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It's been a little more than a year since the state cap on malpractice pay-outs took effect, but both supporters and opponents say it will be years before its impact is felt -- if ever.

The law took effect in July 2005 and limits damages commonly known as pain and suffering to $350,000 per defendant and a total of $1.05 million if more than one provider is involved. It does not affect economic losses.

Supporters of the caps say they are needed to reduce high jury awards and frivolous lawsuits, which they say led to soaring malpractice premiums that have been driving doctors out of the profession.

Opponents say the premiums were so high to offset insurers' investment losses, artificially low premiums offered to attract business in the 1990s, and other industry factors. They also say caps hurt those who've suffered legitimate injuries.

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Consumer groups say the rate of lawsuits and million-dollar awards has actually declined, and that there's been no flight of doctors from South Carolina.

Since the caps became law, premiums have still gone up, but that was expected, said Dr. Gerald Harmon, president elect of the South Carolina Medical Association.

"We did not expect to see an immediate reduction in the rates," he said. "We are hoping to see a flattening of the rates and perhaps in the future lower rates."

Malpractice premiums charged to about 5,000 physicians in the state by the South Carolina Joint Underwriting Association increased 7.2 percent in June 2006, said Tim Ward, vice president with Marsh USA, Inc., which administers the JUA. Premiums increased 12.7 percent, 28.8 percent and 28.7 percent in the previous three years, he said.

Insurers typically look at 10 years of activity to set premiums so they can collect enough to cover potential pay-outs, Ward said.

But when Marsh began administering the JUA in 2001, its reserves weren't based on actuarial projections so premiums were not as high as they should have been, he said. As a result, he said, adjustments were made to premiums in the first few years, which are now settling down because reserves are sufficient.

Because of the lag between a malpractice suit being filed and its resolution, Ward said it will be at least another year before any impact is felt on pay-outs, and five years before that affects premiums.

The South Carolina Medical Association says high premiums led some doctors to leave the state and others to stop performing certain high-risk procedures, although they have no numbers.

But according to the State Budget and Control Board, Office of Research and Statistics, South Carolina gained 800 doctors between 2000 and 2005, including in obstetrics, neuro-surgery and emergency medicine, three of the specialties with the highest premiums.

Harmon, a family practitioner, says it would be "a stretch" to conclude that two new obstetricians in Georgetown where he practices were the result of the cap law. And he says he's not aware of any leaving in the past year. But he says that in Texas, the hike in malpractice rates leveled off after a cap was instituted and that it has helped recruit doctors there.

Taylor Lincoln of the national consumer group Public Citizen said that historically premiums have gone up independent of malpractice pay-outs.

"One of the things we noticed in their advocacy for these laws," he said, "was that insurance companies when asked wouldn't pledge to lower their rates."

A Public Citizen analysis found that the number of malpractice pay-outs dropped 9 percent between 1991 and 2004 -- 16 percent between 2001 and 2004 alone -- and that the number of multi-million dollar pay-outs, which represent just 1 percent of all awards, declined 56 percent during that time, a time when premiums increased most.

Noting that double-digit premium increases have been seen in other areas as well, the group says what's needed is reform of insurance industry business practices.

Greenville malpractice attorney Mike Parham says he hasn't seen any effects as a result of the cap, but he's still handling cases filed before the law took effect. Nonetheless, he says, new cases are being handled the same way.

"(The cap) may affect the way a lawyer who is looking at a case who does one every 10 years," he said. "But for the 10 or 12 law firms that do 90 percent of the caseload representing victims of medical negligence across the state, I haven't seen any changes. It certainly hasn't affected us."

Moreover, Parham says, he doesn't believe it ever will. That's because he doesn't think the cap will hold up to legal challenges, including the constitutional rights to equal protection, due process and free access to the courts.

"I am confident that the Supreme Court of South Carolina will declare the caps provisions unconstitutional," he said. "There have been successful challenges in several states. I expect the same kinds of challenges will be brought here."

Fayrell Furr, past president of the South Carolina Trial Lawyers Association, said he hasn't seen any impact yet either. But because mounting a malpractice case can cost upwards of $100,000, the cap could affect some cases without economic losses -- such as the death of a child or an injury to a mother who doesn't work outside the home, he said.

He estimates that would be about 2 percent of cases filed.

Patient safety advocate Helen Haskell of Columbia, who settled a malpractice suit for $950,000 after her 15-year-old son died as a result of surgery in 2000, suspects there's been little impact from the cap so far.

But she points to government reports of the thousands of Americans who die from medical errors every year, along with untold numbers of medical injuries, whose families are often left with staggering hospital and doctor bills and disability in addition to their grief. And she says that "penalizing" injured patients through caps is not the way to go.

"I find it interesting that they're talking about all these frivolous lawsuits and yet admitting all these medical errors," she says.

"It's truly remarkable that there is so much indignation over lawsuits and virtually none over the literally millions of patients who have been grievously harmed. If doctors applied a fraction of the effort to patient safety that they do to tort reform, they would solve their problem."