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Good golly, Miss Molly...

Wednesday, January 31, 2007
Humorist Molly Ivins passed away today, after battling breast cancer. May she rest in peace.

Here's a 2002 column of hers on the need for health reform. And here's a 2000 column that mentions her battle with cancer, as part of a witty but accurate review of what works in health reform, and what doesn't. It also happens to critique President Bush's health care plan, which doesn't seem to have changed in seven years--in fact, it seems to have gotten worse...

Just don't get sick
by Molly Ivins
September 14, 2000

AUSTIN, Texas -- When I was in my 20s, the subject of insurance was so vastly boring that it was a way to describe a bad date: "like talking to an insurance salesman." It's still sort of like your teeth -- something you'd rather not think about but have to take care of -- so let's plunge in.

As Jonathan Cohn pointed out in the May 1 New Republic, the object of health insurance is to get as many people as possible into one big pool, mixing the sick with the healthy. This way, the healthy pay a little more than they otherwise would, but those who get sick pay a lot less.
Since everyone gets sick eventually, if only from old age, it works out fairly. Your chances of never being sick a day in your life and then dropping dead of an undiagnosed heart condition at an early age are less-than-lottery-slim.
In most advanced countries, this led logically to national health insurance -- everybody in the same pool, only one administrative agency instead of hundreds...

As a cancer survivor, I am now part of a network regularly called upon to help raise $300,000 to $400,000 for some individual whose insurance company has found a way to drop her. Always a life at stake. The hundreds of thousands of you who have had your HMOs fold under you know how chancy the present system is.

George W. Bush's solution is to promote medical savings accounts -- MSAs. Individuals buy a cheap insurance plan covering only catastrophic illness and then put money aside, tax-free, to cover their medical bills. If there's any left over at the end of the year, they get to keep it. The theory is that this will discourage people from spending frivolously on health care.

"In reality, MSAs simply allow people who expect to be healthy to opt out of larger insurance pools," said Cohn. "Small businesses like the accounts because they transfer the onus for medical coverage more squarely onto individuals. But most experts who have looked at MSAs have concluded that, by further segregating healthy and sick in the health-care market, they make it tougher for people likely to incur high health-care bills to get insurance."

The other piece of the Bush plan is to set up association health plans allowing small businesses to clump together to buy health insurance as cheaply as the big corporations do.

The Catch-22 is that most states already have small businesses clumped together in an insurance pool. The only difference the Bush plan would make would be to exempt those plans from state regulation -- i.e., requirements for minimum benefits like mental-health coverage.
The result would be further segregation of health coverage -- employees healthy, rates go down; a couple of employees get very sick, rates go up; company can no longer afford coverage, drops policy; end result, more uninsured.

Neither move is going to help the 44 million uninsured in this country, and both are likely to increase their number. This is not a solution. For the uninsured, Bush proposes a $2,000 tax credit per family to allow them to buy their own health insurance -- but $2,000 doesn't nearly cover the cost, and nothing is more expensive than buying health insurance as an individual....

For those whose faith in the free market is religious, this is not something to debate. But even Adam Smith admitted that the free market can't take care of everything. And one of the things that no country has yet found a way to make it do is health care. The upside to having government as the only insurer is that it's cheaper because profits don't enter into it.

Worth considering, even if boring.


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posted by Anthony Wright | Permalink | 5:47 PM


The Senate Republicans take a seat at the table...

Tuesday, January 30, 2007
It's good that the Senate Republicans have put something on the table. (The Assembly Democrats were quick with a statement noting the lack of a plan by the their Republican counterparts.)

The initial take is that it would take us in the wrong direction.

Rather than bringing new resources to improve our health care, the plan proposes to rob Peter to pay Paul: increasing access to some by undermining access to care and coverage for many. For example, it would take money from safety-net hospitals on which we all rely. It would fund children's coverage by taking from other children's programs.

For both public and private coverage, it seeks to increase underinsurance, encouraging high deductibles and scaled-back benefits. And in addition to the problems of what's there, there's also the problem of what's missing: standards for employer-based coverage; better outreach and real streamlining of public programs; more, rather than less, oversight over insurers.

Don't get me wrong: with more legislators at the table, we are still optimistic about the debate and the outcome. The focus on both access and coverage is important, and we support the push for more community clinics...we don't think that should come at the expense of other parts of the health system. And with the other proposals on the table, from the Governor's to Senator Kuehl's, the time is ripe for action.

posted by Anthony Wright | Permalink | 1:46 PM


It's really not a choice...

Senate Republicans released their health proposal today with no new surprises. They want high deductible plans, they want Health Savings Accounts. Things we oppose.

But what I found most irksome were the statements about 1 million people who are eligible but not enrolled in Medi-Cal or Healthy Families.

"Many just don't sign up,'' said an incredulous Sen. George Runner, of Palmdale-Lancaster, in spite of the money spent on outreach and education about these programs.

Runner shouldn't be surprised. Each public program has a different "entry point'' making applying to all of them confusing and cumbersome. According to Kaiser Family Foundation, 67% of children who were eligible, but not enrolled had been denied for technical reasons.

Office hours are limited making it difficult for working adults to take the time off. It takes months to be approved. People are randomly dropped off public program rolls.

These should all be familiar issues for Senate Republicans, who would have heard all this in past years when efforts to streamline enrollment wended through the Legislature.

In spite of this not a single Senate Republican voted for last year's SB437 (Escutia) -- which the governor endorsed and encourage -- which makes it easier to enroll (and keep children enrolled) in Medi-Cal and Healthy Families.

Republicans like to complain about all the processes businesses have to go through to keep track of government regulations and rules. I wish they had the same level of empathy for mere mortals.

To see the Republican plan, visit: http://republican.sen.ca.gov/calcare

Health Access will have a more thorough analysis of the Senate Republican plan later today

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posted by Hanh Kim Quach | Permalink | 1:04 PM


The health of Obama-hype...

Monday, January 29, 2007

So while in DC last week, I saw the speech in person, a leader providing a national voice on health care issues.

No, not by the current President. But potentially the next one.

Senator Barack Obama spoke at the Families USA conference I was at, and even made a little news, stating, "I am absolutely determined that by the end of the first term of the next president, we should have universal health care in this country." A clear goal which sets the bar appropriately high.

While Health Access California is nonpartisan and doesn't make endorsements for elected officials, I was personally intrigued by Obama. (Indeed, some of my California colleagues were ready to swoon.) I identified with him as a fellow mixed-race post-baby boomer who got their start in community organizing. (In fact, some of his organizing mentors were also mine.)

For those of us from the West Coast, it was noteworthy that he started off referencing the health care crisis, and how states "from Maine to California" are pursuing reform. That was a constant theme of the convention for me and other Californians, that the weight of the national movement for health care for all is now on our shoulders.

The speech had great turns of phrases, such as warning that health plans should not "collapse under the weight of Washington politics," or that "tinkering and half steps belong to yesterday." There has been an active blog debate from Tapped to Atrios over whether the speech said enough or not enough. The wonkish crowd at the conference gave him standing ovations, but didn't seem totally won over. After all he only detailed the problem, rather than provide policy specifics or even a general direction. Sen. Obama, who was trailed by countless media, said that his team was working on a health plan later, which he would unveil at a later date. Fair enough.

My biggest content complaint: he called the Bush plan "tinkering." I actually do think there's a big difference between something that is ineffective, and something that actively takes us in the wrong direction. The Bush proposal is the latter.

But again, the key is that we are talking about major health reform, in the states in 2007 and 2008, and at the national level, with a new President, in 2009.

posted by Anthony Wright | Permalink | 11:31 PM


Spinning the YOYO

Just back from Washington, DC, and saw the discussion on ABC's This Week on the President's health plan.

Apparently, it's in the conservative talking points that George Will was using to simply deny the problem exists, as he and his colleagues also do with global warming. He sought to downgrade the issue of the uninsured, to suggest that since some of the uninsured are only "temporarily" uninsured, it's not much of a problem. I hope he tells that to the folks who have the emergency, the accident, or the ailment while "temporarily" uninsured, and face the hospital bill as a result--perhaps the largest bill that anybody sees in their lifetime.

But even President Bush doesn't deny the problem anymore. Yet his solutions take us in the wrong direction. He adds no new money to deal with these problems, and even when reshuffling the deck of existing funds, he seeks to do so in an inefficient, regressive, and unwise ways.

The Economic Policy Institute appropriately lays out the impacts of the tax change, which is to discourage group coverage (through employers) and shift more people to buy coverage alone as individuals. This not only goes against the notion of insurance as the enterprise of sharing risk, it's also more costly! Rather than expanding public programs (which are far cheaper per person than private coverage) or expanding group health coverage (which enjoy a group discount), he is encouraging people to get coverage in the most expensive way possible.

Most of the articles have been about who is impacted, that those with good health care would be negatively impacted; those who buy health coverage on the individual market would get a decent tax deduction. But the nature of the deduction (rather than a credit, for example) would be regressive, since lower-income folks are in lower tax brackets. The vast majority of Americans who are now uninsured (many low- and moderate-incomes) would not find this helpful, and would not take it up: it would be the equivalent of a three-foot rope to get out of a ten-foot hole.

Kevin Drum at the Washington Monthly and Max Sawicky also make clear this is about the abandonment of group health care. And Ezra Klein and Brad Delong make the excellent point that as health costs rise, the folks who are disadvantaged increase, and the ones who are helped decrease.

Message: You're On Your Own. President Bush would take away the ongoing and open-ended assistance by the federal government for group coverage, and replace it with a fixed assistance to get more expensive private insurance, leaving the individual consumer to face the increating cost of health care all alone.


posted by Anthony Wright | Permalink | 1:11 AM


"Gold-plated'' vs. tin foil....

Friday, January 26, 2007
I know President Bush's health care proposal is pretty much dead, but I wanted to address his reference to "gold-plated" health plans.

He is actually referring to comprehensive health coverage that could actually provide patients protection from crushing medical bills should they ever get sick, and I suspect we'll hear others begin to characterize health insurance (insurance that actually works, that is) this way too.

"The more expensive the health insurance plan you receive through your employer, the more tax relief you get." (Fact sheet on Bush's 2007 Health Care proposal).
Bush needs a reality check. How many people, when choosing their health plans, look at the list of offerings and say "Which one will give me more tax relief?'' The more relevant questions people ask are: What will my monthly premium payment be? How much will my co-pays/co-insurance be? Is my doctor covered? How much is my deductible?

The truth is, if you can afford it, you choose a plan that you think is going to be a good shield, protecting you against the misfortune of getting sick, getting cancer, having asthma and having flat feet. It also protects you against having to foot the entire bill for having this misfortune.

The kind of coverage President Bush is actually suggesting we get, something that's more "affordable,'' is more like tin foil -- a thin layer of protection that tears easily and exposes us to the elements.


posted by Hanh Kim Quach | Permalink | 6:00 AM


Walking the halls of Congress...

Thursday, January 25, 2007
Just got back from DC. On the first day, I visited a number of California Congressional offices, along with representatives of the California Pan-Ethnic Health Network and Latino Issues Forum, on the issue of coverage for children.

We got a relatively warm reception at many of the offices, including Democrats and Republicans. But it's going to be a big battle. The State Child Health Insurance Program (SCHIP)--the Healthy Families in California that covers around 800,000 children--is up for reauthorization. The real issue is what level they will fund the renewal at, beyond current levels: enough to keep these children covered? enough to continue enrolling new children? enough to cover all the children in the state? enough to cover their parents as well?

All the health care reform proposals by the Governor and legislative leaders rely on the expansion of Healthy Families to cover all children, but also rely on SCHIP providing a 2-to-1 match. This federal fight is crucial not just in the effort to cover all children, but for health reform in general. We made this point, and many others, to a receptive audience on Capitol Hill.

It was interesting that President Bush's speech, which made a focus on health care, didn't even mention this. Children's coverage will be the focus around health care in Congress, rather than his misguided proposals.

SIDE NOTE: MAYORS! At one of our visits, we walked passed Sacramento Mayor Heather Fargo, doing her own lobbying. Back at the Mayflower Hotel, Oakland Mayor Ron Dellums held court in the lobby area, with his crown of white hair providing him a regal aura. If there were others in town for the Conference of Mayors, I don't think I ran into them.

posted by Anthony Wright | Permalink | 3:56 PM


Delayed care often means denied care...

Wednesday, January 24, 2007
With all the talk about reducing the crowding of California's emergency rooms, the conversation often goes toward placing financial and other barriers on patients, to make us "self-triage" our health conditions. The philosophy seems to be: blame the victim, burden the patient.

But there are far better remedies.

Our Governor and legislative leaders are right to suggest this is one of the many reasons why we all have an interest in covering the uninsured. While the uninsured are *less* likely to go to the emergency room (they are uninsured, and thus get billed full price), when they go they are *more* likely to be in worse condition, and a situation that could possibly have been prevented has now become more expensive.

But the bulk of ER visits are from the *insured*. And there's a portion of ER visits by the insured that happen because the patient simply can't get into see a doctor in a timely manner, and simply can't wait for an appointment. So they end up going to sit out the wait in the emergency room, even though a doctor's office would be a better (and cheaper) place to get care.

Even if you have insurance, have you had the experience that you can't get your doctor's office on the phone? Can't get an urgent care appointment within a few hours or days? Can't get a specialist for a couple of months? These are all reasons why people end up going to the emergency room when they should be seen far less expensively in a doctor's office.

And no consumer should be expected to self-triage. Consumers are not health professionals: they do not have the training of a doctor or a nurse. Is a kid with 101 temperature an emergency or the kid that just threw up for 30 minutes? If stomach pain wakes you up in the middle of the night, should you be seen that day or can it wait? The reason people have health insurance is so that they can trust that a doctor or a nurse will answer these questions, not a new parent, a worried spouse, or worse yet, you by yourself when you are sick.

New regulations can help fix this, both so that those with coverage get the care they need *when* they need it, but also to help relieve problems throughout the system, like ER overcrowding.

At the newly redesigned website of the Department of Managed Health Care(DMHC), there's a notice on new hearings and draft regulations to implement AB2179(Cohn) c.797 of 2002, a bill sponsored by Health Access California to ensure patients have *timely* access to care. The hearing notice is here: http://www.dmhc.ca.gov/library/reports/news/aron.pdf

Health Access has waited five long years for these regulations-but patients wait for care every day when they should not. It's time to get these regulations done and time to redeem the promise that was made in 1975 when HMOs were licensed in California: the promise that networks of care would mean that people get health care when they need it, instead of being forced into emergency rooms for care that can better be provided in a doctor's office.

We'll be watching this one closely-and continuing to advocate for consumers.

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posted by Anthony Wright | Permalink | 3:06 PM


President Bush has a Health Plan of his own

January 24, 2007

  • Would tax employer-sponsored health benefits for the first time in history
  • Would eliminate state consumer protections against insurance companies; would take money from public hospitals
  • Ranking members of House Ways and Means committee say proposal is “dead on arrival.”

Now, even President George Bush wants to join the “health reform’’ bandwagon. But rather than seek out more moderate middle ground as he navigates the new Democratic Congress, Bush swings his proposal far to the right.

In his State of the Union address Tuesday evening, Bush unveiled his health care plan, which relies on tax dedcutions to encourage the poor to buy coverage, loosening – or abandoning – consumer protections, and pilfering funds from public hospitals.

House Ways and Means Chairman Charles Rangel (D, New York) and health subcommittee Chairman Pete Stark (D, Fremont, Calif.) have already declared the measure a non-starter.

“President Bush's proposal will make a bad problem worse. I do not intend to consider this particular health care proposal in the Ways and Means Health Subcommittee, but would be happy to meet with the President to consider alternative ideas, starting with the expansion of Medicare,’’ said Stark, a proponent of Medicare for everyone.


The cornerstone of Bush’s proposal relies on changing how health coverage is taxed. It would impose a new tax on 60% of working families who now receive their benefits through work, thus discouraging the purchase of insurance in a pool where risk is spread across the larger employer group.

Bush’s plan, in turn, would give a $15,000 deduction ($7,500 for an individual) for those who buy their coverage on the more expensive and fickle individual market, where they would bear all the risk.

“Changing the tax code is a vital and necessary step to making health care affordable for more Americans,” Bush said.

Tax deductions, by design, however, favor the wealthy. U.S. Rep. Pete Stark, explains why the plan won’t work.

"The President's so-called health care proposal won't help the uninsured, most of whom have limited incomes and are already in low tax brackets," said Stark. “But it will hurt middle-income Americans, whose employers will shift even more cost and risk to their employees.”

In Bush’s policy papers, the administration claims that his idea would lower health costs because most people are choosing “expensive’’ plans through employers. The President, in turn, attempts to encourage more high-deductible plans, with Health Savings Accounts. Of course, the effect of such a proposal would be to make Americans sicker, as high-deductible plans – forcing patients to delay care rather than shell out thousands in out-of-pocket costs.


The president also resurrects a plan that failed last year. The proposal, by Sen. Mike Enzi (R, Wyoming), would have allowed businesses to band together across state lines to purchase insurance.

In order to do this, it would lower all insurance regulations to the lowest common denominator, casting away important consumer protections contained in California’s HMO Patient Bill of Rights, such as cancer screening, disease management and the right to a second opinion.

Another feature of the president’s plan would also shift money away from public hospitals – to the tune of $700 million, according to today’s Sacramento Bee.

To see an outline of the president's proposal, click here.

The San Francisco Chronicle, today, also has an analysis of Bush's proposals.

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posted by Hanh Kim Quach | Permalink | 10:52 AM



Tuesday, January 23, 2007
Thank God for bi-partisanship, post-partisanship, three branches, checks and balances -- whatever.

Our friend, U.S. Rep Pete Stark (D, Fremont), who believes in Medicare for all, and is the chair of the relevant and powerful House Ways and Means Committee, has proclaimed that the president's health care proposal is dead on arrival.

posted by Hanh Kim Quach | Permalink | 4:51 PM


Now that he's eviscerated Iraq....

What voices were whispering in George Bush's head when he drafted the "health proposal'' to be unveiled tonight.

His plan would give families $15,000 tax deduction for having health insurance ($7,500 for a single person) - BUT health insurance through your employer would be considered "taxable income.''

This design would essentially encourage people to pull apart from a buying pool, and take on the risk all by themselves by buying insurance on their own (to take advantage of the tax credit, rather than being taxes. This is exactly the wrong direction we should be going if we really want to hold down costs. We can save money by pooling together, not pulling apart.

And does he really think a family of three making $42,000 a year (in among the lowest tax brackets) needs a tax break for health insurance as they still struggle to pay for basic necessities.

posted by Hanh Kim Quach | Permalink | 1:04 PM


Making sure a victory takes hold...

It is true that we all pay a cost for the broken health care system, of having so many uninsured patients. It's one of the reasons why everybody has an interest in covering the uninsured. However, let's not leave the impression that the uninsured get off with free care now.

Far from it. The uninsured often are asked to pay *more* than anybody else in the system, whether for prescription drugs, or for hospital care. The financial repercussions for being uninsured include severe medical debt and personal bankruptcy.

This article in the Sacramento Bee over the holidays shows a case in point. Megan was working but in the waiting period of her job before getting coverage (in her case, a few months, but many employers now make workers or their families wait a year or three being being eligible for coverage). She was riding her bicycle and broke her arm. Like many uninsured patients, she knew the financial hit she was about to take, and took steps--sometimes dangerous to her own health--to avoid expenses. In her case, she explicitly did not call an ambulance, and relied on other ways to get to a hospital. Still, her bill for the hospital visit to get a splint was over $6,000. She incurred other bills from the actual doctors at the hospital, and in follow-up visits, in her path to recovery.

Let's focus on the biggest bill from the hospital. That bill was three or four times larger than insurers get charged for the same service. Insurers have the ability to negotiate down from the "sticker price." Individual consumers, lacking market power, get the main bill.

But that's hopefully going to change. Because of pressure from consumer groups, investigations from Congress, pending legislation in California, and class-action lawsuits, hospitals have begun to change their billing practices, to allow uninsured patients to get a fair price for services.

At the end, Megan was able to pay a rate similar to what Medicare pays for such a service. It's still a lot of money--over $1,500. But for many people, the $5,000 difference is the difference between debt and bankruptcy.

A new law passed this year in California, AB774(Chan), sponsored by Health Access California, to ensure that many uninsured and underinsured patients are not overcharged at hospitals. But as in the case of Megan, it's critical that patients know about their rights and options in the first place. Megan would not have known about the policy at the hospital if she wasn't a friend of mine.

The Office of Statewide Health, Research and Development has a new website about the bill, at:

I'm presenting on this landmark bill as part of a panel on medical debt at the Families USA conference in Washington, DC on Thursday. I wouldn't be surprised if you have many states pursuing this type of common-sense remedy.

posted by Anthony Wright | Permalink | 9:27 AM


Nunez's take & our goals for 2007

Saturday, January 20, 2007
It's hard to follow any good speaker. It's even harder to follow a person known as "The Speaker." But that was my challenge this week when I presented at the Working Families Summit on Thursday, to describe the Health Access California agenda for 2007.

Speaker Nunez talked at some length about his health reform proposal, which included his commitment to cover *all* children, and to require "fair share" participation from employers as well as employees. At the same time, he expressed his appropriate concern with an "individual mandate" approach, but was interested in Governor Schwarzenegger's proposals to place better rules and oversight over insurers. He ended with his optimism about passing major health reform this year, and asked the audience to keep him and other elected leaders accountable for this goal. We intend to.

The last time I presented at the Summit two years ago, I offered three goals: 1) to protect public health programs from severe budget cuts (Check!), 2) to pass major consumer protections, including to prevent the uninsured from being overcharged, for hospital care or prescription drugs (Check!), or 3) to pass major health reform and expand coverage. (Well, we certainly tried on many fronts, but we had to leave something for this year!)

My presentation complemented the Speaker's comments. A concise paper that describes our recommendations and philsophy for health reform and coverage expansion is now posted on our website, at:

posted by Anthony Wright | Permalink | 2:00 AM


Unholy Alliance

Friday, January 19, 2007
The big news yesterday was the announcement of a diverse coalition -- which includes Families USA (the national health advocacy organization), U.S. Chamber of Commerce, Kaiser, Blue Cross/Blue Shield, American Medical Association, AARP and others -- that has joined together to unveil an "historic agreement'' to expand healthcare coverage.

I eagerly clicked on the document to see what this unlikely group could have proposed. (link above)

I was disappointed. Don't get me wrong. I really believe that all children should be covered, and the proposal suggests expansion and streamlining of SCHIP and Medicaid (Healthy Families and Medi-Cal, respectively, here in CA), which is a great step towards that goal.

I also like that they it expands Medicaid to really really poor adults (singles making less than $10,000 a year).

But the proposal is a little heavy on tax credits (some advanceable) to help purchase health coverage.

Sure, everyone likes a tax credit. But for the population they're talking about, (300% FPL and below, which is $60,000 for a family of four), what kind of tax credit is going to really help buy good, meaningful coverage that averages about $11,000 a year?

And how many of those that are hovering on the lower end of the income scale are paying high enough levels of taxes to even really feel the impact of a tax credit?

It seems like it'll just cost a lot to give tax credits, but not really spending enough to create anything valueable.

To, look at the coalition's website, visit: www.coalitionfortheuninsured.org

posted by Hanh Kim Quach | Permalink | 10:07 AM


Next week: Reports from DC...

Thursday, January 18, 2007
Next week, I go to Washington, DC, to find out what's going on in the other 49 states.

We'll be blogging from the Families USA Health Action conference, which is always informative. We sometimes have policy differences with our colleagues (see yesterday's post), but they are good and friendly folks who have been doing really important work in the last several years, especially defending health care from lots of bad stuff. (Full disclosure: They also presented their Consumer Advocate of the Year award to Health Access California last year, the only organization that has received the award twice.) For the over 60 Californians who will be in attendance, it'll be interesting to see how the conversations go in the new political environment.

Our posts will try to provide some flavor about the DC health reform conversation... We'll probably get a lot of questions about Governor Schwarzenegger and his plan. Lots of DC stars are scheduled to speak, including Senators Kennedy, Brown, Smith, and yes, the star of the moment, Obama. We'll give you the update here...

posted by Anthony Wright | Permalink | 11:39 PM


Tigger's response...

Dan Walters at the Sacramento Bee seems to channel Eeyore about the prospect of major health reform, saying that passage of any law would be "a political miracle."
Eeyore, as depicted by Disney
I am a lot more optimistic about getting something done this year. We've had a Legislature for the past four years that has passed fairly significant health legislation and coverage expansions: SB2 (Burton) to cover workers of large employers in 2003; AB772 (Chan) to cover all children in 2005; SB840 (Kuehl) for a universal single-payer health system in 2006. There were major opponents and many of the same issues that Walters raised in these debates as well, yet the political will in the Legislature remained. The major obstacle was the Governor, who has now proposed his own plan, that has significant common ground with these past proposals, but as part of a broader reform package.

So let's look at the landscape: A Legislature that has shown political will to pass major health reform, and has yet to see a legislator lose a race over these votes. A popular Governor with four more years who has laid out a serious proposal and wants a legacy on this issue. Major areas of agreement. A public that wants reform.

The story isn't that health reform might not happen--that's not news--but that there's a once-in-a-generation opportunity for something major to happen here, for California to take control of our health care future, rather than to let our current system erode and ultimately fail for consumers, businesses, and providers alike.

It's not going to be easy, and there's lots of possibilities of this falling apart. At the end of the day, whatever gets passed is going to be different from anything on the table now. So while we have issues with the Governor's proposal, we are optimistic about the process...

posted by Anthony Wright | Permalink | 12:44 AM


MD law may need an MD, but CA could have an Rx

Wednesday, January 17, 2007
A federal appeals court Wednesday upheld a lower court's decision that struck down Maryland's so-called Wal-Mart Act.

In 2005, Maryland passed legislation requiring businesses with more than 10,000 employees to spend at least 8 percent of their payroll on health coverage. Only four businesses met the law's description, Johns Hopkins University (which was exempt because it is a non-profit), Giant Food (a union grocery chain which spends more than 8 percent), Northrop Grumman, a defense contracter (which also spends more than the law required because of its high-salaried workers), and Wal-Mart -- ultimately the only target.

After the law passed, retailers sued, claiming -- among other things -- that Maryland could not legally force businesses to spend a certain amount on its "health insurance costs'' because it violated the 1974 federal law that says states can't interfere with businesses' benefit plans. The courts so far have agreed with Wal-Mart.

What implications does this ruling have for an employer requirement in California, in the different variations proposed by Governor Schwarzenegger, Speaker Nunez, or Senate President Perata? Not much.

The courts -- and ERISA -- do not say that state and local governments can't dictate spending on "health care services'' -- just benefits. So -- there is a way for states to make policy in this area without running into the constraints of the federal law.

San Francisco's Health Access Program (no relation), which has created an employer mandate, is believed to have a much stronger legal case to actually get around the federal restrictions.

San Francisco's Health Access Plan requires employers to spend a minimum amount on 'health care services.' Businesses could satisfy this requirement several ways--by providing insurance, contributing to a city pot to cover the uninsured, or reimbursing employees for medical expenses, among other things. The latter two examples would not violate federal law because it has nothing to do with a specific benefit plan.

A second point -- which is mainly just a beef but I'll make it anyway -- is that Maryland's 8 percent threshold would have hardly caused Wal-Mart to make any changes to its workers' health benefits. Wal-Mart testified in court that its coverage spending was between 7-8 percent, already (7.7 percent if their website is to be believed).

For Wal-Mart, that means having to increase its spending on 16,000 Maryland employees, who make an average of $14,400 a year. That means -- at most -- another $2.3 million a year. That doesn't even amount to one-one thousandths of Wal-Marts net profits in 2006.

The passage of the Maryland law was a important signal, after SB2/Prop 72 in California, that other states were looking at the issue of employers scaling back or dropping coverage, and the impacts not just on the uninsured, but on the public programs and thus taxpayers as well.

The concept that everybody--including employers--should pay their "fair share" is an important one. But given how different Maryland's law is from similarly-themed approaches, including those in New York City, Massachusetts, San Francisco, etc, the court ruling will have little actual impact on what has passed in other places, or what is being proposed.

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posted by Hanh Kim Quach | Permalink | 10:12 PM


Senate Committees Named...

Marty Omoto at the California Disability Community Action Network has posted a list of the new assignments for Senate committees. Of those relevants for health activists:

Democratic Members (7) : Mike Machado (Chair), Lou Correa, Dean Florez, Alan Lowenthal, Gloria Romero, Jack Scott and Patricia Wiggins.
Republican Members (4): George Runner (Vice Chair), Dave Cox, Dennis Hollingsworth and Bob Margett

Democratic Members (9): Denise Ducheny (Chair), Elaine Alquist, Christine Kehoe, Alan Lowenthal, Mike Machado, Alex Padilla, Jack Scott, Joe Simitian, and Darrell Steinberg
Republican Members (5): Dennis Hollingsworth (Vice Chair), Dave Cogdill, Bob Dutton, Bob Margett, Mark Wyland

Senate Budget Subcommittee #3 on Health, Human Services & Veterans Affairs
Democratic Members (2) : Elaine Alquist (Chair) and Alex Padilla
Republican Member (1): Dave Cogdill

Democratic Members (6): Sheila Kuehl (Chair), Elaine Alquist, Gil Cedillo, Gloria Negrete-McLeod, Mark Ridley-Thomas, and Leland Yee
Republican Members (4): Sam Aanestad (Vice Chair), Dave Cox, Abel Maldonado, and Mark Wyland


posted by Anthony Wright | Permalink | 8:22 PM


"Plastic Safety Net''

Massachusetts-based Access Project has a new report called "Borrowing to Stay Healthy,'' which shows about families who use their credit card to pay health expenses.

In the study, nearly one-third of those with credit card debt said medical expenses contributed to that debt.

Among key finding: those who have medical debt have higher credit card debt ($11,623) related to their medical debt than those without medically-related credit card debt ($7,964).

This problem, of course, will be exacerbated if more low- to middle-income people are foisted into high deductible plans, as Rick Brown from UCLA Center for Health Policy Studies writes in the LA Times today.

posted by Hanh Kim Quach | Permalink | 10:39 AM


D for Democrats, D for Part D

Tuesday, January 16, 2007
While we were lost in California-centric discussions about universal coverage, the House on Friday passed a measure to allow the federal government to negotiate drug price directly with pharmaceutical companies, marshalling the buying power of 43 million Medicare enrollees.

Twenty-four Republicans joined Democrats to pass the bill 255-170. Of course, the fearless President Bush has already warned he would veto any such measure and who knows what will happen in the Senate.

Read about the action in the Washington Post and the New York Times.


posted by Hanh Kim Quach | Permalink | 9:14 PM


Why else would people join Costco?

Monday, January 15, 2007
The Wall Street Journal just published this story about the Bush Administration's nascent plans to boost the use of HSAs and high-deductible plans to make insurance more affordable for low-income workers.

Here's the lead of the story:

With health-care costs emerging as one of voters' biggest domestic concerns, President Bush is considering promoting a tax-code change making it easier for people to buy health insurance for themselves in the open market, rather than relying on employers.

Bush is expected to announce this plan when he releases his budget and state of the union later this month.

Bush, and proponents of HSAs believe that high-deductible plans will make people more cost conscious. Early evidence does show that costs drop -- because people don't go to the doctor. And when you are "low-income" earning $50,000 with two small mouths to feed, it's easy to forgo the doctor.

What gets to me, though, is this idea -- as the Journal article says, that the idea would "make it easier'' for people to buy insurance on their own, rather than relying on their employers.

Why would *anyone,* particularly health policy advisers, think a single person could get a better deal on health coverage than a group?

Society has all kinds of "group'' activities that help people pool together to join risk -- think office lottery pools or a membership to Costco, where you pool together and amass buying power to get lower prices. Maybe you don't need two gallons of Pepto Bismol, but the person that pays the membership fee and uses that Pepto Bismol is also helping you buy your lower priced flat-screen TV.

I have to believe, though, that Bush understands the point of pooling risk, as he said in this 2003 speech where he advocated getting rid of state consumer protections (like the HMO Patients' Bill of Rights) to help small businesses:

Small businesses must be allowed to come together in order to pool risk in order to provide their employees with reasonably priced health care.

So who knows what has spurred this latest Bush boondoggle; maybe it was this cartoon that inspired him.

(PS the Wall Street Journal requires a subscription to read. If you'd like to read the article and you don't have a subscription, email me at hquach@health-access.org and I'll send you a copy)


posted by Hanh Kim Quach | Permalink | 8:48 PM


Hilarious....but accurate?

Saturday, January 13, 2007
Steve Weigand in the Sacramento Bee sums up -- with humor -- how different sectors are feeling about the gov's healthcare plan.

In other reading, an interesting piece on national interaction with California's health care debate on The Health Care Blog.


posted by Hanh Kim Quach | Permalink | 12:10 PM


Meanwhile, back at the ranch..

Friday, January 12, 2007
Lost in all the attention about the Governor's announcement on broad health reform was this article by Clea Benson in the Sacramento Bee last Sunday, about what's going on at the Department of Managed Health Care (DMHC).

It spotlights a key member and ally, the California Pan-Ethnic Health Network, and their work to implement a landmark law they co-sponsored to ensure cultural and linguistic access to care.

There's lots of important work going on at the DMHC that needs to be watched, including a process to prevent the practice of balance billing, and the implementation of a law to set standards for timely access to care, which has been delayed, ironically.

posted by Anthony Wright | Permalink | 12:49 AM


Blogwatch: The Governor's plan...

Wednesday, January 10, 2007
The online magazine Slate has a rundown of bloggers and their reactions to the Governor's plan. Some rabid response against it, especially from the right; Others acknowledge parts of it; Some are just digesting it.

Two commentators worth noting: Good thinkers at the magazines The New Republic (Jonathan Cohn) and Washington Monthly (Kevin Drum) took a look at the Governor's health care proposal, and like us, found things to like and things not to like. Both are single-payer universal health care supporters, and while they see issues, they acknowledge the significance of the rules on insurers, and of a Republican governor endorsing these ideas. (Kevin then responds to Jonathan here.)

Bob Salladay's Political Muscle investigates the shady outfit that ran a television ad against the Schwarzeneggger plan merely 30 hours after it was announced. No actual stakeholders are involved here. These are consultants wanting a piece of the action, when the opposition develops. They also had an Internet ad against Prop 72, but that never went anywhere. It does show that even though the Governor's plan is a mixed bag, there are formidable opponents for even the modest steps forward in the proposal, including the employer fee.

posted by Anthony Wright | Permalink | 11:41 PM


"Angry'' and in pain, governor defends health care proposal

Our update about the state budget is below, but some notes of interest from the press conference:

A tired-looking, beefy Governor, hobbled onstage with crutches, and admitted to reporters that his broken femur has handicapped him, making him "very angry a lot of times'' and causing life to be difficult for him and his wife. Still, the governor fielded questions tangentially related to the budget -- but mainly about his health reform proposal.

Asked about his "evolving definition of taxes,'' he referred to the "dividends'' from having more insured people that doctors and hospitals would get under his health proposal. Schwarzenegger said those parties assessed a fee would benefit from higher revenues and reduce the "hidden taxes'' under his proposal. Therefore, it wouldn't be a tax.

Questioned on whether his reform plan would cover undocumented adult immigrants, the governor reiterated his answer from Monday, saying the state was already required by federal law (EMTALA) to provide emergency care in the emergency room to ALL patients. His health proposal simply would redirect patients to more cost-effective care.

posted by Hanh Kim Quach | Permalink | 10:06 PM


Health unscathed.in state budget. But wait for the feds...


Wednesday, January 10, 2007

* Health budget escapes unscathed, though social services get cuts
* Health reform plan not included in budget
* New prescription drug & child enrollment efforts get funding for implementation
* Looking ahead to SCHIP reauthorization in Congress and Healthy Families funding
* Visit the
Health Access WeBlog: Governor's Q&A, Health Plan Fallout, Media Reaction

Gov. Arnold Schwarzenegger on Wednesday released his fourth state budget, in which he says he eliminates the annual operating deficit, where the state spends more than it takes in. For the budget year, Schwarzenegger has proposed a $143 billion budget that is only 1 percent larger than this year, even though revenues are 7 percent higher.

To view the budget online, visit: http://click.icptrack.com/icp/relay.php?r=1012041699&msgid=3519375&act=XIOO&c=5484&admin=0&destination=http%3A%2F%2Fwww.ebudget.ca.gov%2F&l=2.


The Health and Human Services Agency budget will total $76 billion in 07-08 (both state and federal funds). Thats an increase of 3.5 percent over the current year. But that increase isnt felt agencywide. A full summary is available at the Department of Finance website, starting on Page 137, at:

The Governor's budget proposal does NOT reflect any of the proposals in the Governor's health proposal, such as the expansion of coverage for all children, as well as adults in poverty, or the shifting of funds away from counties and public hospitals.

Health programs, such as Medi-Cal, Healthy Families and ADAP will see modest increases reflecting standard program growth, but no policy changes are proposed to either cut or expand eligibility. Yet other programs such as CalWORKS and food stamps will suffer cuts, which could cause problems for the same populations served by the public health programs.

Medi-Cal is budgeted at $37.4 billion ($14.6 billion general fund), an increase of $1.9 billion from 2006-07, not reflecting any policy change but increases in caseload and cost per eligible person. The average monthly caseload for Medi-Cal is forecast to be 6.7 million, an increase of 1.6%--but less than the growth of the state as a whole.

Under the Managed Risk Medical Insurance Board, Healthy Families is budgeted at $1.1 billion, ($392 million general fund), an increase of $32 million general fund. The enrollment is expected to rise by 73,900 children, or 8.8 percent, to 915,600. Access for Infants and Mothers (AIM) is expected to increase by 1,815 to 13,912 uninsured pregnant women.

The Governor's Budget includes $40 million for the Managed Risk Medical Insurance Program (MRMIP), which provides coverage for 8,700 "uninsurable" people who have been rejected for coverage by insurers due to "pre-existing conditions." Since the program is capped to the funding provided, there is a waiting list of 80 people. This program and related issues have been the subject of legislative bills for reform last year and this year, and they are addressed in the Governor's health reform proposal.


The governors write-up on health care spending gives particular focus on legislation passed last year, namely, prescription drugs, and Healthy Families enrollment.

* AB2911 (Nunez/Perata) The California Discount Prescription Drug Program. The governor allotted $8.8 million and 15.2 positions to implement this program next year. This program is expected to allow uninsured Californians to obtain a discount card at a $10 annual fee to purchase prescription drugs that a price negotiated down by using the state's purchasing power.
*AB2877 (Frommer) California Rx Prescription Drug Website. The budget sets aside $96,000 and 1 position to maintain this site, which will help Californians get information on do comparison shopping by price for prescription drugs.
Also on prescription drug prices, the proposal would switch the basis of drug reimbursements on pharmacy claims from Average Wholesale Price (AWP) to Average Manufacturer's Price (AMP). This is seen as closer to the actual cost of the producing the drug, rather than AWP, which is sometimes termed "Ain't What's Paid." This change is expected to result in general fund savings of $44 million.
* SB437 (Escutia) Enrolling children in public programs. The budget includes $16.9 million ($35.9 million state and federal) and 9.4 positions dedicated to finding and enrolling children who are eligible for Medi-Cal and Healthy Families but not yet enrolled. New streamlined programs in the programs could enroll as many as 30,000 children in the budget year; about 447,000 children are eligible, but not enrolled in public health programs.


As we work with policymakers this next year on universal coverage expansion, one element not to overlook is the reauthorization debate about State Child Health Insurance Program (SCHIP)--called Healthy Families in California--which will be up this year in the federal budget.

President George W. Bush is expected to release this national budget later this month and its expected to be ugly, in attempts to reduce the federal deficit. In spite of the fact that Congress is now controlled by people who are sympathetic to this program, it will be important to impress upon the delegation that California s SCHIP-Healthy Families Program needs significantly more money to continue the rate of growth in the program. Healthy Families currently provides health coverage on a sliding scale to nearly 900,000 children who would otherwise be uninsured.

The California Budget Project estimates the state will need up to $3 billion more in the next five years to keep the program going without having to place children on waiting lists or drop them from coverage. Particularly as Governor Schwarzenegger looks to the Healthy Families program to provide coverage to even more children, continued support from the federal government will be critical.

Health advocates are planning to visit Congressional members in trips to Washington, D.C., later this month and through the year. For more information on these federal issues, contact Elizabeth Abbott or Jessica Rothhaar at Health Access California.

For more information about the budget, contact Hanh Kim Quach, policy coordinator, Health Access California, 916-497-0921, or hquach@health-access.org.

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posted by Hanh Kim Quach | Permalink | 7:39 PM


But does it hit home runs?

Some commentators have cheekily called the Governor's proposal "Massachusetts on steroids." Lots of people have lots of contradictory thoughts on the Massachusetts plan. So do we. Here's a 17-page Health Access discussion paper, which is more relevant than ever, at:

So what's the response of a consumer advocate in MA to the Governor? Here's John McDonough, former Democratic state legislator and head of the MA group Health Care for All (not related to the group of the same name in California), and the wonkish but always interesting "A Healthy Blog":

"The Massachusetts law was constructed to provide benefits to everyone possible and minimal pain to anyone. The Schwarzenegger plan has something to alienate almost everyone — business will hate the payroll tax; docs and hospitals will hate the assessments; many insurers will balk at a ban on medical underwriting; many consumers will balk at the individual mandate; progressives will claim it’s way to stall single payer. Not a promising political recipe."

As we detail in our paper and in this one-pager about the differences between MA and CA, once the Governor went down this road, he needed to do something much bigger because the problem is bigger in both scope and size: California starts with many more uninsured, less funding in the system, and fewer rules and oversight for insurers than Massachusetts. In many ways, the Governor didn't go far enough to even make up ground to where Massachusetts is. But that's what the legislative debate will be about.

posted by Anthony Wright | Permalink | 5:52 AM


It's easier to cover fires...

Tuesday, January 09, 2007
While some of our California media have been distracted from health care issues in the last two days because of the big story--burning celebrity oceanfront mansions in Malibu!--the national news has taken note of Schwarzenegger's plan.

What's interesting, both in the state and national news, is how this debate is portrayed.

Media stories, which thrive on conflict, simply fall into old debates, even if they are not totally applicable.

One trope is to make this an illegal immigration story, even though it is a relatively small portion of the story. Undocumented immigrants are not anywhere close to being a majority of the uninsured, yet that get a disproportionate focus of media attention.

Many of the stories I've seen focus on the employer fee, with the predictable business/tax spin. The thing is, the employer fee is a real small part of this proposal. Most businesses provide 7-10% of payroll for health care... that's far more than the 4% assessment, which is only levied, it seems, only if the employer is simply providing no coverage whatsoever. With 80% of employers being exempt for being too small, it also doesn't touch those larger employers that may have many uninsured workers--since theyo impose signficant premium costs on their workers, or force workers to wait for a year or two to get coverage. I've seen lots of media stories where the businesses interviewed actually wouldn't be impacted by the Governor's proposal. The employer fee only raises $1 billion out of the $12 billion that is cited. Again, this gets disproportionate interest from the media, given its relatively meager scale.

Finally, a common media story is that "everybody gets a little, everybody gives a little," of the stakeholders, including insurers, employers, doctors, hospitals, and individuals. In this context, any objection--like our opposition to the individual mandate--looks self-serving on behalf of who we represent.

Unlike those other "stakeholders," consumer and community groups have been active proponents of many health care reform proposals--to cover workers, children, or all Californians--and all required some form of an individual contribution. But all the other "stakeholders" have their contributions capped with consideration for the ability to pay, and that's why it falls short of "shared responsibility."

But my main problem with the frame is that consumers are another interest group. My point is that "individuals," whether as patients, workers, or the public, aren't just "stakeholders." No one would say that the system should be designed to primarily benefit insurers, hospitals, doctors, or employers.. everyone says that it should primarily benefit patients. In my mind, helping health care consumers is the entire point.

And despite the (relatively small and capped) contributions of other stakeholders, the Governor's proposal shifts the most burden and financial risk onto the individual--especially those over 250% of the federal poverty level (roughly 25K for an individual; $50K for a family of four) who get very little help. They are forced to buy private coverage as individuals, without the market power of group purchasing, without subsidy, and with little guarantee of the quality of the coverage.

There's a Sacramento game to watch about how the different interest groups fare, but at the end of the day, the question should be how Californians fare.

posted by Anthony Wright | Permalink | 11:47 PM


Reprise, why we dislike the individual mandate...

Dan Weintraub, in his regular weblog, criticizes consumer groups -- I am assuming Health Access is included in that -- for praising the insurance market aspect of Gov. Schwarzenegger's plan (calling for guaranteed issue and community rating) while panning the individual mandate.

His point is that the insurance market would become a death spiral if people only joined the insurance market when they needed it, and were not forced to pay into it when they are healthy.

Let's be clear, we're not opposed to individuals sharing in the responsibility of obtaining coverage. We support a tax system where everyone pays into a pool and gets something out of it. We like the way Speaker Fabian Nunez has fashioned his health proposal, which would require workers to take up insurance, IF their employer offers it and IF the coverage is affordable.

Those who support an individual mandate, however, often characterize the uninsured as "immortals,'' people who believe they don't need insurance and are "choosing'' to go uninsured.

The numbers, though, tell a different story:

  • Of more than 6 million uninsured, only 8.7 percent did not take up coverage that was offered to them on the job.
  • Most of the working population makes less than three times poverty, which means most would be poor enough to qualify for the governor's subsidy program (his cut-off is 250% poverty)
  • That means 2 percent of the entire population of uninsured, that's 87,000, make more than three times poverty and are not buying insurance.

Proponents of the individual mandate then, are really attempting to punish this 2 percent of the population that is not buying coverage.

In reality, though, the individual mandate would affect everyone.

Say you're a family of four with a total income of $51,000 in San Francisco. This is how the plan would affect you:

  1. Cost of a qualifying health plan (meaning that it doesn't have a $30,000 out-of-pocket limit as many plans I searched on ehealthinsurance.com did) could cost about $1,600 a year (with no drug coverage) or $3,000 (with no lab/test coverage) or $6,000 for premium coverage.
  2. Up to $7,500 in out-of-pocket costs (of which prescription drugs or labs/tests would not count)

So let's the family chooses the more moderately priced $3,000-a-year high deductible plan. They have a medical emergency -- someone breaks a bone, is diagnosed with a disease, and require health care that adds up to $10,500 for the year. That's more than 10% of the family's entire income.

For these middle income, this plan would hurt the most.

The structure of the governor's individual mandate has no limits for what consumers would be asked to pay. On the other hand, employers know their obligation would be capped at 4 percent of payroll. Doctors and hospitals would have their obligations capped at 2 and 4 percent, respectively. Even insurers know they have to spend up to 85 cents of every premium dollar on health care -- which HMOs are already required to do (PPOs aren't.)

posted by Hanh Kim Quach | Permalink | 11:56 AM


What's in the news....

Here's a compilation of health-related news coverage for today:

posted by Hanh Kim Quach | Permalink | 11:24 AM


Whatever your opinion, it's not small or vague...

Tuesday, January 9, 2007

* Sets new rules for insurer practices; requires employer contribution to health care
* Requires all individuals to buy coverage (for many, regardless of ability to pay)
* Expands Medi-Cal & Healthy Families for all children, some adults; some subsidies
* Takes half of money to care for uninsured patients from safety-net hospitals
* New on the
Health Access blog: Build-up and ongoing reaction, fees vs. taxes, etc.

Gov. Arnold Schwarzenegger on Monday unveiled a detailed and sweeping proposal to cover all uninsured in California, emphasizing “shared responsibility” – between individuals, employees and government, as well as providers and insurers.

Speaking from Los Angeles (because he is under doctor’s orders not to travel by plane more than once a week because of his broken leg), the governor said California has an opportunity “to make history, just like last year," referring to the passage of key legislation. See text of the governor’s prepared remarks here.

The focus of the Governor's materials are threefold: 1) prevention, health promotion, and wellness; 2) coverage for all Californians; and 3) affordability and cost containment. In particular, the Governor's proposal focuses on removing the "hidden tax" of caring for the uninsured from the cost of private health coverage, by "creating an efficient, competitive market dynamic." The governor's health team estimates that his proposal could cut the "hidden tax'' that average families pay ($1,186) by half.

To read the proposal, view his comments and other paperwork from the governor’s plan, visit the Health Access website at www.health-access.org/advocating/ref.htm.
A core part of this plan is an individual mandate to purchase private coverage, with some public program expansions and subsidies for some low-income families, as well as rules on and contributions by employers, insurers, and providers.


Consumer and community groups were poring over the details since the announcement. Some of these provisions are proposals that consumer groups have long supported as stand-alone legislation, especially around setting rules on insurers and employers, and the expansion of public insurance programs for children and adults. But there lies significant concern about the placing of risk to the individual consumers and families, through the individual mandate as well as other components of the proposal.

This is the beginning of the legislative year, and the Governor's proposal will need to be negotiated with members of the legislature, many of whom have their own proposals. The attention to health reform, and the Governor's new consensus with legislative leaders about the need for expanded public programs, and standards for employers and insurers, suggests that there is reason for optimism.

Consumer advocates will need to be vigorous in opposing elements that are steps backward, pushing on provisions are steps forward but that don't go far enough, and keeping the urgency and visibility of this issue in the forefront, in the goal of winning reform that helps health care consumers.


Among the concepts and elements that have been supported by consumer and community advocates in the past:

1) Universality: The plan sets the goal to ensure that all Californians have access to coverage and care, and the Governor has stated that this is his top priority this year.

2) Expansion of public programs: The proposal does expand Medi-Cal and Healthy Families, for children and adults.
A) Adults without children at home living at or below the poverty level ($9800 for an individual; $13,200 for a couple) would now qualify for Medi-Cal--an expansion of 630,000 adults.
B) Both Medi-Cal and Healthy Families would be expanded to cover all children up to 300% of the federal poverty level ($49,800 for a family of three; $60,000 for a family of four), regardless of immigration status.
C) To comply with the individual mandate, subsidies to a state purchasing pool will be provided to low-income families (101-250%) to help purchase health coverage. While such coverage would be a comprehensive benefit package (Knox/Keene plus prescription drugs with a $500 hospital deductible), there would not have the protections in public programs, including vision or dental coverage, or cost-sharing limits. The premiums charged to these low-income individuals and families will be 3% of gross income for those 100-150% of Federal Poverty Level (or $9,800-14,700 for an individual, or $20,000-30,000 for a family of four); 4% of income for those 151-200% of FPL (or $14,700-19,600 for individual, $30-40K for a family of four); and 6% of income for those 201-250% of FPL (or $19,600-24,500, or 40-50K for a family of four). Many advocates for low-income consumers would prefer public program coverage, and at least much lower financial burdens. In addition, there is significant concern about the need for assistance for those over 250% of the FPL ($25,000 for an individual, $50,000 for a family of four.)
D) The plan also proposes increasing Medi-Cal rates for providers, hospitals, and health plans, which is likely to have a positive impact for those on Medi-Cal to have access to care by these providers. Some of these increases would be tied to "pay-for-performance" measures.

3) Rules for Insurers: The plan would make major changes to the individual insurance market, many long advocated for by consumer advocates, as a first step toward greater oversight over the insurance industry.
A) The plan would set the principle ("guaranteed issue") that nobody should be denied coverage because of their health status--so-called "pre-existing conditions."
B) A related provision ("community rating") would prevent insurers from setting different rates based on health status or anything other than age or geography.
C) Finally, the plan would require insurers to dedicate 85 cents of every premium dollar to health care. While HMOs are already required to meet that threshold (known as a "medical loss ratio"), PPOs now spend as little as 50 cents per premium dollar on actual health care.
D) There will be a mandated minimum in the open insurance market limiting deductibles to $5,000, and out-of-pocket costs to $7,500 for an individual and $10,000 for a family. While there is no out-of-pocket cost maximum now, such costs still would place a insured person in medical debt and risk for bankruptcy.

4) Employer Contribution: The plan does require employers with 10 or more employees to contribute to the health care system, to either provide some coverage or pay 4% of the payroll. While this employer "in lieu" fee is projected to raise $1 billion as part of the plan, it does not set a standard for on-the-job health benefits. According to the March 2005 Current Population Survey, employers now spend an average of 7.2% of their total payroll on health care and slightly over 10% of the payroll of those for whom they provide coverage. (Wal-Mart, for example, which now spends 7% of payroll, would not have to increase coverage or spend any more.) Also, since the fee is assessed as a broad aggregate of health spending, and not on a per-worker basis, an employer that provided very good benefits to management or long-time workers but little or nothing to new or part-time workers could still meet this low threshold. Unless the requirement were signficantly more and differently structured, this would not provide greater security to the 19 million Californians who now get coverage through employers.


While the theme of the proposal is "shared responsibility," the focus of the responsibility is on individual consumers. Based on what was proposed on Monday, patients and workers bear a disproportionate amount of risk.

* The individual mandate: The core of the proposal--the individual mandate--is something that has been opposed by consumer groups as unwarranted, unworkable, and unwise. Unlike the many health plans supported by consumer and community groups in the last several years, which have people share--and in many cases required to share--the cost and burden of health care (at the worksite, through public programs, or through a universal system), an individual mandate places the financial and legal risk and burden of coverage on individual patients and families.

Some of the other provisions attempt to mitigate these problems, but they don't provide the protections regarding the ability to pay, or provide a defined benefit of value. Most importantly, there is concern that the individual mandate would actually undermine the group coverage that many have now, especially through employers. Health Access California has a paper regarding individual mandates at:

Under the plan, everyone must prove they have health care insurance, with some limited assistance to low-income families, but beyond that with no consideration for ability to pay. Some specific issues:

* Unfairness: Unlike the employer or provider contributions to this plan, which are capped and based on ability to pay, the individual burden to buy coverage is unlimited. Even the only other state to ever adopt an individual mandate, Massachusetts, included a broad exemption if coverage was unavailable or unaffordable.
* Undermining existing coverage: Such a dynamic--with a low and capped employer contribution, but an ongoing and unlimited individual requirement--could lead employers to continue to shift more costs into workers.
* Enforcement: The plan envisions using providers to help enroll and expect proof of insurance. For those that are inevitably left out, it may discourage them to get needed care. Other enforcement mechanisms include the payroll through the Employment Development Department, and then with submitting proof of coverage on tax returns. Individuals would have to prove that they have health coverage through their tax returns. If their tax records show they have not purchased coverage for the year, there would be mechanisms to either enroll qualified individuals in the subsidized pool, or auto-assign people with a private plan for which they would have to pay.
* Those low-income Californians that qualify for public programs would certainly be better off insured, and the mandate would simply serve as an enrollment function. But those in the state purchasing pool (adults from 100-250% of poverty), will find themselves having to pay a major amount (3-6%) of their incomes, which many consider to be unaffordable for those living on such tight budgets.
* The most impacted are those with no subsidies, because of their income or other disqualifying criteria. They will have two choices: either they will attempt to get a good comprehensive benefit at a extremely high cost, relative to their income, or they will attempt to mere the bare minimum of the mandate by spending good money on a product of dubious value. For instance, individuals above 250% of poverty (more than $24,500 for an individual, $41,500 for a family of three, or $50,000 for a family of four) are concerned. Yet, they’d be forced to go into the market – on their own – and purchase healthcare that could amount to nearly one-fifth of their annual income. Or to just meet the requirement they have to buy a high-deductible plan that may well be a little cheaper, but still a lot of money and of little value.

* Concern about the safety net The proposal takes half of the money ($2 billion) that currently goes to public hospitals to pay for their care of uninsured patients. Even with more insured people, this could provide huge problems for key public hospital that we all rely on, yet which have been chronically underfunded. For example: Kern and Monterey Counties , which have been teetering on closure; San Francisco, which relies on San Francisco General and network of clinics to administer its not-yet-implemented Health Access Program for universal access, and in Los Angeles King-Drew hospital, which has had its own set of issues, and LA County/USC Medical Center. The closure of any public hospital would be hugely damaging for all Californians, who rely on trauma centers and emergency rooms in their community to provide care when they need it.

* A review of of health plan benefits, provider, and procedural mandates could be a threat to key consumer protections, such as the HMO Patients' Bill of Rights. The plan also considers "the elimination of unnecessary health plan reporting requirements," which may be a concern for consumer advocates.

* Some low-income patients may lose some protections: While the proposal does significantly expand Med-Cal coverage, it also shifts Medi-Cal recipients (excluding pregnant women) over the poverty level ($9800 for individual, $20,000 for a family of four) to other public programs, including Healthy Families and that have some fewer benefits and protections. This would impact 680,000 children and 215,000 adults.

* The proposal also encourages underinsurance and high-deductible plans, by offering a state tax break for Health Savings Accounts (which are only available for high-deductible plans). While employers aren’t paying enough, individuals would pay too much. The governor’s plan would establish a “minimum benefit package’’ requiring people who must buy insurance on their own to have at least a $5,000 deductible plan. Health Savings Account holders would get a tax credit, taking money away from state coffers to provide access to health care.


Contrary to predictions that the plan would be small or vague, the proposal also is broad and detailed (although there are some questions that are not answerable, given that it is not in legislative language.) There are other major components that Health Access and other groups will be looking at in the weeks to come, including:

* Structuring benefits and providing incentives to promote prevetion and wellness, including a "Healthy Actions" requirement on public programs and to be offered in the private market to provide rewards and incentives.
* Major efforts and campaigns to focus on diabetes, obesity, and tobacco use.
* An effort to prevent medical errors, including requiring electronic prescribing of medication by 2010 and require new reporting of health safety measures at health facilities.

* Requiring employers to provide (but not fund) a Section 125 plan so their workers can use pre-tax dollars to pay for premiums of insurance in the individual market.
* A effort to reduce "regulatory barriers," including allowing the growth of retail-based medical clinics by making scope-of-practice changes for nurse practitioners and physician assistants.
* A new "'worst first' system of hospital conformity to seismic safety requirements.
* A new "24-Hour Coverage" pilot program for CalPERS (with opt-in for pricate sector) to coordinate worker's compenation with traditional group health coverage.
* A major Health Information Technology effort, which includes the adoption of standardized Personal Health Records, and a major focus on tele-health and tele-medicine.


What the governor proposed Monday is clearly only the beginning. In his announcement, he invited several people from a range of sources, to comment and critique his proposal. The range of views was as disperate as the panelists. To view the panel and the announcement, visit the Governor's web site at:

Health Access will continue to analyze this plan and provide you with updates in the coming days. For more information, contact Hanh Kim Quach, hquach@health-access.org, or 916-497-0923.


posted by Anthony Wright | Permalink | 10:39 AM


A taxing debate...


Bob Salladay’s Political Muscle tribute to Max Headroom is welcome, although ironic. The show (one of my all-time favorites) was actually a vicious critique of the media.

My bone to pick with the media today, and more specifically, this LA Times article that Salladay also endorses, is some lack of balance about the Governor’s plan with regard to fees and taxes, and whether his health plan is a change of position for him.

First of all, the Governor has made these statements about his health care views through the re-election campaign. On the first day of the general election, the Governor was quoted on the campaign bus talking about making health care his number one issue. When asked about his opposition to Proposition 72, the requirement on employers to provide for health coverage to their workers, he said he didn’t like the 80-20 split, but would rather be for something like 50-50. He actually said this in 2004, too: (granted, those of us who were campaigning for Prop 72 didn’t take much comfort in this, or even believe him.)

But he’s been somewhat consistent, including through the summer and fall where he said that health reform would require participation by employers, individuals, and government. (As advocates, at times, for both fees and taxes to help unfunded parts of our health system, we certainly faulted him for being vague, but his general direction was clear.)

As for fees, the Governor not only signed a similar provider fee for nursing homes, but he put it in his campaign literature.

I know that rhetorically anything that government does that involves money is often called a “tax,” but you don’t have to read the legal analysis that Daniel Weintraub posted to know that there’s a specific distinction between a “fee” and a “tax”—one that a man-on-the-street will understand.

A tax is broadly based, and goes for broad purposes.

A fee is specific, and provides either a reward or remedy regarding the payor's actions.


* You pay a fee to enter into a state park, but get the benefit of enjoying that park. The fee goes specifically for the park’s upkeep.

* A paint company pays a fee that goes to lead paint removal. The fee goes specifically to lead paint removal.

* With the Governor’s proposal, only employers who don’t cover their workers (and thus have their workers impose costs on the health system) pay the fee. And they get the direct benefit of a healthier, more stable, and more productive workforce The fee goes specifically to health coverage, not to unrelated expenses.

This is more than a semantic distinction, both in terms of indicating the narrowness of impact, but also because of legislative rules: a fee only requires a majority vote; a tax requires a two-thirds (and thus significant Republican legislative support) to pass.

So let’s be clear that it’s not just political spin: there’s law and common sense behind the difference between a fee and a tax. Too bad the article didn't explain that.

posted by Anthony Wright | Permalink | 8:43 AM


An initial reaction...

Monday, January 08, 2007
Here's the statement that Health Access California released today.


"While the Governor's proposal sets some needed and better rules for insurers, employer, and public programs, it inappropriately places the risk and burden of health coverage mainly on individual consumers and families." said Anthony Wright, executive director, Health Access California, the statewide health care consumer advocacy coalition.

"The point of health reform is to provide relief for Californians from the burden of health care, but the individual mandate proposal will take us in the wrong direction, potentially undermining the coverage that people have now." said Wright. "However, the importance of Governor's proposal is not the details, but the spotlight on health reform as the issue for action this year, and the agreement to set stronger standards for insurers, employers and everybody. We are optimistic and committed to having a proposal that helps health care consumers get enacted this year."


NEW RULES ON THE HEALTH SYSTEM ARE STEPS FORWARD: "The Governor has appropriately moved to set rules regarding employer-provided coverage and insurance company practices. Our health system has been like the Wild West without a sheriff, with insurers who profit from denying people coverage because of their medical conditions, and employers who scale back or drop coverage for their workers, unfairly undercutting their competitors."

· RULES ON INSURERS: "We agree that it should be a principle that no Californian should be denied coverage, or discriminated against by price, because they actually need care. The Governor’s proposals for guaranteed issue, community rating, and minimum medical loss ratios, are a good first step toward better oversight of the insurance industry."
· EXPANDED PUBLIC PROGRAMS: "We support expanded eligibility rules for public insurance programs like Medi-Cal and Healthy Families, for children and adults."
· EMPLOYER CONTRIBUTION: "The Governor's support for requiring an employer contribution is a important step, but it falls far short of setting a standard for on-the-job coverage. The standard is 4% of payroll, when most employers--even Wal-Mart or Safeway--do much more. We may debate where a minimum wage should be, but nobody would say that setting it at $3 or $4 dollars would help anybody. This capped contribution will not provide greater security to the 19 million Californians that get coverage through their employer."

NEW RISK FOR CONSUMERS ARE MAJOR STEPS BACKWARD: "We oppose a structure that places the legal and ongoing financial and health risk and burden on the individual patient and family. We will vigorously oppose elements that would actually destabilize the coverage and/or the access to care, of many."

· INDIVIDUAL MANDATE: "The uninsured shouldn’t have a financial penalty onto top of the health and financial consequences of being uninsured. This isn't shared responsibility: It's unfair to have employers and providers have their contributions capped and based on ability to pay, when most individual Californians have unlimited liability, now and in the future. By shifting the risk to the individual, we undermine the group coverage that people have now."
· SAFETY-NET: "For all of us who depend on public hospitals for emergency or trauma care, we would be at greater risk with de-funding of safety-net institutions, including those that specialize in treating our most vulnerable. Given how little California funds the care of the uninsured, it’s hard to see how to take significant funding away from public hospitals, even with a major increase in coverage, especially since there will inevitably be Californians who are left out of coverage or subsidy."


posted by Anthony Wright | Permalink | 4:26 PM


For your perusal....more to come. ..

On our website at www.health-access.org/advocating/ref.htm, you will find 3 documents from the governor's office on his health reform proposal.

Analysis to come....

posted by Hanh Kim Quach | Permalink | 3:36 PM


The actual stakeholders...

After the Governor announces his plan at noon today, there will be a panel where various stakeholders will be allowed to say what they like and they don't like about the plan. It should be interesting.

Later today, Health Access California is joining with other community, consumer, labor, and constituency groups will have a 2:00pm press conference to focus on the real stakeholders in this debate: actual Californians who now suffer through our health care crisis: the uninsured, the underinsured, those who go through great lengths to get coverage but are concerned that it won't be there when they need it.

We decided to bring up these stories before we knew what the Governor's plan said, so some of these folks may be helped, some may be hurt. We'll see.

But the Governor's announcement today is only the beginning. Our point is that by the end of this year, we want to help resolve their health coverage and care issues, and those of the millions of the rest of us. Regardless of what is in the Governor's plan, health care reform is now the topic of the year, and we will work to ensure that reform is passed, and that such reform is in the best interest of consumer, patients, workers, and families.

posted by Anthony Wright | Permalink | 9:10 AM


Risk: Not just a board game

As we get the details about the Governor's proposal, two of the main questions that I will ask are:

What are the rules? Who faces the risk?

In the Wild, Wild West of health care, insurers profit from denying coverage and discriminating against patients because of "pre-existing conditions;" Californians are more likely to be uninsured than those in most other states because employers are less likely to provide health coverage to their workers. Will the Governor be the new sheriff in town to stand up to these interests? Will we have strong standards and accountability for insurers, employers, and providers?

Even with new rules, ultimately, who will face the risk? Who will bear the burden of health coverage? Will the risk truly be shared, as many Californians do through the worksite or through public programs? Or will that burden be shifted to individual patients and families? Will group health coverage be strengthened, or undermined?

posted by Anthony Wright | Permalink | 12:37 AM


Post-partisanship, sponsored by...

Friday, January 05, 2007
Here's a selected list of health-related interests who were "Silver Sponsors," who contributed more than $15,000 to Governor Schwarzenegger's inauguration committee. This does not even include lobbying firms or individuals that have health-related interests, nor does it include major employer groups who were "Gold Sponsors," like the California Chamber of Commerce, the California Grocers Association, and the California Retailers Association. For the full list of sponsors, click for the Governor's inauguration website.

Association of California Life and Health Insurance Companies
California Academy of Ophthalmology
California Ambulatory Surgery Association
California Association of Health Plans
California Association of Physician Groups
California Dental Association
California Hospital Association
California Medical Association
Health Net, Inc.
Physicians for the Group Practice of Medicine

Mike Zapler from MediaNews papers had a related article over the holidays about the funds contributed to the Governor by health interests.

posted by Anthony Wright | Permalink | 11:55 PM


More on moral hazard...

I'd rather not restart the drawn-out debate about HSAs on the Sacramento Bee Crossroads blog that I've been having with former Assemblyman Keith Richman, HSA salesman Dr. James Knight, and the moderator Daniel Weintraub.

But the reason I got drawn in to the back-and-forth was not just that I couldn't leave so many statements unchallenged, but that the debate seemed to go to the very core of the health care debate: between community solutions vs. individual burdens, between blaming rising costs on patients or the health care industry, between whether health care consumers are getting a free ride or suffering under medical costs, between whether patients get too much care or too little; between faith in the market vs. evidence of market failure, and finally about the value of the very concept of coverage.

I referenced lots of studies in the Crossroads debate, but one article I should have linked to was this Malcolm Gladwell article in The New Yorker, which talks about the concept of "moral hazard" that undergirds much health policy, and which he is effective at debunking in the context of health care. It's a good read and good background...

posted by Anthony Wright | Permalink | 10:56 PM


Me? Insurance? Naaah....

Interesting story in the Boston Globe about Massachusetts ' attempts to implement their new health care program, which includes an individual mandate.

"Few uninsured residents know anything about the landmark initiative, and fewer
still understand that the new law requires them to purchase health coverage
beginning July 1.

The state is now spending millions in grants to try and get coverage to the 500,000 currently uninsured residents -- educating them about both the mandates and subsidies available. (Try telling that to 6.5 million!) There were no illusions that the Massachusetts plan would cover 100 percent of residents, but getting to that number will be a slog even though that state has guaranteed issue and community rating, making it somewhat easier to obtain coverage.

posted by Hanh Kim Quach | Permalink | 5:21 PM


The schedule for Monday (Part 1)

Here's the Governor's Advisory about Monday's announcement. These are invite-only events, but watchable on the Governor's website.

Gov. Schwarzenegger to Announce Health Care Reform Plans

11 a.m.
California Health Care Presentation
California Department of Health Services Auditorium
1500 Capitol Ave., Building 172
Sacramento, CA

Governor Arnold Schwarzenegger will share his plans to reform California's broken health care system. The event will be webcast live at www.gov.ca.gov<http://www.gov.ca.gov/>

Following the Governor's presentation at 12:30 p.m., members of the Governor's Administration will host a live video web discussion with stakeholders and members of the public. Questions canbe submitted live at www.gov.ca.gov <http://www.gov.ca.gov/>. Participants include Kim Belshé, California Health and Human Services Agency Secretary; Richard Figueroa, health care advisor to the Governor; Ruth Liu, associate secretary of health care policy development for the California Health and Human Services Agency; John Ramey, senior health policy consultant to the Governor; Herb Schultz, senior health policy advisor to the Governor; and Daniel Zingale, senior advisor to the Governor and chief of staff to Maria Shriver.

In California, 6.5 million people - more than any other state - have no medical insurance for all or part of the year. A recent New America Foundation <http://www.newamerica.net/publications/policy/a_premium_price> white paper estimates the average family pays about $1,186 a year in health insurance premiums to cover the uninsured. Last July, Governor Schwarzenegger convened a groundbreaking Summit on Health Care Affordability <http://gov.ca.gov/index.php?/press-release/2570/>. Experts from various fields, such as academics, government, business, health care and labor, seriously discussed California's health care cost and coverage challenges.

Additional background information is available at www.gov.ca.gov<http://www.gov.ca.gov/>

posted by Anthony Wright | Permalink | 11:17 AM


Is it only Jan. 5th? Big week, next week.

Friday, January 5, 2007

* Governor to announce health reform plan on Monday
* State of the State speech on Tuesday, Budget released Wednesday
* Field Poll reveals voters are anxious for action
* New on the
Health Access Blog: RSS Feed; New Updates from Sacramento

Especially for those who advocate for health reform, 2007 seems to have been shot from a canon. The good news is health care is at the top of everyone’s mind here in Sacramento. Already this week, we’ve had two Field Polls telling us that voters want change, press leaks about what might be in Gov. Arnold Schwarzenegger’s health care plan, the start of inauguration festivities, and the swearing in of the new Speaker of the House, Nancy Pelosi.

Hints About the Governor’s Plan

Gov. Arnold Schwarzenegger will give his “State of Health Care ’’ speech on Monday at 11 a.m. It will be webcast, which you may view at http://www.gov.ca.gov. Already on that site, websurfers can view a slideshow, “Fixing a Broken Health Care System,” where the governor sets the stage for the healthcare debate.

The Los Angeles Times and Sacramento Bee had stories about one aspect of the governor’s plan: his intention to cover *all* children up to 300% of poverty ($60,000 for a family of four) by expanding the Healthy Families program. The San Francisco Chronicle also hinted at some requirement on employers and individuals.

A one-page document circulated from the governor’s office Thursday also unveils two specific ideas that are expected to be among many:
* Section 125 plans, making it easier for workers to pay premiums of individual insurance with pre-tax dollars. Similar to a provision of the Massachusetts plan, this would require employers to facilitate (but not fund) Section 125 plans, thus giving workers the ability to save up to 40% of their premium. While this would not help most uninsured who still would find buying insurance as individuals unaffordable, it will help more Californians take advantage of federal tax breaks.
* Rewards (such as vouchers and credits for “health-related goods”) for patients who try to stop smoking, lose weight, properly take care of their diabetes, and chronic illnesses, etc. While the governor is careful to say that people who don’t engage in “healthy action plans’’ will not be penalized, some advocates were concerned with the focus on "personal responsibility" rather than systemic solutions for healthier living.

Schedule of Events

We won’t know for certain, however, exactly what’s in the Governor's health plan, or his budget, until next week. Health Access hope to provide real-time information through our blog, and these E-mail updates. Here’s a schedule of events for next week:

* MONDAY, January 8, 2007, 11:00am: Gov. Arnold Schwarzenegger to deliver a "State of Health Care" speech and present his proposal.
* TUESDAY, January 9, 2007, 5:00pm: Governor’s State of the State address.
* WEDNESDAY, January 10, 2007: Governor unveils state budget, which may contain information about possible cuts in health and social services, and could contain relevant information about financing his health care plan.

Events are being planned to publicly respond to the Governor's proposal, and for advocates to meet, analyze, and strategy around the these plans. For more information, E-mail Hanh Kim Quach at hquach@health-access.org.

Field Poll Results

With all this talk of health reform, there's been some reporting on what voters actually think on the subject. According to a Field Poll released the past two days, 81% believe the government needs to step in to help ensure everyone has health care. A surprising finding was that even though only 10% of voters are uninsured, large majorities reported feeling insecure about health costs, their coverage, and whether it will be there for them when they need it. Finally, the poll suggested that voters were supportive of several reforms, and in particular those efforts--supported by consumer groups--to build and expand employer-based health coverage and public insurance programs.

See all the questions and results at http://www.health-access.org/advocating/ref.htm

New Materials and Resources from Health Access

NEW FEED FOR BLOG: Through the holidays and this busy time, Health Access staff are continuing to post quick updates and comments on the Health Access blog. You may now keep up with the Health Access blog via a “site feed.’’ To subscribe, you need to be a member of a “news aggregator,’’ which compiles all your news into one convenient location. Health Access uses www.NewsGator.com, but you can select from a list of them at AtomEnabled.org.

Once you have logged into a news collection site, you can enter this address to start receiving updates (whenever we post) from Health Access.


If you have problems, contact Hanh Kim Quach at hquach@health-access.org, who will do her best to help.

NEW MATERIALS: Also new on the website are various facts sheets and talking points on such relevant issues as the Massachusetts plan, individual mandates, good and bad cost containment ideas, etc. New resources for health care advocates include a list of the new health committee chairs and members (as we know them), and list of currently pending bills on health consumer issues:
Legislative Calendar
Legislative Committee Assignments, so far.
2007 Bill List, so far.


posted by Anthony Wright | Permalink | 1:04 AM


Who's uninsurable?

Thursday, January 04, 2007
LA Times' Patt Morrison writes this punchy column on that all-too-common practice of denying potential policyholders based on pre-existing conditions as innocuous as ear infections, varicose veins or mild depression.

My favorite part -- when she speaks to an Oregon insurance broker about insuring a "someone'' we all know:

"Say there's a man who wants to switch careers start something on his own. He's 59, married, four kids, comes to you for health insurance. He smokes cigars. ("Mmmmm,'' I heard Luke say.) And he had heart-valve surgery almost 10 years ago.

"Luke stopped me right there. The man would never get coverage. I didn't even get to ask Luke about the risk factors of riding motorcycles and skiing.''

A sidenote: Morrison references this LA Times story from 12/31/06 about the insurer practice of denying coverage.

posted by Hanh Kim Quach | Permalink | 8:06 PM


From the Gov.

The governor's office has just posted a beautiful presentation setting the stage for his big announcement on Monday.

See the slideshow at www.gov.ca.gov.

posted by Hanh Kim Quach | Permalink | 4:27 PM


We've officially joined the blogosphere.

You can now get updates whenever Health Access posts a new blog item by subscribing to our site feeds at:


posted by Hanh Kim Quach | Permalink | 3:47 PM


The Sally Struthers Pitch

With leaks purporting that the governor plans to cover all children -- including children of undocumented immigrants, I wanted to call attention to a recent RAND study about immigrants and the cost of health care.

Contrary to popular belief, immigrants use "disproportionately fewer medical services and contribute less to health care costs in relation to their population share.''

Why? 1) they're healthier and 2) they're less likely to be using health care services because -- they're uninsured.

According to the study, the cost per household (nationally) to care for the *uninsured* is $843 a year. Of that, the total cost, then, of undocumented immigrants: $11 a year.

That's less than $1 a month.

posted by Hanh Kim Quach | Permalink | 1:07 PM


Small Business fret

The Small Business Action Committee released a survey today on attitudes toward health care. See the survey questions and results here.

The upshot:
  • 21% of businesses surveyed believe we need to re-look at the HMO Patient Bill of Rights.
  • 72% believe reductions in the health care system need to take place (Read: shift more costs to workers).

posted by Hanh Kim Quach | Permalink | 12:05 PM


Polling Voters, Part 2

The Field Poll released the second of two polls about voters' attitudes toward healthcare today. Find the press release and chart pack on the reference page of the Health Access website.

Interesting insights:

  • 78% believe employers should be mandated to provide insurance to workers, including 61% who identify themselves as "strongly conservative.''
  • 64% believe emergency rooms, trauma centers are under-funded.

posted by Hanh Kim Quach | Permalink | 11:39 AM


Nitpicking the blogs...

Thanks to the LA Times' Political Muscle for the link about our comments on children's coverage in the Governor's plan. This being a blog, we have to take exception to something, in particular the reference to young adult being "fearless" and "invincible" as a reason they are uninsured. To Salladay's credit, he does mention they are generally "low-income" which, along with the types of jobs that have (think McDonalds, Wal-Mart), is the overwhelming reason they are more likely to be uninsured. I go into this in more details defending young adults here.

Matthew Holt has a whole column at Spot On that reasonably accurately details the context for our health reform debate, in California and nationally. He's a lot more pessimistic than I am about reform at the state level: One stat: 49.2%, suggesting that even the wrath of McDonald's and Wal-Mart couldn't convince half of California to vote against Prop 72. The recent Field Poll suggested that now, support for the concept of setting a standard for employer-based coverage is at 78%. That's consistent with private polling as well. If I were at the Chamber of Commerce or the California Restaurant Association, I would want to figure out a truce in the legislature, than go to war and risk the verdict of voters again.

Finally, I have a slightly different conclusion than Frank Russo of the California Progress Report in looking at the Field Poll. It does show large majorities for the types of policies that Health Access has advocated for: securing employer-based coverage, expanding public programs, etc. The question that is being seen as describing a single-payer plan talks about "replacing" our current situation with a "state-run system." Even Senator Kuehl's SB840 did not propose a British-style National Health Service where the government hires all doctors and runs all hospitals, which is what the question implies. Her proposal is more like Medicare for all, leaving in place the current private network of doctors, hospitals, etc.

That said, we will continue support proposals that take steps forward, improving access to health care, that bring people together to share the risk and cost of care (through the worksite, a public program, or a universal system), while opposing those that take us in the opposite direction, that place the burden on the individual patient and family.

posted by Anthony Wright | Permalink | 10:58 AM


Putting the kids to bed...

News reports, in both the Los Angeles Times and Sacramento Bee indicate that the Governor's plan will include coverage for all children.

It's about time: he made such a promise during the one debate during the recall campaign in his first run for Governor, to insure all California's children. He previously missed opportunities, including a bill (AB772 in 2005) and a ballot measure (Prop 86 in 2006), to support plan to acheive the goal. But his opposition was based on specific details presented to him--not the concept, so now it's incumbent on him to put forward a plan of his own.

The other hint in the reports has been that the Governor's plan will include some requirement on employers. Similarly, he opposed the legislature's previous attempt to set a standard for employer-based coverage, but objecting to specific provisions, rather than the concept as a whole. So we'll see what he proposes on that front as well. But the recent field poll suggests there nearly 80% support for the concept.

posted by Anthony Wright | Permalink | 12:27 AM


A trifling

Wednesday, January 03, 2007
The LA Times has an interesting story about Kaiser health plans working with the state to develop standards "to protect'' policy holders from abrupt and unfair insurance coverage cancellations.

Oakland-based Kaiser said its proposed standards would include the requirement
that it consult with policyholders before deciding whether to rescind their

So, is that kind of like the playground bully asking my permission before playing Wac-a-Mole? (me being the mole)

Such a consultation would help the HMO determine whether policyholders
intentionally submitted inaccurate information about their health conditions in
order to obtain coverage. (emphasis added)

The Times says, "With the move, Kaiser embraces a standard for cancellation pushed by consumer advocates, the first sign of a substantive split within the health plan industry on this issue.''

While I appreciate that Kaiser is breaking with the status quo -- such as Blue Cross and Blue Shield, who think it's OK to take back hundreds and thousands of dollars in treatment, let it be clear that it's not good enough.

It still allows insurers to subjectively decide -- after (rather than before) they've asked patients if they "intentionally submitted inaccurate information.'' It does not use independent and consistent standards and there is no neutral third party (ahem, Department of Managed Health Care, anyone?) that is stepping in to police.

It also assumes patients have the medical background and knowledge (without the benefit of having been to medical school) of knowing what to report.

Patients are bombarded with these kinds of seemingly simple, innocuous and nebulous questions when applying for insurance. When I was 21 years old and not yet eligible for health insurance at my first job, my worrywart mother made me go out and get insurance on the individual market. I filled out a lengthy questionnaire and disclosed that I used to have shortness of breath as a child. I was denied coverage.

Should I have reported the shortness of breath? I had never been diagnosed for asthma - therefore, could truthfully say that I didn't have a chronic illness. But I had been checked out by a doctor for the shortness of breath. Had I not reported that visit, I could be willfully withholding information.

posted by Hanh Kim Quach | Permalink | 4:27 PM


Fretting about health care

A whopping 81% of Californians think government should be responsible for ensuring everyone has health care, according to a Field Poll released today, which shows the increasing nervousness about eroding health coverage.

Other interesting stats:
  • 39% report being "very concerned'' that they or someone close to them will
    be without coverage
  • 77% agree that as many people need to be insured as possible
  • 65% blame profit-driven insurance and drug companies for high costs
It's the first of two polls specifically about voter attitudes toward health care. The second, to be publicly released tomorrow, promises to be interesting also.

posted by Hanh Kim Quach | Permalink | 3:56 PM


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Anthony Wright is the executive director,
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.