A Big Island legislator, trying to pressure the Hawai'i Medical Service Association, questioned yesterday whether the state's largest health insurer should keep its tax-exempt status, saying he believes it does not give enough money back to the community.

State Rep. Josh Green, D-6th (N. Kona, Keauhou, Kailua, Kona), a doctor, released figures that showed HMSA has collected $13.4 billion in revenue over the past decade. The HMSA Foundation, created to conduct research and support the healthcare needs of the community, has committed $9.3 million to community projects over the same period.

HMSA argues that it is an unfair comparison, since nearly 93 percent of its revenue was paid out to doctors and hospitals, but Green is using the figures to prod lawmakers to restore health insurance rate regulation and to evaluate HMSA's tax-exempt status next session.

"The bottom line is they're cheapskates," Green said. "They're out there right now trying to kill rate regulation. They are not doing enough on doctor reimbursements or to help with the state's healthcare problems.

"These numbers are so shocking to me that I think, next session, their tax-exempt status should be revoked."

Summerlin Life & Health Insurance Co., a Nevada-based for-profit company, is the only major health insurer in Hawai'i that pays state taxes on premiums. If HMSA had to pay a 4 percent tax on premiums over the past decade, it would have cost more than $500 million.

Green, the chairman of the House Health Committee, said that money could have been used to help the state contain rising healthcare costs. But Cliff Cisco, an HMSA senior vice president, said the tax would have been passed on to companies. "That's a big ticket for the employers to pay," Cisco said.

HMSA and other insurers are state tax-exempt because they are not-for-profits that provide benefits to the community. J.P. Schmidt, the state's insurance commissioner, said that except for the HMSA Foundation, the community benefits are primarily through providing health insurance.

HMSA's financial figures show that it lost money on underwriting in six of the past 10 years but turned a net gain in all but one year — 2002 — because of investment income.

Cisco said HMSA has funded several community initiatives from its reserves in addition to the money committed by the HMSA Foundation. He noted that HMSA helped subsidize healthcare for workers who lost their jobs after the 9/11 terrorist attacks and recently pledged $50 million to support the HMSA Initiative for Innovation and Quality.

Green has been scathing this session in his criticism of HMSA, which, like Hawaiian Electric Co. and the Hawai'i Government Employees Association, is an influential force at the state Capitol. Last month, Green publicized the salaries and bonuses of HMSA's top executives, a move he acknowledged was to get their attention.

Lawmakers often use their power as leverage, but it is unusual for Green to take on HMSA so publicly. He requested the HMSA salary and financial data from the insurance commissioner and has freely shared the information — along with some icy correspondence with HMSA lobbyists — with the news media.

"He seems to be using this strategy to see if he can influence us to make certain adjustments in physician reimbursements," Cisco said.

Cisco said HMSA adjusts doctor reimbursement rates annually, based on its research. Asked whether Green was having any influence, Cisco replied: "I would say not."

The House is expected to vote today on restoring health insurance rate regulation as it prepares to exchange bills with the Senate on Thursday. The current version of the bill would regulate HMSA for three years, but some lawmakers may propose an amendment to restore the law that expired last summer, which included Kaiser Permanente and others.

Among House Democrats, there are different accounts about whether leadership wants rate regulation to survive or whether it is destined for failure in conference with the Senate, as happened last session.

Schmidt, the insurance commissioner, said it does not make sense to exclude Kaiser from regulation. Schmidt and some lawmakers have said that singling out HMSA might be a strategy to kill the bill, since lawmakers could argue it is unfair.

"It makes me wonder if there is an attempt to kill rate regulation but to do it under cover," Schmidt said.

Reach Derrick DePledge at ddepledge@honoluluadvertiser.com.