyers and insurance companies -- said last month that they might be on the verge of a breakthrough.
During a meeting at the State House, representatives of the three groups pitched a plan to Ehrlich that would have allowed Med Mutual and other insurers to freeze their rates by setting up a state-run reinsurance fund. The state, in effect, would cover a portion of the companies' malpractice payouts.
T. Michael Preston, executive director of the Maryland State Medical Society, said the idea represented a rare instance in which all parties actually agreed on something. "That was an important and unusual feature of it," he said.
Ehrlich emerged cool to the idea, which, by one estimate, could cost the state as much $50 million a year. During his appearance before doctors at Greater Baltimore Medical Center, Ehrlich recounted his reaction to seeing trial lawyers and insurance executives in the same meeting: "I reached for my wallet," he said to laughter. "That's a bad approach, and it's been rejected."
In an interview Thursday, however, Senate President Thomas V. Mike Miller Jr. (D-Calvert) said he is continuing to explore the approach. Miller said he is looking at several ways to pay for it, including an additional fee for motorists with drunken-driving convictions. Ehrlich's solution, reducing payouts to malpractice victims, would take years to have any real impact on premiums, Miller argued.
"This is the only way we can avoid a huge rate increase this summer," he said. "It does no good for the governor to talk about caps and things that don't do the job."
Aides to House Speaker Michael E. Busch (D-Anne Arundel) said he is open to the idea of a state fund, but he is not committed.
Ehrlich's aides suggest he will continue to be a hard sell. "It doesn't deal with the underlying problem," said Donald J. Hogan Jr., a legislative aide. "The governor is looking for a long-term solution, not a Band-Aid."
During the past legislative session, Ehrlich's approach focused exclusively on new limits on jury awards and settlements paid to malpractice victims, including a reduction in the existing cap on damages for "pain and suffering" from $635,000 to $500,000.
Such caps are being pushed nationally by Republicans including President Bush, who argue that excessive jury awards are largely responsible for escalating malpractice premiums.
Ehrlich's bill died in March in the Democrat-controlled Senate, where it faced stiff opposition from trial lawyers, who argue that such caps are unfair to those grievously injured by medical mistakes. Both Frosh and Miller are trial lawyers.
This summer, Ehrlich has appointed a task force charged with "coming up with a better bill." Aides say the group will use Ehrlich's defeated legislation as a starting point but also consider other approaches, such as new measures for patient safety.
But the panel also will consider other ideas certain to rankle some Democratic leaders, including new limits on fees collected by plaintiffs' lawyers in malpractice cases.
The task force, which met for the first time this month, was roundly criticized by Democrats as stacked with doctors and insurance executives partial to Ehrlich's approach. "Nothing can be accomplished when you only have one side at the table," Miller said. "It's all show. It's no-go."
At the very least, Ehrlich's appearances at hospitals have convinced many doctors that they have an ally.
"I think the governor is acutely aware of the problem," said Beth L. Aronson, an obstetrician who saw Ehrlich at the hospital. "I think the governor is asking us to do the only thing he can ask us to do. . . . The legislators just don't get it. They obviously don't care about the general public."
Aronson, who said she pays $75,000 a year in malpractice insurance, said "the trial lawyers have a death grip on this industry."
Some in the medical profession, however, are starting to question Ehrlich's tactics.
Carol Ritter appeared with Ehrlich at a news conference last month to share her decision to end her obstetrics practice in Towson after 20 years because of malpractice rates. She is now practicing only gynecology, which demands less costly insurance rates. In the weeks that have passed since then, Ritter said, she has been frustrated by the tone of the debate.
"You have to give in order to get, and I haven't seen the governor giving anything at this point," Ritter said. "I'm hoping he will. . . . I try to be optimistic about this whole thing, but honestly, I'm scared. It's my profession that's at stake here."
Some argue that Ehrlich will pay a price politically if there is no action on malpractice insurance -- an issue that could affect far more lives if the situation continues to worsen and access to health care is limited.
"As an executive, people expect you to get things done," said Montgomery County Executive Douglas M. Duncan (D), who is considering a gubernatorial bid in 2006. "He'll be judged by whether he got things done or whether he just used issues for political gain."
Schurick acknowledged that there is political exposure for Ehrlich if the standoff over medical malpractice continues, but he said that the governor's work on this issue is not motivated by his next election.
"This is a crisis that merits this level of attention," Schurick said. "The governor is using his bully pulpit on this everywhere he goes, and he will continue to until legislative leaders address this crisis."