hough it has dwelled in the shadow of the presidential contest, Question 5 on November's state ballot would, if passed, restructure Massachusetts' health care system more dramatically than any proposal by George W. Bush or Al Gore, and has spawned a well-funded opposition campaign by HMOs that will saturate Boston airwaves in the coming weeks.
It's a simple yes-no question, 64 words in length, but as sweeping as anything produced on Beacon Hill in a generation: guaranteed universal health coverage, a temporary ban on the creation of for-prof-
it health companies, and the right to choose any doctor.
HMOs argue its passage would throw Massachusetts health care into chaos. Privately they worry that Question 5's innocuous wording, combined with voters' antipathy toward managed care, will result in its passage despite their deep-pocketed opposition.
That opposition is poised to become one of the most costly campaigns against a ballot question in state history. As of Sept. 3, the question's opponents - led by Blue Cross-Blue Shield and Aetna - have gathered $642,600 to fight the measure, according to state campaign finance records. The local high-tech industry has kicked in $50,000, according to records.
Beginning in October, the ''No on 5'' forces say, they will run frequent commercials on radio and TV. And they have paid $150,000 to retain Winner/Wagner & Mandabach, a California consulting firm that specializes in defeating ballot questions, according to election records.
Most of the advocacy groups that once supported Question 5 have bowed out, saying that a patient's bill of rights passed by state lawmakers in August is enough reform.
The remaining Question 5 supporters, a passionate but small band of doctors and nurses, have $4,433 in their coffers and have been outspent about 100-to-1, according to state records.
The disparity will probably grow as their meager reserves dwindle while HMOs spend millions of dollars more, as they have threatened to do.
But, they say, when HMO-weary voters step out of the Election Day hoopla and into a quiet voting booth, they will be swayed by the gentle and optimistic tone of Question 5, which calls for insurance companies to ''guarantee certain rights'' and for the creation of a system ''to provide comprehensive health care coverage for all.''
''Bill and Hillary Clinton couldn't get a plan through that was far less comprehensive than this one because the climate was different seven years ago. Things are very different now,'' said state Senator Mark C. Montigny, a New Bedford Democrat and one of Beacon Hill's leading voices on health care.
The debate over Question 5 is taking place over a backdrop in which 600,000 people in the Commonwealth are without health insurance and some HMO premiums are set to increase up to 30 percent next year.
It landed on the ballot after supporters mounted a months-long campaign to collect 110,000 signatures.
As it became clear this spring that the petition would succeed, lawmakers on Beacon Hill revived a patient bill of rights that had been in legislative limbo for three years.
Then came the schism. The high-profile members of the Question 5 coalition promised lawmakers they would abandon their pursuit if they got a patient bill of rights to their liking.
In August that happened. The new bill establishes medical necessity as the governing standard for the doctor-patient relationship. It also mandates the creation of a state HMO watchdog agency and the issuing of annual HMO report cards.
In addition, patients can now appeal HMO decisions to an independent panel of health care consultants, women can pick the obstetricians or gynecologists of their choice, and people can visit emergency rooms whenever they feel it reasonable.
Finally, the bill would create a panel to study the problems of the uninsured and creates greater scrutiny of health care deals involving for-profit companies.
''Question 5 doesn't do anything wrong. But this law is sufficient because it enacts a strong patient bill of rights, takes a first step toward universal care, and takes a stand on for-profits,'' said Natasha Perez, executive director of the Coalition for Health Care, which once led the drive for Question 5 but now opposes it.
If Question 5 passes, the patient bill of rights would be invalidated. The details of what Question 5 would do are spelled out in a 13-page explanation, part of a larger voters' guide, that will be mailed to voters this month.
Instead of prescribing exactly what the new health care system would look like, it would create a state Health Care Council that would devise a universal coverage plan. The Legislature would be required to pass it by July 1, 2002.
The question would also bar the creation of any for-profit health companies in the state until universal coverage was in place. And it would enact HMO controls similar to the patient bill of rights, but going further by allowing patients their choice of any doctor for a small fee, and by putting a cap on how much HMOs could spend on upper management salaries and administrative costs.
Question 5 sets policy destinations but does not provide a map, an uncertainty that its detractors promise to exploit as Election Day approaches.
''This mandate leaves out the most difficult question: What is this going to look like and how will we pay for it?'' said Richard C. Lord, president and CEO of Associated Industries of Massachusetts, which represents hundreds of businesses.
Lord said Question 5 would dramatically increase health care costs, which would cause many business to drop coverage for their employees. The only option left, he predicted, would be to create a Canadian-style system, in which the government pays for everything.
But Dr. Timothy Guiney, a Massachusetts General Hospital cardiologist, calls this fearmongering.
''It doesn't have to be some Kremlinesque system,'' he said.
Some people outside the fray, worried about Question 5's potential impact, foresee another scenario: It is adopted by voters but legislators quickly pass a law voiding it.
''I don't think that the standards set out in the question are realistic, financially or otherwise,'' said Montigny, adding that he is open to legislatively voiding the question.
But overwhelming electoral support could make scrapping the question a politically dangerous proposition.
At the moment, voters do not appear to be aware that they will make such a hefty health care decision on Election Day.
The ''Yes on 5'' forces hope that larger political winds, like Gore's bashing of HMOs, will help buoy their cause.
But their opponents said they are prepared to spend up to $3 million to make their case, which would make Question 5 one of the most costly in Massachusetts history.
''In ballot questions, there's a direct correlation between money spent and which side wins,'' said Perez.
