The Republican budget would make other cuts as well, that were not proposed by the Governor. It also includes a strict spending cap that would force further cuts in health care, now and in the future.
There's lots of other proposals as well, although many that are not fleshed out and so we will have to see what they mean. One includes tax *cuts* for Health Savings Accounts, further encouraging underinsurance.
We will see if the Republican legislators will want to fully own the full consequences of this budget.
An important bill, AB2 (Dymally), to improve the state's high-risk pool, the Major Risk Medical Insurance Program (MRMIP), passed 41-27 in concurrence with Senate changes. It now heads to the Governor.
Right now, there's a waiting list of nearly 1,000 patients who have been denied by insurance companies for "pre-existing conditions," even though the program is obscure and has never been advertised. The bill would help reduce that waiting list, and also remove the $75,000 cap on benefits, which left these "high-risk" patients significantly underinsured, at risk of financial ruin with a major bill.
AARP, Health Access, American Cancer Society, and many others supported the bill, and urge its signature.
The argument that insurers are using is that the bills would eliminate low-cost products. That's untrue--it leaves lots of options, including high deductible products in place: in fact, the bill explicitly categorizes plans into five tiers, expectation that their will be continue to be a wide variation and range in insurance products. But it better labels those products so people are clear what they are getting.
But in doing that categorization, there some choices that may provide so little coverage that even the lowest rating isn't appropriate. Requiring hospital, doctor, and preventative care is a pretty low standard--but would phase out only a handful of products that are "hospital-only coverage."
But is it really "health coverage" if it doesn't cover 80% of all surgeries? Yet that's what hospital-only coverage does (or doesn't) do. This may have made sense 30 years ago, when the vast majority of care was inpatient. But medicine has changed, most surgeries and other care is outside of a hospital. People pay premiums but only get a false sense of security.
Does anybody benefit from such a policy that covers so little care, other than the insurer that collects the premium? We wouldn't allow car insurance to cover only accidents with red cars. Why certify coverage that only covers patients in one setting, but not another?
That's why the bill is actively supported by prominent groups representing low-income families, like ACORN, Western Center on Law and Poverty, and Having Our Say, a coalition of groups representing communities of color, including California Pan-Ethnic Health Network, Latino Issues Forum, and others. It's these groups, not the insurers, that are looking out for low-income and Latino Californians, by supporting SB1522(Steinberg).
After a debate that we have mostly seen before in the state Legislature, SB840(Kuehl) to create a universal single-payer system, got a 44-31 vote in the Assembly today. It was a party line debate and vote, with Republicans voting against, and most Democrats voting for it, except for Parra and Galgiani--who voted No--and Nunez not voting. (Soto was an excused absence.) It now goes to the Senate for concurrence.
The insurers' top legislative priority to kill was actually SB1522(Steinberg), to provide consumer information and protections and set standards in the individual insurance market. It started and ended the day in the Assembly, and got 36 votes, short of the 41 votes needed for passage. That was also a mostly party-line vote, with Democrats generally in support.
Republicans voted with Blue Cross and some other insurers and against the bill, joined by Democratic Assemblymembers Fuentes, Parra, Solorio, and Torrico, all voting No. Not voting was Assemblymembers Calderon, De Leon, Galgiani, Furutani, Mendoza, Nunez, and Portantino. (Soto is an excused absence.) The bill is up for reconsideration.
Health Access California opposes the Senate Budget Proposal considered the morning of August 29th, 2008, which would significantly harm health care in California, now and in the future.
Here's the health impacts of the Senate Budget Proposal:
* The proposal includes all the cuts agreed to by the Budget Conference Committee (AB1781). In health care, those cuts include more onerous reporting requirement for children's coverage through Medi-Cal, and an increase in Healthy Families premiums, among other reductions. This is expected to deny coverage to over 250,000 children over the next three years.
* The Senate Budget Proposal includes even deeper cuts in health care and other vital services. In health care, this includes a delay in restoring the Medi-Cal provider rates until March of 2009. The Legislature and Governor made 10% cuts to provider rates earlier this year, but proposed to restore them. This would make additional hundreds of millions of dollars of cuts to California's health care providers by delaying that restoration. (This is assuming, of course, that the State is successful in its appeal of a court decision that struck down the cut.)
* The budget relies on a *temporary* 1-cent sales tax, a revenue stream that will expire in three years. Since California's health care needs are expected to grow, not shrink, in three years, this would likely force a budget crisis and additional cuts at that time in three years. At best, this only delays the inevitable decision to either revenues or make cuts permanently.
* Most concerning in the long view, the proposal makes permanent, problematic changes to the state’s budget process in exchange for a temporary tax increase that would leave the state facing significant budget shortfalls in 2011-12, if not sooner, and beyond.
-- The so-called “reserve” that functions as a spending cap that would drain money away from health care, education, and other vital services, locking in inadequate funding levels--California is 51st in the nation in per-patient Medicaid spending---and as health costs rise, forcing additional cuts in the future, especially to health and human services.
-- In particular, the proposal would give the Governor unprecedented power to make unilateral cuts mid-way through the budget year. This and future governors would be given sweeping power to cut payments to families and children, payments to providers of state-funded services, higher education, and other programs based on estimates prepared by the governor’s appointees.
The Senate just voted 24-15 on a state budget, which includes further cuts beyond the Conference Committee proposal (which already would leave more than a quarter-million children uninsured). No Republicans voted for the measure and Perata challenged the party to come up with an honest plan that says what they say behind closed doors -- things like "Medi-Cal is Cadillac coverage."
The Senate is voting on a budget tomorrow morning, reportedly with some agreement within the Senate between the parties--but not with either party caucus in the Assembly.
The word is that it is similar to the Governor's "August Revise" but with some modifications: more cuts in addition to the Conference Committee budget (including a further delay in restoring Medi-Cal provider rate cuts), a temporary 1-cent sales tax increase, and a spending cap.
Just saw a video broadcast at Mile High Stadium before Al Gore and Barack Obama's speeches. It was about an Obama supporter whose mother had cancer, and her experiences with a health system that needs to be reformed.
"It was horrible. It was one of the worst experiences to go through. I saw the medical system firsthand, and it was horrible.... Towards the end, she had gotten stable, and was stable enough for transfered, to be removed from the ICU. When I was trying to get a doctor to admit her to another hospital, the doctors couldn't admit her because they didn't have the proper insurance. She had Medi-Cal. These doctors didn't accept Medi-Cal...."
Alas, she's a Californian, and at least this part of her story shines a national spotlight on the process of access for the 6.8 million Californians with Medi-Cal coverage.
Yet at the same time, the budget crisis threatens to cuts further into Medi-Cal, including the already lowest-in-the-nation provider rates that lead more than half of the state's doctors not to take Medi-Cal patients.
California still has the highest number – not percentage – of uninsured residents at 6.7 million, compared with 5.7 million Texans. The Texas number is up from 5.5 million in 2006.
But the numbers are misleading, said John Goodman, president of the National Center for Policy Analysis, a right-leaning Dallas-based think tank. Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)
"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.
"So, there you have it. Voila! Problem solved."
Amazing...a McCain advisor wanting to simply define away the uninsured... in a just world, that should get a public rebuke worse than Sen. Gramm suggesting that America was only going through a "mental recession."
Some commentators have already pounced, including Ezra Klein and Joe Klein (no relation).
But even these rebukes don't actually explicitly refute the misconception that Goodman's comments are based on--so I will. Yes, Health Access California was founded 20-years ago, from a coalition working for a law that people are not turned away from emergency rooms based on insurance status. The eventually-passed federal version of that law, EMTALA, is important, but let's be clear what it does, and doesn't do:
* The law only requires emergency rooms to stabilize patients, not treat them. If you just had a car crash or heart attack, they will treat you, but if have cancer, asthma, diabetes, or any other long-term illness, there's no obligation by the hospital.
* Even in an emergency situation, there's no prohibition on what the hospital can charge. And in fact, the uninsured is often charged 2-4 times what insurance companies and public programs pay for the exact same service. That's the bill they get.
So even our EMTALA law does not ensure access to care, and certainly not *coverage* for care. People need care, and they need coverage to pay the bills. And the Census figures show a staggering number of people who have neither.
The irony is that the Census figures do have a "voila" moment. It shows that policy matters: states like Hawaii, Massachusetts, and Minnesota--that have set standards for employer based coverage, or have expanded public programs--have significantly lower uninsured rates in comparison to other states.
We know what we need to do to say "Problem solved!" But it's not by sweeping it under the rug.
I love the Divided We Fail/AARP commercials that are running during the Democratic National Convention that highlight how financially devastating the current health care system is to the 1.85 million Americans who must declare bankruptcy annually.
AB2 (Dymally) which would fund California's high risk pool just passed the Senate on a party-line vote with every Democrat voting aye (except Sen. Ed Vincent who has been absent due to illness) and every Republican voting no.
Senator Kuehl presented AB2 by describing its key provisions, including a fee of $1 per month on consumers who buy individual insurance to finance the high risk pool.
Senator Aanestad who had introduced a competing measure, SB1x 27, spoke in opposition. In a blog, Senator Aanestad called AB2 a "cement shoes" because it denies consumers the option of high deductible/low premium plans. Sen. Aanestad thinks that medically uninsurable individuals should have the option of high deductibles and health savings accounts, for which they would not be able to save since they already need more care than most of us. On the Senate floor, Aanestad said that MRMIP needs to be fixed but instead he called AB2 "guaranteed issue lite" because it requires health plans and insurers either to pay fee or to take assignment of uninsurables. Aanestad also complained about his bill not being heard in the Senate Health.
Senator Kuehl, the chair of Senate Health, responded that SB1x 27 was introduced and amended late in the game (August 19!) and that the only option that those enrolled in MRMIP would have would be a high deductible policy of $2500 per individual or $4000 for a family---or even higher deductibles.
With that the Senate voted the measure out. The health insurers are divided on the measure with some supporting and some opposing. Health Access and other consumers groups are in support.
AB2 moves back to the Assembly for concurrence in Assembly amendments. The Assembly floor has been a contentious place of late so even though this should be one of the easiest steps in the process, Health Access encourages organizations to voice their support. Then the challenge will be persuading the Governor to sign the measure. But one step at a time. posted by Beth Capell | Permalink | 9:54 PM
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Getting a sense of the landscape...
It's useful context to look at the broad numbers:
Out of nearly 300 million Americans, 253.4 million (85%) have coverage, nearly 45.7 million (15%) do not. 202 million (67.5%) have private coverage: About 177.2 million (59%) have employer-based coverage, and a relatively small 26.7 million (9%) buy coverage as individuals. 83 million (28%) have coverage through public programs: 39.6 million (13%) have Medicaid, 41.3 million (14%) have Medicare, and 11 million (4%) have coverage through the military.
California's uninsured rate inched up, to a 3-year average of 18.6%, up from 18.4% and 18.5% earlier in the decade. The Census figure pinpoints the number at 6.7 million uninsured. There are other figures, such as those from the California Health Interview Survey of the UCLA Center for Health Policy Research, which have different survey technique, and ask some different questions (Are you uninsured now? vs. Have you been uninsured in the past year?) Even with those differences, the Census data is important to indicate scale, trends, and baseline comparisons with other states.
Only six states have a higher percentage of uninsured residents than California: Texas, New Mexico, Florida, Arizona, Louisiana, and Mississippi.
The states with the lowest rate of uninsured are Massachusetts, Hawaii, and Minnesota, which suggests that state policy matters: you can you could look to the policies and reforms in the states to see how they have been able to reduce the uninsured rates.
The Census released its annual report on Income, Poverty and Health Insurance Coverage for 2007 today. The good news is that there are fewer uninsured Americans -- 45.7 million as opposed to 47 million the previous year.
But lest anyone think this means we can sit and twiddle our thumbs and not do anything about our rapidly degrading health care system, think again. More Americans are falling into our public safety net -- the ones that are *always* in jeopardy during bad budget years.
The report shows:
Private insurance: DOWN (67.5% from 67.9%)
Employer-based insurance: DOWN (59.3% from 59.7%)
Public insurance: UP (27.8% from 27%)
Medicaid (Medi-Cal here) increased by 1.3 million Americans.
Also of cheer -- the number of children who were uninsured nationally also declined from 11.7% to 11%.
Of course, the gains of the past year that can be attributed to California could be wiped out as our budget impasse continues. Already, the Conference Committee budget would leave nearly 300,000 children without public coverage -- such as Medi-Cal and Healthy Families -- by the end of three years.
Other cuts could also resurface, totalling more than 1 million uninsured by the end of the Schwarzenegger administration.
He's been involved in every major debate around health reform over the past half-century (even ones that he is not publicly involved, such as the fight for SB2/Prop 72 in California). He believes that a President Obama will provide him a final opportunity to bring everything he has learned, all his legislative experience and background and relationships and institutional memory, to the cause of passing health reform.
A lot of our coalition work this year, such as working with Health Care for America Now!, is trying to ensure there is a Congressional commitment to major health reform next year, but it looks like there will be a home grown push as well. Good. We need both.
The state budget impasse is nearing the end of its second month and shows no signs of abating. For every day that California goes without a budget, we get anxious because it means that more cuts are possible.
The May Revise budget contained nearly $1 billion in cuts to health services, which would have translated to more than one million additional uninsured Californians by the end of the Schwarzenegger administration. The Conference Committee restored many cuts, but the Conference Committee budget would result in the loss of health coverage for nearly 300,000 children by the the Schwarzenegger administration. The LA Times had a story this weekend.
As the budget debate drags on, and Republicans refuse to agree to increased revenues to fund our state's basic needs, more lives will be on the line. There have been rumored mutterings of more cuts -- meaning more children will be unable to get eyeglasses, teeth cleanings and basic health services that would keep them healthy and in school for years to come.
After years of making progress of covering children, California may be going backwards, reports Jordan Rau in Sunday's Los Angeles Times. Actually, it's heartbreaking that there will be kids that are being dropped from coverage, in Alameda County now, and soon statewide.
The budget debate is no longer should kids be discouraged and denied away from coverage, but how many. The Democratic proposal would increase premiums in Healthy Families, and increase reporting in Medi-Cal--both that are expected to decrease enrollment. If we raise less than the $8 billion+ in revenues, then the cuts would need to be even steeper.
Or we can decide covering California kids is a prioirity, and raise the money to finish the job.
The Riverside Press-Enterprise this week had an editorial called "Health Stumble'' bemoaning Sen. Sheila Kuehl's SB1440, which would require all health insurance offered in the state to spend at least 85% premiums on providing health care -- that is physical exams, surgery, mammograms -- you name it. SB1440 is now awaiting concurrence on the Senate Floor -- thank goodness.
They cite a Rand Corp. study which *only* looked at health plans regulated by the Department of Managed Health Care. Those health plans are not allowed to spend more than 15% on administration (of course, that doesn't count profit, but at least it's a target). But, as we know, health insurance plans in California are regulated by two agencies -- DMHC *and* the Department of Insurance.
Until a couple of years ago, some plans at the Department of Insurance (ahem, Blue Cross) spent as little as 51 cents for ever premium dollar on health care. (This we gleaned from a DOI powerpoint presentation at a public hearing). Meanwhile the company would spend 23 cents of every dollar consumers pay to use against consumers -- fighting bills for patient services, scouring health records in order to retroactively rescind policies, and other administrative costs. The remaining 27 cents is reserved for profit and executive bonuses.
That was changed and the DOI now requires that health plans spend at least 70% of their premiums on providing health care -- but that's still far short of 85%.
The Press-Enterprise argues that "medical loss ratios'' don't really tell us much about the plan's efficiency or quality of care. True -- but right now, we have *nothing*.
In an information void, such as the one we have now, the percentage of premium dollars spent on patient care is an important (though not the only) measure of a plan’s value. Unfortunately, low-value products (like the ones offered at DOI) are marketed to consumers for their low premiums. Patients do not have the actuarial expertise, or information to assess whether a particular low-premium product will actually provide them value – meaning it would pay for physician visits, drugs and other health costs when they need it.
Products that have low medical-loss ratios often:
do not have maternity coverage,
do not cover prescription drugs,
have high deductibles,
high co-insurance, and
lack caps on how much consumers need to spend out-of-pocket for their illnesses.
Such flimsy coverage causes consumers to deter care, or leaves them saddled with medical debt. And that's a stumble.
While Senator Steinberg was being sworn in as the new President Pro Tem on the Senate side, and calling for “health access for every Californian,” insurance company lobbyists were actively attacking Senator Steinberg’s health care bill, SB1522, on the Assembly side.
Without a strong case to make, they are resorting to mischaracterizations of the bill, hoping nobody pays attention to the facts in the heated last days of session.
The bill is modest but meaningful. It would ensure that consumers have more confidence in their coverage, and that they know what they are getting when buying coverage as individuals.
Right now: · It’s impossible to make price comparisons, since each plan from insurer has different deductibles, co-pays, out-of-pocket maximum, benefits, or networks. · It’s hard to know what a plan covers, or doesn’t cover, or how comprehensive any given plan is. · Some consumers think they are well covered, and find out they are not only when it is too late. Some plans are marketed as quality coverage but actually cover only hospitalization, but not surgeries, outpatient treatments, or doctor’s visits. (It would be like having car insurance, but only for accidents with red vehicles.) Some plans leave consumers with significant gaps in coverage, sometimes with unlimited exposure to medical bills.
SB1522 (Steinberg) does the following: * Requires health insurance to cover doctors, hospitals, and preventive care * Requires all health insurance to have a maximum out of pocket cost. * Categorizes all health insurance into five categories so that consumers can know whether they are buying comprehensive coverage with low cost sharing or a high deductible, catastrophic policy. It allows for "apples to apples" comparison.
Contrary to the misrepresentations of Blue Cross and other insurers, here is what SB1522(Steinberg) does NOT do: - SB1522 (Steinberg) does NOT eliminate so-called “low cost”, low premium products with high deductibles. In fact, that’s why there are five categories, so that those products are better labeled. - SB1522 (Steinberg) does NOT require all health insurance to cover specific benefits. There are other bills: AB1962 DeLaTorre requires maternity coverage, for example. - SB1522 (Steinberg) does NOT force people to leave the coverage they have. Anybody with a current plan can renew it indefinitely.
These mischaracterizations and misrepresentations show why we need the bill: Just as consumers are rightfully skeptical about their insurance policies and what’s in the fine print, legislators should be skeptical of the claims of the insurance companies. The point of this bill is to give consumers more confidence that their coverage will be there for them when they need it. I am not sure there’s a legislative remedy for the representations of insurers in the halls of the Capitol.
Assemblymembers should join key organizations, including Health Access California, AARP California, ACORN California, AFSCME, CALPIRG, California Teachers Association, Congress of California Seniors, Community Health Councils, Consumers Union, Having Our Say, Jericho, Latino Issues Forum, MALDEF, MS Society, Planned Parenthood, SEIU, Small Business Majority, and Western Center on Law & Poverty in supporting SB1522(Steinberg).
Even better than the "mensch" award I saw him get...
Thursday, August 21, 2008
Senator Darrell Steinberg was officially sworn in to be Senate President Pro Tem today, in a touching ceremony on the Senate floor this afternoon. With the current Senate President Pro Tem Don Perata making the motion, and the current Republican leader Dave Cogdill seconding the motion, it was approved unanimously by voice vote.
The "Pre-Tem" thanked the current Perata, Cogdill, his fellow Senators, including those in the Democratic caucus that elected him to the post, his family, his staff, and his constituents.
He also gave a speech that seemed to counter the cynicism about public service and government these days, which seems especially ripe right now because of the budget standoff. He talked about the advances made in some areas, whether infrastructure, stem cell research, or mental health, and suggested that progress could be made in other areas as well. As Shane Goldmacher at the Sacramento Bee reports:
"I love this institution," Steinberg told his colleagues. "I believe in this institution as a force for good..."
He outlined an agenda of improving public education, providing "health access for every Californian" and fixing the "maddening system" of public finance.
We appreciate that he listed health reform and coverage expansion as one of his top three prioirities. We are proud he is the author of one of our bills this year that starts the process--SB1522(Steinberg)--and we look forward to working with him on it next year and beyond.
Gov. Arnold Schwarzenegger scolded lawmakers via Capitol press conference today, saying both sides (especially Republicans) needed to stop being stubborn sticks-in-the-mud and grow up, and that the Republican idea to paper over our budget gap sucks. (That's not a quote, I'm paraphrasing).
"Let us get together and let us work this out. Don't come to the table with the same stubborn position. The Republican came in and said 'No taxes. No taxes. No taxes. ' The Democrats say 'No cuts. No cuts. No cuts,'''' the governor said at today's press conference.
He looked pretty annoyed that the whole thing wasn't done with already. I'm not sure how a public scolding is going to help matters, but I did want to point out one thing: We've taken our lumps. The budget has been cut already and we can't take anymore.
Setting aside the Medi-Cal reimbursement issue -- which was just blocked by a federal judge yesterday -- California's services will be cut no matter which budget we're talking about -- the May Revision or Conference Committee. In health services, we anticipate nearly 300,000 children to lose coverage because of burdensome paperwork requirements and increased premiums for Healthy Families and community clinics will lose some sources of funding.
It's unfair to go back and ask for more...we've done our part. Let the others do theirs.
California's budget is now 50 days late and we are headed toward our longest budget impasse *ever*. But today brought a bit of good news: A Los Angeles judge has blocked the state's 10% Medi-Cal reimbursement cut, which took effect July 1.
In order to get a jump start on closing the state's $17.2 billion shortfall, lawmakers and the governor approved a bunch of borrowing and initial cuts. One of the cuts was to reduce the reimbursement rates paid to providers caring for Medi-Cal patients. California already ranks among the lowest-paying states for Medicaid providers -- this cut made things even worse, as Anthony pointed out in the Sacramento Bee article today.
Of note: HD Palmer in the Department of Finance says the judge's ruling would "cost'' the state $575 million. We would argue that NOT paying providers their normal, abysmally low reimbursement rates would cost the state -- not only $575 million in matching federal dollars, but:
It's a temporary victory as we await the inevitable appeals by the state, which approved the cut earlier this year, and which started on July 1st. The Budget Conference Committee proposal sought to restore those cuts in September, but that is in the context of a proposal with over $8 billion in revenues: the Governor's budget did not make those restorations.
The court agreed that the Medi-Cal cuts would reduce access for the 6.5 million children, parents, seniors and people with disabilities that depend on Medi-Cal coverage. Many providers already don't take patients with Medi-Cal coverage, given that the reimbursement rates are among the lowest in the nation.
But this doesn't means the fight over health care cuts is over, not by a long shot. We need to be as vigilant as ever.
This suit was only about the provider cuts. Other cuts sought to reduce the benefits provided to Medi-Cal patients. Others--including ones adopted by even the Conference Committee, and voted for by the Assembly Democrats on Sunday--seek to reduce the number of Californians, particularly children, on Medi-Cal coverage.
What this court decision makes clear is the stark choice for the budget negotiators: we need to raise the revenues needed to prevent the cuts that are so drastic, they may be illegal.
Those who believe in investing in health care, education, and other vital services appropriately focus in the budget debate on the devastating impact of the specific budget cuts.
Those who oppose the revenues and taxes that are needed to find those programs generally make a broad anti-tax argument, often with an economic case. Witness many of the Republican Assemblymembers who spoke during the five hour+ debate on Sunday.
In a recent study "Significant Side Effects: The Economic Impacts of Health Care Cuts in California Communities," Health Access California (my organization) looked at just the health care cuts: and the comparison is stark. It finds that, due to federal tax deductions and matching Medicaid dollars, preserving California’s health care budget would have three times the positive economic impact as preventing an equivalent amount of increased taxes for upper income Californians.
In fact, the worst thing you could do for an economy is make health care cuts, which immediately translates to twice the impact just from the lost federal matching funds denied to our economy. There are also economic ripple effects, from lost jobs and wages, increased private health premiums, and more.
Money spent on health care immediately goes into circulation, through wages and vendors, which then gets recycled and multiplied in the economy. In contrast, an upper-income bracket tax impacts money that may be in the economy, or may simply be in the bank. Also, state income taxes are deductible on federal returns, which means that translates to be 35% less to the upper-income family, and in effect, more money in the California economy, courtesy of DC.
We need to forcefully rebut arguments that make economic claims about taxes without considering the economic repercussions of the cuts. Preventing the cuts is not just good for our health, but the health of the economy as well.
* Handful of consumer bills on the line, including single-payer, insurance standards, medical loss ratios, recission review, coverage for those with "pre-existing conditions." * Budget remains unresolved: negotiations continue on cuts, revenues, and caps.
Click for What's New on the Health Access WeBlog: More on Budget Negotiations; The Return of Harry & Louise; How to Improve the Economy; The Insurance Companies "Listening Tour"; HSAs; The Folly of a Spending Cap; The Consumers Union Cover America Tour RV Comes to Sacramento; New Studies; NJ Prohibits Hospital Overcharging; Premiums Going Up; The DNC Platform on Health Reform; Preparing for Denver; ER Overcrowding and Timely Access to Care; Ups and Downs of the Budget Fights; MegaLife and Mega Problems
The 2007-08 Legislative Session is fast coming to a close. Bills are up for final floor votes in the next several days--the last chance for health care advocates to weigh in with legislators about pending legislation is now.
While midnight August 31st is the deadline for bills to pass, legislative leaders have, at times, indicated they wanted to end session sooner – as early as this Friday, August 22nd. It is unclear whether either house will actually complete their legislative work at the end of this week, given that a state budget still has not passed. While both have national party conventions to attend over the next two weeks, the budget may keep the legislators in town through the 31st, and perhaps later. Adding to the uncertainty, Gov. Arnold Schwarzenegger has vowed to veto any and all bills that land on his desk if a state budget is not passed.
Regardless of the exact last day of session, legislation will be considered in the next several days that will have a major impact on health care consumers, from those trying to compare and purchase insurance, to those denied for "pre-existing conditions."
Health Access continues to track a number of health consumer-related bills. Several bills work to ensure that consumer have more confidence that there coverage will be there for them when they need it. More information is available on the Health Access website, at: http://www.health-access.org/advocating/2008_bills.html
Here's a selected list of pending legislation that Health Access California, the statewide health care consumer advocacy coalition, supports:
ON ASSEMBLY FLOOR
* INSURANCE MARKET STANDARDS: SB 1522 (Steinberg) Would provide standards for health insurance policies in the individual market. This would weed out "junk" insurance and sort policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic," to enable consumers to better track premium, benefits and cost-sharing. Benchmark policies would assist consumers in making apples-to-apples comparisons between plans. SUPPORT/SPONSOR * SINGLE PAYER: SB 840 (Kuehl) Would establish the framework for a universal, single-payer health care system in California that would enable all residents to have health coverage. SUPPORT * HOSPITAL DISTRICT ASSET TRANSFERS: SB 1351 (Corbett) Would require Attorney General oversight into transactions involving district hospitals. SUPPORT * INSURANCE COMPANY FINES: SB 1379 (Ducheny) Would use millions in fines levied on insurance companies for improperly rescinding coverage to fund two programs: high-risk pool for those rejected by insurance companies because of "pre-existing conditions"--which has a waiting list of nearly 1,000 Californians and financial aid program for physicians who serve in underserved areas. SUPPORT * PREDATORY DENTAL PRACTICES: SB 1633 (Kuehl) Would prohibit dentists’ offices from offering high-interest loans to patients while they are under the influence of anesthesia. Would also prohibit dental offices from charging lines of credit before services have been rendered. SUPPORT * UNFAIR BUSINESS PRACTICES: AB 2842 (Berg) Would protect Californians from insurance agents trying to sell them private Medicare plans through cold calls and bait-and-switch tactics. SUPPORT * HOSPITAL CLOSURES: AB 2400 (Price) Would require public notice before closing a hospital. SUPPORT
ON SENATE FLOOR
* HIGH-RISK POOL: AB 2 (Dymally) Would reform the Managed Risk Medical Insurance Program, which provides coverage for “un-insureables” who have “pre-existing conditions.’’ Would institute reforms and generate revenues through fees to make the high risk pool more affordable and available. SUPPORT * BALANCE BILLING IN EMERGENCY ROOMS: AB 1203 (Salas) Would prohibit balance billing by doctors and hospitals for care received after an emergency patient is stable enough to be transferred to a contracting hospital or released. SUPPORT * MENTAL HEALTH PARITY: AB 1887 (Beall) Would require health plans to provide coverage for all diagnosable mental illnesses. SUPPORT * LIMITING RESCISSIONS: AB 1945 (De La Torre) Would create an independent DMHC/DOI review if an insurer wants to rescind coverage, and raises the standard in existing law so that coverage can only be rescinded if a consumer willfully misrepresents his health history. SUPPORT * BROKER ACCOUNTABILITY AND FAMILY COVERAGE AFTER RESCISSION: AB 2569 (De Leon) Would require brokers who take applications to attest that the information is complete and accurate to the best of their knowledge. Also ensures that family members whose coverage depends on that of the rescinded person may be offered another individual policy. SUPPORT * PUBLIC INSURER: SB 973 (Simitian) Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices. SUPPORT * DURABLE MEDICAL EQUIPMENT: SB 1198 (Kuehl) Would require group health plans and insurers to offer coverage for durable medical equipment, such as wheelchairs and shower seats. SUPPORT * CONFIDENTIALITY CLAUSES: SB 1300 (Corbett) Would prohibit confidentiality clauses, which keep secret information on pricing and health care quality from consumers, in contracts between providers and insurers. SUPPORT * CAPPING ADMINISTRATION AND PROFIT: SB 1440 (Kuehl) Would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care. SUPPORT * FREQUENT ER USE: SB 1738 (Steinberg) Would continue pilot program in six counties that has provided frequent emergency room users with more cost-effective preventive care and disease maintenance through clinics and other resources. SUPPORT
HEADING TO GOVERNOR’S DESK
* MATERNITY COVERAGE: AB 1962 (De La Torre) Would require all individual insurance policies to cover maternity services. SUPPORT * BOUTIQUE HOSPITALS: AB 2697 (Huffman) Would require so-called “boutique hospitals’’ to asses their impact on a community’s health system annually, specifically whether they siphon doctors, workers, providers from hospitals caring for less affluent populations. SUPPORT * DEPENDENT CARE: SB 1168 (Runner) Would allow adult dependent children, who are still covered under their parents’ health plan, to stay on that coverage even if the child takes a medically necessary leave of absence from school. SUPPORT
For more information, contact the author of this report, Hanh Kim Quach, policy coordinator at Health Access California, at hquach@health-access.org.
Harry and Louise, the couple that helped take down health care reform, are back... but this time on the opposite side.
There's a new ad, being run during the political conventions, that feature the same actors from a decade-and-a-half ago: http://www.harryandlouisereturn.com/
The sponsors include groups in support of reform, from Families USA to the American Hospital Association and the American Cancer Society, and also on group that vocally opposed reform--the National Federation of Independent Buisnesses.
Here's the "making of" video:
For a blast from the past, here's the original ad attacking the Clinton health care plan. It's a sobering reminder of the attacks that any reform with come under by insurers and other opponents:
Anthem Blue Cross offered *all California hospitals* a piddling $11.8 million to settle a class action lawsuit that was filed after the hospitals were left with millions in unpaid medical bills (not to mention the patients who also suffered financially, emotionally and health-wise) when Blue Cross retroactively cancelled patients' coverage, according to the Sacramento Business Journal.
$11.8 million might sound like a lot, until you consider that the state fined the company $10 million over 1,770 rescissions made since 2004. The hospitals' suit covers a longer time frame.
...and don't forget the $950 million in our premium dollars that the company sent *out of California* to its parent.
The vote wasn't a surprise, but it's still disappointing. The budget vote, largely along the Conference Committee framework, but with a rainy day fund, lottery securitization, and other elements, was voted on Sunday night.
While getting more than a majority of vote a long partisan lines with Democrats voting in favor(45-30, those not voting including Parra, Torrico, Aghazarian, and the medically excused Runner and Soto), the budget failed to get the Republican votes needed to pass the 2/3 threshold for passage for a budget and taxes.
We appreciate the Assembly leadership’s attempt to raise the revenues needed to prevent the worst of the proposed cuts to health care and other vital services—cuts that not only will make a millions of Californians pay more and get less care, but also harm the health system we all rely on. The cuts would also hurt our economy--resulting in lost federal matching funds, wages, and jobs into the billions.
But let's be clear: the budget considered tonight already has tough cuts—including denying a quarter-million children health care—and yet it is being held up, by those who want more cuts now, and a deceptive, arbitrary ceiling that will force ongoing cuts into the future. That’s the wrong direction. But that's the direction it looks these negotiations are going.
Steve Lawrence at the Associated Press writes about the new, troubling unemployment numbers released yeaterday. There was an attempt to make a connection with the budget, but some legislators came to the wrong conclusion.
Republicans said the jobless figures provided more evidence that lawmakers shouldn't consider tax increases to help eliminate a $15.2 billion state budget deficit.
"Our unemployment rate will grow far worse and more Californians will lose their jobs if we pass a budget that increases taxes," said Assembly Minority Leader Mike Villines, R-Clovis.
But health care advocates said state budget cuts would also lead to more job losses, partly because the state would be unable to put up seed money needed to attract hundreds of millions of dollars in federal aid. "The worst thing you can do for the economy is make cuts, especially to health care," said Anthony Wright, executive director of the nonprofit advocacy group Health Access California. "I think it's very clear that health care cuts specifically would have three times as great an economic impact as an increase of taxes on the upper income."
The Bakersfield Californian also has a quote from a Republican Senator, one we wholeheartedly agree with.
“Reductions in Medi-Cal causes increases in costs in other places,” said Sen. Roy Ashburn, R-Bakersfield, who wants the 10 percent cuts restored in the budget. “The fact is that the state underfunds the program.”
By raising the revenues needed to prevent cuts to health care, legislators can BOTH restore crucial funding to our health care system, and help stimulate our economy.
NEW STUDIES: PROPOSED HEALTH CUTS WOULD SIGNIFICANTLY HARM CALIFORNIA'S ECONOMIC HEALTH
*Study Reveals Over $2 Billion in Lost Business Activity, Shows County Breakdown of Lost Federal Matching Funds, Lost Wages, and Lost Jobs As Result of Budget Cuts * As Legislators Weigh Budget Choices, Study Shows Health Cuts Would Have Three Times Economic Impact as Compared to Upper-Income Tax Increase
*Study Shows $290 Increase in Private Insurance Premiums Due to Health Cuts
Click for What's New on the Health Access WeBlog: More on Budget Negotiations; Spending Cap Proposals; Pending Health Legislation in Sacramento; The Health Reform Discussion
SACRAMENTO--On the day the California Employment Development Department released jobless statistics showing unemployment rates reaching 7.3%, with 15,000 Californians losing their jobs in July alone, two new Health Access reports exhaustively detail the significant economic impact of proposed health care cuts.
As California lawmakers debate budget cuts, taxes, and the economy, the two studies shows the proposed $850 million in health care cuts would lead to over $2 billion in lost business activity and 16,500 jobs lost as a result of budget cuts -- three times the economic impact of an equivalent increase in upper-income taxes -- and families facing a $290 increase in private insurance premiums to make up for the lost revenue in the health care system. The reports are available at: www.health-access.org.
One report utilizes standard economic tools to show the significant economic impacts of the proposed health services budget cuts, of jobs, lost wages, and lost business activity on a county-by-county basis. Another report includes new data by researcher Peter Harbage that shows that costs for insured families will rise due the need to make up for the lost revenue in the health care system as a whole.
The reports suggests that if policymakers are concerned about the economy, the worst choice would be to approve these health care cuts, which would force California to lose hundreds of millions of dollars in federal matching funds--which then has ripple effects throughout the economy, impacting jobs, wages, and even health insurance costs.
Key findings of the report include:
· More Than a $2.1 Billion Economic Loss Statewide in the First Year, including 16,500 Lost Jobs: By cutting nearly over $800 million billion in health care spending, California will lose its dollar-to dollar federal matching funds. The loss of these dollars in circulation had additional economic consequences of more than $2 billion, in lost commerce, lost wages and lost jobs.
· Severe Reverberations in Both Urban & Rural Counties: Fifteen counties in California are expected to see losses in economic activity in excess of $30 million. Areas severely impacted by the proposed cuts include the Central Valley, with Kern, Fresno, and San Joaquin counties losing an estimated total of $183 million in business activity and $64.8 million in wages.
· Increased Health insurance Premiums Rise by $290: The budget cuts propose to deny coverage to around one million more Californians, leading to a cost shift from medical providers will end up treating more patients who cannot pay for services.
This paper also shows how, due to federal tax deductions and matching Medicaid dollars, preserving California's health care budget would have three times the positive economic impact as preventing an equivalent amount of increased taxes for upper income Californians.
Additionally, the report "Significant Side Effects: The Economic Impacts of Health Care Cuts in California Communities," by Hanh Kim Quach and Anthony Wright, also describes other economic impacts from the cuts and from the additional uninsured, including lost productivity, lapses in school attendance and education funding, and increased instability of family finances.
The other report, "Adverse Reaction: Proposed Health Care Budget Cuts Would Lead to Increased Health Insurance Premiums," was written by Harbage Consulting. Both studies were commissioned by Health Access Foundation, the statewide health care consumer advocacy organization. Earlier this year, Health Access had released a report detailing the coverage impacts of the health care budget cuts, which would deny over one million Californians coverage when the cuts were fully implemented.
I was pleasantly surprised, this week, by my periodic email from HSA Weekly. Usually, the publishers of this news compendium of Health Savings Account news send out articles intended to promote Health Savings Accounts and their crummy high-deductible health plans.
But this week, I got an article about how HSAs aren't doing all that well because consumers have been rightly wary of them.
The article sums it up well, but essentially, health care is a very complex system to navigate. The idea that "consumer choice'' and "cost-conscious'' behavior is going to drive down costs is ludicrous when you consider that:
a) the most expensive care (ie. emergency care) is not voluntary, nor do you have time to make "cost conscious'' decisions about which hospital you should go to when you're having a heart attack. b) it's impossible to find price stickers on the care that we need c) consumers aren't medical experts and don't know what care is most effective and less effective d) "choice," as proponents of high-deductible plans like to promote, is not neccesarily a good thing. Think of how overwhelming it is to choose a flavor at Baskin Robbins.
A month or so ago, America's Health Insurance Plans, representing the insurance industry, launched a "listening tour," as part of their campaign to organize 100,000 people who are satisfied with their health coverage--and presumably to stop many of the health reforms that are being proposed. Many suspect that's the actual goal of their Campaign for an American Solution.
The insurers probably were spooked by the protest by Health Care for America Now and local health consumer and constituency organizations in Columbus, Ohio during their first "listening tour" stop. But if they are serious about listening, that means listening to their critics--and having . Otherwise, it's just PR.
With all the rumors swirling about, let's be clear: Spending cap? Unless the details can address several key issues, we're opposed. And a temporary tax increase is not an incentive to change that position.
Health Access California has been devoting significant effort to working to prevent devastating health care cuts. But it wouldn't make sense to prevent some of those cuts now, in return for a spending cap that would force those cuts, and more, in the future.
There may be reforms to the budget process that do make sense--I'll mention that we were a leading voice and organizer in the campaign for Proposition 56 which had several ideas in it--since some policymakers are in the mood of resurrecting the provisions past ballot measures.
But most spending cap proposals I've seen have been fundamentally destructive to the health care system we all rely on. All Californians who care about health care should be wary, if not outright opposed.
* A spending cap is unlikely to take into account medical inflation, so when health care costs rise as a faster clip, that would create even more pressure to make cuts.
* Other areas of the budget have voter-approved protections and dedicated revenue streams that health and human services largely do not, making these vital services at greater risk of cuts.
* Finally, and most importantly, a spending cap condemns us to the health care system we have. It may keep us at 49th in the nation in Medicaid per patient spending, and having one of the largest uninsured rates in the country. It may prohibit coverage expansions and health reform in general.
When these budget issues occur, there are choices to be made to make the budget balance: make cuts? raise taxes? both? But we shouldn't pre-suppose to make those choices now, and to top the scales to force cuts, now and into the future.
Consumer Reports Health’s Cover America Tour, a nationwide road trip chronicling the difficulties many American families face getting affordable, high quality health care, rolled into Sacramento Tuesday, with a message around state and federal reform.
Consumers Union staff, including former Health Access staffer Meg Bohne (pictured), had driven an RV over 12,000 miles before coming to Sacramento, talking with health care consumers and videotaping their stories with the health care system. Among their stops on the way back to the East Coast will be Denver and Minneapolis, as they make the case to elected leaders of all parties and political stripes of the need for health care reform next year.
But the RV stop in Sacramento also focused on what we in California can do--not just next year, but in the next few days and weeks.
Health care reform may have stalled earlier this year, but there are pending bills in the California legislature that can help our state move down the road to reform, that can help Californians have more confidence in the quality of their care and their coverage.
Those bills include:
* HOSPITAL INFECTIONS: SB 1058 (Alquist) and SB 158 (Florez), geared to reducing hospital acquired infections. SB 1058 would mandate public disclosure of hospital acquired infection rates, and require hospitals to screen high risk patients to identify those colonized with methicillin-resistant Staphylococcus aureus (MRSA) bacteria, and to take special precautions with those who test positive to prevent its spread to other patients. SB 158 gives the Department of Health Services additional authority to investigate infection outbreaks and complaints about lax infection control practices. The Department of Health Services estimates that as many as 9,600 Californians die from hospital infections annually, and it is esimated that hospital infections add a staggering $3 billion to California’s health care bill every year.
Speaking at the press conference was Cindy Gaston of Elverta (pictured speaking), who developed a serious MRSA infection following the C-section delivery of her child. She had to be rushed back to the hospital a few days after giving birth when her surgical incision burst open and it became clear that she was very sick. She required multiple surgeries to clean out the infection and ended up staying another ten days in the hospital while undergoing IV antibiotic treatments. Cindy was surprised by the sometimes poor infection control practices she observed at the hospital and how little information she was provided about how to prevent the spread of her infection to others. She has had three outbreaks of her antibiotic-resistant infection since she was discharged from the hospital and hopes that she won’t become sick again.
* TRANSPARENCY: AB 2967 (Lieber) would require public reporting of information about the cost and quality of care delivered by health care providers in the state. It would establish the Health Care Cost and Quality Transparency Committee to develop a plan for making cost and quality data available to the public. The goal is to provide the public and purchasers with data to seek more cost effective care that improves patient outcomes and to enable hospitals and other care providers to compare themselves with their peers and identify areas where improvement is needed.
* HEALTH INSURANCE STANDARDS: SB 1522 (Steinberg) would set standards to help consumers compare health insurance products and weed out “junk” insurance plans.
Under existing California law, health insurers can sell products characterized as health insurance that cover only hospitals or only physicians. Health insurers can sell products that have no maximum out of pocket cap, exposing consumers to hundreds of thousands of dollars in out of pocket costs in the case of catastrophic illness. Insurers can sell health insurance that covers only a small fraction of the actual cost of care.
SB 1522 would help eliminate “junk” insurance by requiring health insurance to cover doctors, hospitals, preventive care, and any existing statutory mandates, and to have a cap on out-of-pocket expenses. The bill also requires the Department of Insurance and the Department of Managed Care to create five coverage categories that would help organize the insurance market so that consumers can shop more knowledgably. Insurers would be required to offer benchmark plans to assist with apples to apples comparisons.
Senator Elaine Alquist (pictured above and left), who is on the Senate Health Committee, also spoke on her hospital infection bill, as well as the need for health care reform in general.
In an "MTV:Cribs" moment (see picture left), the Senator also toured the RV, as did Daniel Zingale and Richard Figueroa, who both work in the Governor's office and advice the him on health policy, and who came by to watch the press conference.
These bills are up for final floor votes in the California Legislature in the next week and a half. If they pass that final legislative hurdle, then their fate will be in Governor Schwarzenegger's hands, where he can sign the bills, help consumers and help lay a better foundation for health reform--or just leave us with the deteriorating status quo in California.
Lots of research and studying going on lately, and it seems the general consensus is that lots of people aren't getting sufficient health care, and many need it:
In the Central Valley, UCDavis is looking at farmworker health, finding that lots of farmworkers have chronic musculoskeletal pain, allergies and are overweight;
It's an interesting cluster of studies that shows the need to make health care more *accessible,* both culturally and financially, and that those elements need to be key parts of health reform discussions as we head into our next round....soon.
Congratulations to New Jersey Governor Jon Corzine, who just signed a law to prevent hospitals overcharging the uninsured. Previously in 2006, both California and New York passed comprehensive legislation to prohibit hospitals from overcharging those who don't have an insurer or government program to negotiate for them, and as a result, get charged more 3-4 times or more of what insurance companies or public program pay for the exact same service.
More information about the California law--AB774 (Chan)--is on the Health Access website. We continue to be active in making sure the law is enforced, that patients know about their rights, and to work in the policy arena against overcharging and medical debt. (Watch for more announcements this fall.) It's good to see New Jersey and other states looking at this issue, so that the consumer protections can be more widespread.
Insurance brokerage giant Aon Corporation released a study today showing that even though health care premiums next year will still outpace inflation by more than 3.6 times, at least it's slowing. In the next year, health premiums are expected to increase approximately 10.6 percent. It's been going down steadily since 2002, when increases hovered around 16 percent.
One of the reasons for the slowed increase, the study director says in the SF Chronicle, is that businesses are being much better about ensuring their workers stay well -- through disease management programs -- and attacking underlying reasons for increased costs rather than purely making workers pay more, but allowing them to live less healthy and medically expensive lives.
What I found interesting was the rate of increase for a managed-care plan and consumer-directed plan (many of which are low-premium, low-value, high-deductible and intended to save money by allowing consumers to take control) were approximately the same -- 10.5 and 10.5, respectively.
As the different accounts indicate, there was a successful push to include a greater emphasis to "guarantee accessible health care for all," from supporters of Senator Clinton, who urged an "individual mandate" approach in the primaries, and health care activist focused on a single-payer solution. Obama's plan is neither, but embodies similar principles and goals.
While the platform states that "there are different approaches within the Democratic Party about how best to achieve the commitment of universal coverage," there's a lot of similarity of these approaches: an emphasis on group coverage, rather than the individual market; the use of purchasing pools for bulk purchasing and other efficiencies; fair financing, where people pay based on what they can afford rather than how sick they are; the expansion of public insurance programs and coverage options; and a healthy distrust of the insurance industry, by increasing insurer oversight and offering alternatives to private coverage.
On Day 42 of the budget impasse, I guess I find it somewhat encouraging that Senate Republican Leader Dave Cogdill said over the weekend he didn't believe we could have a cuts only budget. Republicans, so far (and as in previous years), have rejected the Conference Committee proposal which balances cuts against taxes. The Legislature needs a two-thirds vote to pass a budget, which means getting Republican support for the budget.
Cogdill has instead said he'd rather borrow money and repay it with lottery proceeds. But after the borrowing this year, what happens next year?
Of course, Cogdill and his Republican colleagues in the past have derided bonds and borrowing as mortgaging our children's future. Really, though, will there be any future for some children if their schools aren't properly funded, they can't see a doctor and can't afford a public university education.
For us, the May Revise Budget means 1 million more uninsured over the next three years. It means seniors and disabled Californians who live on fewer than $1,000 a month will have to spend their meager allowances paying for -- or going without -- eyeglasses, dental exams even incontinence creams and washes. Is this the kind of state we are?
If anybody reading this is going to Denver (and there are some in Sacramento who don't know yet, because of the prolonged budget debate), there's going to be a forum at the Democratic Convention, entitled, "Winning Health Care Reform in 2009." The Wednesday, August 27th, forum is billed to include "congressional leaders, committee chairs, governors leading state health reform, and many others—in this historic effort to win health care reform."
The invite list includes key Californians, including House Speaker Nancy Pelosi and Representative George Miller, as well as Senator Edward Kennedy, Senator Hillary Clinton, Senate Majority Leader Harry Reid, Kansas Govenor Kathleen Sebelius, Senator Max Baucus, Senator Ken Salazar, Representative Charles Rangel, Massachusetts Governor Deval Patrick, Representative John Dingell, Ohio Governor Ted Strickland, Pennsylvania Governor Edward G. Rendell, Representative Artur Davis, Former Senator Tom Daschle and others. It's a good starting list of the players that will make health reform either happen or not next year.
The event will be held starting at 9:30am in the Seawall Ballroom, at the Denver Center for the Performing Arts, right next door to the Convention Center, with views of the Rockies. Might be a good place to recover from a late night.
Assembly Appropriations Committee, chaired by Assemblyman Mark Leno, is meeting as we speak. Here's some of the bill that are being passed, and are heading to their second floor vote:
* SB840(Kuehl), to establish a single-payer universal health care system, and set up a commission to work out the financing, was passed, with amendments to adjust timing issues.
Other bills passed include: * SB973(Simitian) to facilitate county-based public health insurers to work together; * SB981(Perata) to prevent balance billing; * SB1198(Kuehl) to require insurers to offer coverage of durable medical equipment; * SB1440(Kuehl) to require a minimum level of premium dollars to go to patient care; * SB1522(Steinberg) to provide standards for individual insurance products;
How do we reduce emergency room overcrowding and waiting times?
Certainly, people have pointed to reducing the ranks of the uninsured, who lack primary care and end with worst health conditions as a result; and to prevent budget cuts, that threaten some ERs directly, and the coverage and benefits and clnics that help people avoid the ER in the first place.
"...What's new is the rise ... in frequency in visits, and that's occurring in the insured," said Dr. Stephen Pitts, author of the report and a CDC fellow who teaches emergency medicine at Emory University's School of Medicine.
Pitts said the difficulty in getting primary care appointments could be contributing to the rise in emergency room use, particularly by those with insurance or on government programs such as Medicare or Medicaid.
"The likely cause is there are just fewer and fewer primary care physicians," he said. "If you were to get the flu and your doctor says, 'Sure, I'll see you in two weeks,' you may not be able to wait. It's hard for even insured people to get quick appointments and be seen quickly."
Under managed care plans, people agree to a limited network of providers with the assurance that that network has enough doctors, hospitals, and specialists to provide timely and appropriate care. The state Department of Managed Health Care (DMHC) is charged with ensuring that there is "network adequacy" and people are able to get "timely access" to care.
There is currently a stakeholderregulatory process at DMHC to implement standards for timely access, as required by AB2170(Cohn). Health Access California, the sponsor of that bill, along with Western Center on Law and Poverty, California Pan-Ethnic Health Network, and other organizations, are representing consumers against many, many provider groups.
We hope the resultion will not only ensure that people get timely access to care... and in turn, help with the ongoing issue of ER overcrowding.
Proponents of these deplorable Health Savings Accounts say they like them because consumers can take matters into their own hands in lots of ways: you can "shop around'' for care (although, I'm not sure how we do this when we don't have cost and quality transparency, yet) and you can save for health expenses in retirement.
A new EBRI study takes on the latter point head-on. Their research shows that consumers contributing the maximum to their HSAs (plus catch-up) will only have saved between 16 percent and 33 percent of what they will *actually* need in retirement to cover health expenses.
The study assumes that Medicare will cover half of what a person needs in retirement (about $376,000). With an HSA, an individual would accumlate $59,000 over 10 years (with the catch-up deposits).
A man with average health expenses and an average life span would need to have saved $132,000 to cover drugs, premiums and other out-of-pocket expenses in retirement. That's more than twice what could be saved under the HSA. And that's assuming he's average and dies on time. If he lives longer, he'd need $266,000 -- 4.5 times more than is in the HSA. In the most expensive scenario, he lives a long time with LOTS of health care needs -- he'd need $555,0000.
Women have it even worse since we live longer. A retiring woman would need $181,000 to cover drugs, premiums and other out-of-pocket expenses in retirement. A woman who lives beyond the average life span, and incurs higher than average health costs needs $654,000. Add to this the gender wage gap and......
It's unclear to me whether the savings projections EBRI takes into account the fact that consumes with HSAs will likely be using a chunk of the money they invest in the account because a prerequisite to having and HSA is being underinsured. Bush Administration rules require that consumers must be insured only by a high-deductible health plan (a deductible of *at least* $1,100) in order to open such an account. You also can't save more than the deductible, so......
Seems like a bad deal all around: * You can't shop around * You have a crummy health plan * You're *still* broke in retirement.
The WSJ Health Care Blog today reports that ER visits are at an all time high at a time when the number of emergency rooms is *shrinking.*
What's going on?
While conventional wisdom suggests that the uninsured are crowding the ER, the data suggest that’s not what’s going on. The uninsured (comprised in this survey of those who paid themselves, and those who didn’t pay) accounted for between 17% and 18% of ER traffic in both 1996 ( see this report) and 2006.
A recent study in the Annals of Emergency Medicine noted a similar trend, and found that the biggest rise came from well-off people who typically get their care at a doctor’s office. The real problem, the authors suggested, isn’t the lack of care for the uninsured, but the inability of the insured to get prompt care at the doctor’s office.
Flurry of activity in Appropriations and the rest of this week
Tuesday, August 05, 2008
From our inimitable lobbyist, Beth Capell:
On Monday, August 4, the Legislature reconvened for the last three or perhaps four weeks of action. The Senate Appropriations Committee convened at 10AM with a full agenda of over 200 bills and was still meeting 10 hours later when the last of the Health Access measures had been dispensed with.
On the long list of bills of interest to consumers:
AB1203 Salas: balance billing by doctors and hospitals for post-stabilization care, that is care received after an emergency patient is stable enough to be transferred to a contracting hospital or released. Health Access supports.
AB1945 DeLaTorre: rescission of individual coverage: creates an internal DMHC/DOI review and changes the standard in existing law so that coverage can only be rescinded if a consumer willfully misrepresents, a higher standard than existing law.
AB2146 Feuer: no pay for never events, like cutting off the wrong leg or surgery on the wrong patient.
AB2549 Hayashi: rescission of individual coverage limited to 18 months after coverage is issued.
AB2569 DeLeon: rescission of individual coverage: duty of brokers to be accurate and requirement that family members be covered rather than rescinded.
AB2741 Torrico: health impact analyses for all hospital transactions, not just those involving non-profit hospitals which are already overseen by the Attorney General
AB2910 Huffman: requiring public disclosure and oversight of waivers of the Knox-Keene act. Over the last 30 years, more than a dozen major waivers have been granted with no public input and no public oversight.
AB2942 Ma: standardizing and extending hospital community benefit report
AB2569 passed 8-3. All the rest of the bills went off to suspense. The suspense hearings in both the Assembly and Senate Appropriations Committee are set for Thursday, August 7. AB2967 (Lieber) on cost and quality data transparency will be heard the same day in Senate Appropriations.
Floor votes on measures that pass the Appropriations Committee will happen the weeks of August 11 and August 18.
Behind the scenes and sometimes in public view as during yesterday’s Appropriations hearing, frantic work continues on getting amendments done. The Legislature hopes to adjourn on August 22. That means the deadline for all amendments is functionally Thursday, August 14—and that means amendments must be drafted a few days before that. In a practical sense, all the deals must be cut, all the i’s dotted and t’s crossed this week. Or we can just wait until next year. It makes it a busy week for those who try to get legislation passed and signed.
It's a good thing that the Governor has put a tax on the table, which will raise crucial revenues needed to prevent ugly cuts. It shows progress from the Governor's "cuts only" approach in May.
Some issues that need to continue to be discussed: * The sales tax proposed is not enough--it would only raise $4-5 billion. The Legislative Conference Committee's budget raises $9 billion--through the upper-tax bracket and other means--and still makes severe cuts--so severe that around a quarter of a million children would still lose health coverage. The additional $4 billion more in cuts would be truly devastating. * The Governor's proposal is temporary, and the tax increase would go away after a couple of years--or even become a tax cut, further staving key public services... As if the health and education needs of Californian will somehow decrease in three or four years. * The Governor is also seeking "budget reform," which has included spending caps and proposals to give himself unilateral power to make cuts. It's a short-term gain for a long-term limitation of health, education and other vital services that are important to California's future.
There's clearly more discussion needed. But one hopes that this development signals that there is some movement away from a "cuts only" approach. There's just a lot more movement that is needed, and not much time.
The Senate Appropriations Committee had a looooooong hearing today, and look to do it again later this week. We'll have reports through the week as the legislature gets back into the groove.
It may be August and summer siestas for the rest of the state, but in Sacramento, they are cranking up the Legislature--their hope is to finish all legislative business by August 22nd, so the politicos can attend their respective conventions. Hopefully that includes a budget as well.
It is a good, comprehensive report about several consumer protections moving through the Legislature and to the Governor's desk, which would in particular help those who don't have group coveragae through an employer or public program, and have to buy coverage as an individual. The Governor is currently negotiating with the legislators about the final contents--from SB1522(Steinberg), our bill to better standardize the insurance market, to SB1440(Kuehl), which would ensure a percentage of premiums go to patient care.
It's critical to future efforts around health reform: if people don't have confidence in the value of coverage, then they are less enthused about expanding that coverage.
With a budget still not in place, and devastating health care cuts hanging in the balance, a coalition of health care stakeholders are extending a run of TV ads in the Central Valley, Central Coast, Inland Empire, and Palm Springs areas--all to highlight the issues that are at stake.
Regions that will be hit particularly hard by proposed state health care cuts--Bakersfield, Fresno, Modesto, Riverside/San Bernardino, San Luis Obispo and the Coachella/Imperial Valleys--will continue to see the ads as part of an evolving campaign (of which Health Access California is involved).
Here's the script:
“In Sacramento, cutting funding for doctors and hospitals is just a number on a spreadsheet. But around here, you’re going to see fewer nurses, and fewer hospital services for patients. Cutting back on ambulances will mean slower response times. More time in the waiting room and higher costs we can’t afford. But if the legislators we send to Sacramento do their job, we can keep doing ours. Stop the health care cuts, or we’ll all pay the price.”
Well, it's not a balanced budget deal, but there's some progress on balance billing.
Yesterday, the Department of Managed Health Care (DMHC) issued regulations to the Office of Administrative Law on the contentious issue of "balance billing." The new regulations would restrict the practice of emergency health providers sending the bill to *insured* patients if they are having a dispute with their insurer. The OAL will provide a legal review of the regulations before putting them in full effect.
The patient--and their credit rating and financial future--should not be used as a pawn in these reimbursment disputes between insurers and providers. The regulations restrict this "balance billing" by making it an unfair billing practice, thus allowing DMHC enforcement actions against those providers who engage in activities that unfairly burden consumers.
It's a good step. There is also pending legislation, by Sen. Pres. Perata, Assemblywoman Salas, and others, that would go broader, and look to help resolve these disputes between providers and insurers in the first place. But the first principle is to do no harm--to the patient, or their pocketbook.
with a background as a consumer advocate and community organizer on many issues, including health issues for the last ten years in California and New Jersey.
