Anyone attempting to press for medical malpractice tort reform in this state faces an uphill battle, as Rep. Josh Green has discovered yet again.

But it's a battle that needs to be fought, in the interest of preserving access to quality healthcare in Hawai'i, particularly for those who live in rural O'ahu and on the Neighbor Islands.

Tort reform is only part of the package of necessary changes that will help curb the exodus of needed medical specialists. Raising insurance reimbursement rates will improve the income side of the equation for doctors contemplating a practice in high-cost Hawai'i, and additional incentives are needed to lure doctors to more remote communities.

But expenses need to be curbed, too, and malpractice insurance premiums will only continue to rise beyond reach without sensible tort reform.

House Bill 1992 — sponsored by Green, D-6th (Kailua, Keauhou) — died in the Judiciary Committee last week, withering under the opposition of its chairman, Rep. Tommy Waters. Green vows to find a new vehicle among the bills crossing over from the Senate on Tuesday to keep his proposal alive for this session.

That's fortunate. And Waters, D-51st District (Waimanalo, Lanikai), will have to come up with a better argument against it than what he contends: that the bill denies compensation rights to victims of malpractice.

That's not the case. The truth is that a tort reform bill would assign no limits to the economic damages a victim could collect — compensating them for things that can be calculated, such as lost wages, medical bills and property damage.

The bill would impose a cap on noneconomic damages. Those are the losses that can't be tagged with a dollar value using any reasonable standard. These include damages for pain, suffering and loss of companionship and consortium (love of spouse).

The proposed cap would be set at $500,000 for high-risk medical specialties as designated by the Department of Health and $250,000 for all others.

Finally, in cases of catastrophic harm — "irreversible, life-altering injuries," such as permanent paralysis or brain damage caused by lack of oxygen — the noneconomic damages cap would be raised to $3 million.

Clearly there are routes to compensation for victims under the tort reform plan.

Currently, there are no standards on noneconomic damages, which can fluctuate unpredictably. A cap would give some rational structure to the way the legal system gives relief to victims and the insurance industry assesses risk.

Without a logical basis, the result has been sky-high insurance premiums in some specializations. For example, Hawaii Medical Association figures show that since 2001, orthopedics premiums have risen annually at rates as much as 63 percent. Average annual premiums in 2005 were roughly $56,960.

So it should be no surprise that of the 68 orthopedic surgeons practicing here a decade ago, 20 have left.

Or that of the remaining 48, the HMA reports only two or three as willing to be on call at The Queen's Medical Center, the state's primary trauma hospital. Doctors describe feeling burned out, putting in long hours and constantly being on rotation. Having doctors at their best to treat the victims of an accident flown in from the Neighbor Islands or rushed by ambulance from Honolulu's freeways is critical.

Opponents of tort reform, particularly trial attorneys, dispute findings from other states that show an increase in practicing physicians once damage caps are in place. They argue that increasing reimbursements from health insurance carriers is the key improvement.

But physicians like Dr. Linda Rasmussen disagree. "We already pay our physicians about a third of what they make on the Mainland, and having medical tort reforms is a big factor in whether they choose to practice in Hawai'i or not," says Rasmussen, an orthopedic surgeon who has seen two of her partners leave Hawai'i in the last year due to high costs. Both moved their practices to states with malpractice tort reform.

While several factors certainly contribute toward making an environment attractive for medical practice, it's clear that reasonable tort reform must be part of the picture. Hawai'i or any other state with such a looming healthcare crisis should work toward keeping the medical system well staffed.

Telling doctors there's no limit to the risk they face is not the message we want to send.