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All in, for 2008...

Monday, December 31, 2007
 
I typically write a Year in Review synopsis for Health Access California (see this one for 2006). But even on this last day of 2007, it's too soon to assess the year.

In one way, this has been a banner year for the longstanding effort to expand coverage and reform.
* In California, "The Year of Health Reform" yielded a wide range of policy conversation on many health reform issues not discussed in over a decade, and the serious engagement of the Governor and legislative leaders--a rare combination.
* At the national level, health care emerged as the top domestic issue in the presidential campaign, with all the leading Democrats putting out ambitious yet credible plans for near-universal coverage expansions.
* The conversation has been broad as well--from the Its Our Healthcare! statewide campaign which helped coordinate a consumer campaign at a new level of activity and effectiveness, to the renewed attention to single-payer solutions through grassroots efforts and media. The policy conversation at the state and federal level yielded its own media, along with Michael Moore's movie Sicko, renewed scrutiny of insurance company practices, and new reports on the problems with the "broken health care system."

At the same time, none of this yielded an actual change in policy... yet. The negotiations between the Governor and Speaker yielded a groundbreaking reform proposal, but it still has to pass the Senate and the ballot. And any policy changes out of the presidential campaign won't start at the earliest until a new President is sworn in in 2009.

At the same time, the changes that were made seems to take steps backward, or at least postpone the positive momentum.
* At the state level, budget cuts undid efforts to enroll eligible children in public coverage programs, and delayed the start of a prescription drug discount programs for the un- and under-insured. A looming budget deficit suggests far worse cuts are expected to be proposed.
* Regulations were finally approved at the Department of Insurance and Department of Managed Health Care on language access to care, but other regulatory proceedings are stalled or going backwards, especially on timely access to care.
* At the federal level, there was a brusing battle over SCHIP, the State Child Health Insurance Program, which did show strong bi-partisan support for the program, but a new polarization that led the President to twice veto a re-authorization bill. A bill was finally signed to extend the program only to March 2009.

So with health reform, the budget, the presidential elections, etc., the issue isn't with 2007, but the real question is what 2008 will bring.

I think the analogy for health care consumers is a poker player, who doesn't start off in a strong place, and as the hand continues sees his chips diminish even as the potential of the pot increases.

Next year could be the best of times, with a major health reform passed in California, new revenues supported to make it real and forestall bad budget cuts, and a new President committed to national reform... or the worst of times, with a bad budget deficit forcing bad cuts and choices, with a policy stalemate stopping hope for new revenues, or new reform efforts.

All in...

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posted by Anthony Wright | Permalink | 1:44 PM


 
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The stakes...

 
Bob Laszewski at the Health Care Policy and Marketplace Review, an observer of the national heath policy debate, make a couple of interesting points in his latest blog post about the upcoming ballot campaign.

He correctly notes that the California reform backed by Governor Schwarzenegger and Assembly Speaker Nunez is very similar to the plans of the leading Democratic presidential candidates--Edwards, Obama, and Clinton.

He places huge import of the November 2008 vote on this ballot measure, not just on the fate of California's reform, but of the reform conversation at the national level, regardless of who wins the presidency.

I agree that if California is able to pass reform, just as a new president is being elected, that would be a huge boon to the national effort. It would give the new President a mandate for health reform.

What if the ballot measure loses? Laszewski thinks it would stifle the debate. Losing would not be good, but I am not so sure it would stop the national effort. In 1992, California had a health reform proposal, Prop 166, that only got 32% of the vote, but that didn't stop President Clinton from his major attempt at health reform.

In fact, the experience of Health Access California is that key consumer advocacy issues that were initially unsuccessful at the ballot became some of our biggest legislative victories in the past decade.
* Consumer groups placed HMO consumer protections--Props 214 and 216--on the 1996 ballot, which got no more than 42% of the vote, but which led to the enactment of the HMO Patients' Bill of Rights by 2000.
* In 2005, the prescription drug companies spent $80 million to defeat Prop 79 to have the state negotiate drug prices for uninsured and underinsured Californians, but a different version of that bill was signed into law in 2006.

Two health coverage issues were on the ballot in recent years--a minimum employer contribution to health care, and a tobacco tax to fund hospital care and children's coverage. Both lost, but very narrowly (49%, 48% respectively). The election result did not stop the momentum behind those ideas; in fact, both concepts are in the new package now backed by the Governor and Speaker.

From the right, we also have conservative groups returning to the ballot in 2008 after losing previously, on property rights and eminent domain for a second time, and on parental notification for abortions, for a third time in a row.

Don't get me wrong: it's much better to win. Much. But in California, losing on the ballot is only losing when you give up. And if you don't try, you've given up and you've lost to begin with.

Final thought: The much bigger deal to the prospects of health reform at the national level is who is elected President. And it would be interesting to have the most prominent Republican Governor in the nation stumping for a health reform package that is similar in its outline to that of the Democratic presidential candidate.

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posted by Anthony Wright | Permalink | 1:01 AM


 
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Continuning coverage of the ballot...

Saturday, December 29, 2007
 
There's a decent amount of coverage today on the initiative being filed with the Attorney General, by Michael Rothfeld in the Los Angeles Times, Tom Chorneau in the San Francisco Chronicle, Aurelio Rojas in the Sacramento Bee, and Laura Kurtzman at the AP. They include different descriptions of the content of the initiative, as well as some political tidbits: one suggests that the campaign consultants will include Steve Schmidt (of the Governor's team) and Gale Kaufman (from the Speaker's side).

Blog coveage includes KQED Capitol Notes and the Alan Katz Health Care Reform Blog, which provides a little more on the timetable. With the initiative filed yesterday, Attorney General Jerry Brown has until February 15th to release a Title and Summary; The window to collect signatures will be between whenever the title and summary is released, and April 21st, when signatures need to be turned into the county registrars.

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posted by Anthony Wright | Permalink | 3:20 PM


 
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First take at the ballot measure...

Friday, December 28, 2007
 
It's official and filed.

The initiative would ask voters to approve a majority of the $14 billion a year to get a better health system. It includes some of the financing of AB x1 1, including the employer contribution, the hospital fee, the county share-of-cost, and the tobacco tax, now set at $1.75.

It's submitted by Governor Schwarzenegger and Speaker Nunez themselves. (Interesting side note, as someone who's submitted ballot measures in the past: This mean they are the ones who have to sign all paperwork henceforth, regarding petitions, ballot arguments, etc.)

We'll put out a broader analysis soon, but some things of note:

* The hospital fee language is similar to what has been in print, and would be used to bring in federal matching funds that would go back to hospitals through increased Medi-Cal rates and through coverage expansions.
* The state coverage expansions will provide savings for counties, who now provide some care to medically indigent adults, and some of those savings will be re-invested into the coverage expansion.
* Children's groups were able to get one-time bridge funding, so that children could stay on county children's programs until the statewide universal children's coverage program was up and running.
* The tobacco tax backfills a range of Prop 10 and Prop 99 programs to help ensure they are not impacted by lowered consumption due to the higher tax, with the exception of money that went to children's coverage.
* The employer contribution section is similar to what has been described, where the employer contribution is scaled up to 6.5% of payroll. It seems to pick up on the suggestion of Judge White suggestion in his San Francisco ruling, placing the assessment on all employers, but then offering a "credit" for those they contribute to health care in other ways.
* It is written with the explicit "expectation" that the act is "essentially the same" as the way it was passed in the Assembly. The Senate will likely be able to make clarifications and refinements, but if there are major structural changes, then the ballot measure will probably need to be refiled.

Lots to go over...

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posted by Anthony Wright | Permalink | 5:57 PM


 
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Ballot beginnings...

 
We hear that Governor Schwarzenegger and Speaker Nunez are filing the initiative with the financing for AB x1 1 today. We'll post more when we have more.

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posted by Anthony Wright | Permalink | 1:38 PM


 
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The actual impact of the SF ruling...

 
What's the impact of the court ruling in San Francisco?

As the San Francisco Chronicle reports today, the immediate impact is that Healthy San Francisco will not be able to extend to it full potential, restricting access for 26,000 middle-income San Franciscans. That's the unforunate human impact of the decision. Whether it has a long-term impact on the financing of the rest of the program has yet to be seen, but it's a concern.

But maybe not for long. There's no guarantee of what will happen on appeal. As the Workplace Prof Blog sees it, "I expect an appeal to the Ninth Circuit where all bets are off and panel composition will be key."

As for state health reform? A ruling on one type of health reform is a ruling on... one type of health reform. What was proposed in San Francisco is different in detail, structure, and scope from what is proposed at the state level.

It's not a surprise that a George W. Bush-appointed judge with a background as a corporate lawyer struck down a San Francisco ordinance, based on a ambiguous federal law that this very judge quotes is a "veritable Sargasso Sea of obfuscation."

Despite the fact that "the task of developing a clear rule to identify whether ERISA preempts a particular state law 'has bedeviled the Supreme Court'", this judge took an expansive view of ERISA pre-emption. But even in ruling against San Francisco and the labor unions who intervened, he keeps the door open, and proposed something that could pass muster:

He then describes the very structure in SB2/Prop 72 of 2004, and what is essentially what is expected to be part of the financing of AB x1 1: Assess all employers, but provide a credit/reduction for those who make health expenditures directly for their workers.

It's unfortunate that the decision will impact San Franciscans trying to get care, at least until the appeal. But it shouldn't impact state efforts, whether for AB x1 1 or SB840, and might even offer an opening...

(Largely cross-posted from a discussion at Calitics).

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posted by Anthony Wright | Permalink | 1:07 PM


 
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Why employers matter...

Thursday, December 27, 2007
 
The San Francisco court decision and the ERISA issue in general raises the question: why do health reforms seek to raise money from employers, rather than other sources of funds? (The Sacramento Bee's Daniel Weintraub is like a broken record on this point.)

In front of the LA Times editorial board, Mayor Gavin Newsom gave a good answer a few months ago, in talking about the Healthy San Francisco program:
So $104 million's there; $56 million comes from individuals in point-of-service fees, which are these co-pays and monthly premiums based on ability to pay.

And the rest comes from — and here's the controversy, and this, there's always gotta be a controversy with health care — there's a mandate to businesses, starting with businesses with 50 employees or more. Incidentally, those represent, the mandate will represent only 13% of the businesses in the city, because 87% fall into the category of 50 employees or more or they fall into a category where they don't already provide a baseline of services. So you're affecting about 13% of businesses above 50 employees or more that aren't necessarily investing in the health care of their employees. It works out to a de minimis cost of the overall $196 million. It's about $28 million, the business mandate.

The reason we have a business mandate, again, is for no other reason, it's not intended for the money so much as to create a floor of expenditure. Here's the reason: I've got about 19 small businesses I've created, started restaurants and hotels. If the city said, as I have, that we're gonna take care of health insurance, I'd say fantastic. I'll dump all my health care; city picks it up. Then our uninsured population goes from 82,000 back to 190,000, 200,000, 300,000, and the system collapses. So we create a floor so there's no dumping out. And this is the controversy. The restaurant association, of which I'm a former member and large contributor with our nine restaurants, have sued us. And we'll see if they're successful. And if they are we'll have to be more creative.

AB x1 1 also doesn't raise very much new money from employers, but the employer contribution standard is an important component for practical reasons. The majority of Californians get coverage through their employer, or the employer of a family member. Even if we were to switch to another type of health care system, you would need some mechanism to keep that significant investment in the health system.

Mayor Newsom mentions the issue known as "crowd-out:" The more that a state or city offers coverage up the income scale, the more likely they might replace the coverage of employers that already offer coverage. In a world of limited resources, that'a problem, but can be solved by setting a minimum employer contribution.

Finally, the issue is fairness. Policymakers could simply have a flat tax that impacted all employers, regardless of whether they provide coverage. No one would question that arrangement under ERISA--but that would be grossly unfair to those employers who did offer coverage and were already paying for their workers, in essence asking them to pay more to help pay for the workers of those employers who don't offer coverage.

And that's the irony of the Golden Gate Restaurant Association's lawsuit. Despite their rhetoric, they aren't actually attacking employer contributions for health care. They are attacking the ability to provide some equity for employers who actually cover their workers.

And now, they is undermining San Francisco's important health program, and some of the uninsured that were going to be helped. Hopefully--appeals pending--not for long.

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posted by Anthony Wright | Permalink | 3:59 PM


 
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An opening?

 
On his blog, the Sacramento Bee's Daniel Weintraub opines on the Judge White's decision on Healthy San Francisco.

In reading the decision, he notes something that I noticed as well: that even this George W. Bush-appointed judge, with his very expansive view of ERISA pre-emption, left the door open for state and local health reforms. He even suggested what he thought might pass muster:
"The Court is not convinced that other alternatives for creating a program for providing public health care are not viable. Defendants propose an increased general tax requirement, but state the unfairness of not taking existing health care expenditures into account. Without wading into legislative dominion, the Court can envision such a tax program that take existing health care expenditures by private employers into account in the form of tax credits."
Such a structure was exactly what was proposed in SB2/Prop 72 in 2004, and it's a version of what is being proposed with the financing to AB x1 1.

There's lots of ways to structure an employer contribution requirement, and Maryland was different than San Francisco, which is different from Massachusetts, which is different from SB2, which is different from AB x1 1.

Some legal experts believe that the Ninth Circuit has on-point cases that may lead this case to be overturned on appeal. But even this ruling provides an opening.

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posted by Anthony Wright | Permalink | 3:36 PM


 
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When judges attack...

Wednesday, December 26, 2007
 
A marauding tiger may not be only bad thing to come out of San Francisco this week.

This evening, a Judge Jeffrey White ruled with the Golden Gate Restaurant Association and against San Francisco and a key part of the ordinance that created the Healthy San Francisco program. Here's the San Francisco Chronicle coverage.

We've outlined in previous posts about the line of reasoning about how health reforms might withstand an ERISA challenge. The question of that federal law's impact on state and local health reforms has split judges--such as the appeals court in Maryland--and it's unfortunate that this particular judge sided against San Francisco's important health reforms.

Both sides were prepared to appeal to the Ninth Circuit, and the city is expected to file their appeal on Thursday. The city should appeal: San Francisco has a strong case to make on behalf of its residents, to improve their health care system while giving employers different options to meet their obligations.

Some will over-read this decision, both its implications for health reform in San Francisco and California: This is far from the final word on health reform; it's actually just the first round.

First, there will be an appeal in this case. As for state reforms like AB x1 1 (or SB840, etc.), they have different structures than the ordinance in San Francisco, which had a different framework than previous efforts in other states and counties. A ruling about one does not necessarily impact the other.

The proposed health reform in the California legislature would continue to allow multi-state employers to have a national benefits package for their workers, which is the focus of federal ERISA law. Like other state reforms, it needs to be vetted by the courts, but with its specific language and specificity.

San Francisco should and must appeal; The efforts of California and other states must continue; What's the alternative? Health reform is too important and too urgent to wait for the federal government.

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posted by Anthony Wright | Permalink | 6:56 PM


 
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You want answers? We have answers!

 
Maybe because it's a slow news time, but there's two excellent Q&A articles that help explain the health care reform proposal now pending in the Senate. In the next year, it will be essential for the news media to continue to provide factual descriptions of the plan, racing than just the political jockeying of the moment, which may be newsworthy, but may miss the point.

FOR CONSUMERS:
Timm Herdt at the Ventura County Star does an admirable job of explaining the proposal in plain English, answering the questions of an average Joe--especially those that have insurance, and wonder if there will be any impact on him.

He does spotlight a benefit that many miss: That all workers will be able to pay for their premiums or share-of-premiums with pre-tax dollars. By requiring all employers to offer so-called "Section 125" plans, workers up and down the income scale would be eligible to get a 15-40% discount on premiums. "Thus, workers who pay $2,000 a year in premiums would pay from $300 to $600 less in federal income taxes, depending on their tax brackets."

That's not a small sales pitch to the insured voter, along with the potential cost containment provisions, the improvement of the health system in general by getting federal matching funds and the renewed focus on prevention. And the security of knowing that if they change jobs or otherwise experience a change in life circumstance, that coverage will be available and affordable.

FOR BUSINESSES:
Ilana Debare at the San Francisco Chronicle has a short and simple explanation of the health plan for businesses--which should help allay the fears of small business, especially, that the proposal is more of a benefit than a burden for them.

In a related article, one big business leader, Chris Lischewski, the CEO of Bumble Bee Foods, based in San Diego County, has a supportive editorial in the North County Times. His company is a member of the Safeway-led Coalition to Advance Healthcare Reform.

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posted by Anthony Wright | Permalink | 10:58 AM


 
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Season's Greetings

Monday, December 24, 2007
 
We'll continue posting through the week, as we anticipate continued developments on the budget, health reform, and other issues. But we didn't want to neglect our holiday wishes...


From everybody at Health Access California, may you have a happy and healthy holiday season.

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posted by Anthony Wright | Permalink | 3:05 PM


 
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What a 10% cut means....

Sunday, December 23, 2007
 
Judy Lin at the Sacramento Bee describes the budget situation, and anticipates the kinds of cuts that we will be facing.

If the Governor is serious about trying to solve this budget deficit through cuts alone, it's going to be very ugly, with a significant and dire human impact.

What does a 10% cut in health care--roughly a third of the state's budget--mean? Just for Medi-Cal, it sounds small, but:
* A 10% cut in Medi-Cal eligibility would mean denying coverage to 680,000 of the 6.8 million Californians on Medi-Cal--largely low-income children, parents, seniors, and people with disabilities.
* A 10% cut in reimbursement rates in Medi-Cal would be hard, given that Medi-Cal has one of the lowest rates in the nation already (it's one of the things we are trying to fix with health care reform).
* A 10% cut in benefits would mean having to deny millions of people key services. In the previous budget crises, proposals called for denying coverage for a range of benefits in Medi-Cal, including coverage for prostetic limbs, medical equipment like asthma inhalers and diabetic test strips, and durable medical equipment like wheelchairs.

Here's a comprehensive chart, a multi-year Health Budget Cuts Scorecard, of some of the cuts proposed, both those rejected and those actually made, during the last budget crisis of a few years ago.

In the new year, we're going to have to be clear that these options are not acceptable, and force the conversation to include other options--including taxes and revenues.

This budget crisis can't be solved by cuts alone.

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posted by Hanh Kim Quach | Permalink | 7:12 PM


 
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Commentary on the California plan...

 
Some of our member organizations have just put out their analyses, mostly supportive, of AB x1 1, including CALPIRG and the California Labor Federation. (For good measure, here's our initial analyses.)

In the national perspective, the Progressive States Network, Ron Brownstein of the National Journal, and Ezra Klein has given favorable reviews. With all the handwringing about going to the ballot here in Sacramento, it's interesting to see Ezra's positive take on the ballot option as a way to avoid legislative obstructionism by recalcitrant Republicans.

posted by Anthony Wright | Permalink | 4:17 PM


 
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Mid-terms for Massachusetts...

Saturday, December 22, 2007
 
Community Catalyst, a national consumer advocacy organization we work with, published an end-of year analysis of the much-discussed Massachusetts reform, which provides a direct look and the successes and the shortfalls of that effort.

Entitled "Revisiting Massachusetts Health Reform: 18 Months Later," the report comes out just as the state has indicated that 300,000 people got covered--half of the state's uninsured. At the same time, it acknowledges some of the issues, including their lack of meaningful employer contribution and other questions about long-term financing.

While Massachusetts largely redistributed existing funding, California's proposed AB x1 1 raises significant new resources, so perhaps we've learned some lessons already. Health Access California will be putting out an analysis comparing the two state and the two plans in short order.

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posted by Anthony Wright | Permalink | 6:22 PM


 
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The initial public response...

 
The Field Poll did preliminary polling on the ouline of the health reform proposal in AB x1 1 (Nunez)... and the news is pretty stunning. Three to one support: 64%-23%. Here's the question:

"The broad outlines of the reforms being proposed call for making changes
within the framework of the current health insurance system. Those who currently have insurance could retain their same coverage. Those who do not have insurance would be required to obtain a minimum level of coverage from either an employer, government agency, or by paying for it themselves. The state would subsidize the costs of insurance for low income people. Middle income families would receive tax credits if they need to buy their insurance in the open market. Insurance companies would be required to offer coverage to anyone without regard to health condition. Most employers would be required to offer health insurance to their employees or pay into a state fund."


The cross-tabulations are fascinating, showing broad support in all categories. With even Republicans and Orange County residents show majority support, and they are the only demographic group with support under 60%. Here are the aggragate results (support-oppose):

Democrats: 74%-16%
Independents: 61%-22%
Republicans: 52%-34%

San Francisco Bay Area 68%-20%
Los Angeles County 67%-17%
Other Northern California 65%-21%
Other Southern California 62%-24%
Central Valley 62%-26%
San Diego County 60%-22%
Orange County 54%-34%

Female: 65%-21%
Male: 61%-26%

18-29 year olds: 67%-20%
30-39 year olds: 68%-19%
40-49 year olds: 64%-25%
50-64 year olds: 65%-25%
65 or older: 55%-27%

African-American: 68%-20%
Latino: 66%-21%
Asian/other: 62%-23%
White non-Hispanic: 62%-25%

Less than $20,000: 69%-16%
$20,000 - $39,999: 68%-20%
$40,000 - $79,999: 61%-26%
$80,000 or more: 67%-25%

Following health reform efforts very closely: 69%-23%
Following health reform efforts somewhat closely: 68%-22%
Following health reform efforts not too closely: 59%-24%
Following health reform efforts not at all closely: 55%-26%

The tobacco tax also had broad support: 63%-33%, with 50% in strong support. That's consistent with last year's Prop 86 campaign result, where the proposal got 48.2% support despite $60 million spent against it by the tobacco industry, and for a proposal that would have provided a much narrower benefit.

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posted by Anthony Wright | Permalink | 5:43 PM


 
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Making the ballot...

Friday, December 21, 2007
 
Shane Goldmacher has the full description about the "real deadline" for health reform making the November 2008 ballot. It explains exactly where we are with health reform--or what are the options left.

Happy holidays!

posted by Hanh Kim Quach | Permalink | 5:58 PM


 
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Comparisons...

 
The most surprising aspect of the critiques of the proposed health care reform, AB x1 1 (Nunez), by Senator Sheila Kuehl and Mayor Gavin Newsom is that they both came out first in the blogosphere.

After all, both these Democratic politicians, along with the active critics from the Republican legislative delegation, are authors of their own health care plans. Senator Kuehl has SB840, and Mayor Newsom has Healthy San Francisco. They are excellent reforms--Health Access California supported and worked very hard for both health reforms last year, getting Healthy San Francisco passed and implemented, and SB840 on the Governor's desk.

But we don't think it is an either/or situation. As Mayor Newsom indicated, "we all need to understand that building a workable Single Payer system will take time," and that he could support "interim steps" to that goal.

Some of the critiques are overstatements ("nothing is provided"? a few million more folks with Medi-Cal coverage might disagree). Some are misreadings of the bill, but it's good for these to be pointed out, so that the issues are addressed with clarifying language. (We'll address specific points from these and other critiques in another post.) We at Health Access California are seeking some similar assurances ourselves. Other suggested changes are things we directly support (such as expanding public program coverage to undocumented adults, or increasing subsidies further), but are constrained by political or financial pressures.

I agree with one of the themes of both posts, which is that AB x1 1 is not "universal" coverage. It's a major, comprehensive health reform that will help millions, expanding coverage for the uninsured (particularly low-income Californians) while providing more security and savings for those with coverage. Maybe it should be called "near-universal." But that's a big improvement from the status quo.

And the comparison isn't with the Kuehl or Newsom plans, but with the status quo.

And as Timm Herdt wrote in the Ventura County Star, the status quo is simply not acceptable, and no one defends the current system.

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posted by Hanh Kim Quach | Permalink | 12:11 PM


 
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Kudos to CUs

 
Saw a report tonight in the NewsHour with Jim Lehrer on lead paint in toys as a major health issue. As a father of a 14-month old, it got my attention, and that was before it interviewed a college classmate, and her economic studies showing a correlation between lead and crime statistics.

But much of it hailed the work of Consumers Union, the publisher of Consumer Reports magazine, taking on the lackluster oversight provided by the Bush Administration and the Consumer Product Safety Board on this issue.

I was reminded of a recent New York Times article spotlighting Consumer Reports and its parent organization, Consumers Union. The article, called "Success Without Ads" gives only a hint of the work that CU goes through to maintain its independence and reputation. Not only do they not take ads, they refuse to let their name be run in other people's ads. They don't accept any sample products.

The article talks about the test facility in Yonkers, NY, which I had the priviledge of touring many months ago. It's pretty impressive and surreal. One room is totally devoted to washers and dryers, another just on light fixtures and ceiling fans. It's pretty impressive.

I've had the chance to work alongside the good folks at CU for the entirely of my career in consumer advocacy, in one way or another, working with DC advocacy, their Yonkers headquarters, and most recently, their San Francisco office. I am proud they have been an active members of the Health Access California board, and it's great they have been getting a little more attention.

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posted by Anthony Wright | Permalink | 1:38 AM


 
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The Status Quo

Thursday, December 20, 2007
 
The California HealthCare Foundation has just released its annual California Employer Health Benefit Survey.

Rundown of interesting numbers:
  • California premiums increased at a rate faster than the rest of the nation -- 8.3% v 6.1%.
  • Firms are requiring HMO copays of $20 more than doubled from 14% in 2004 to 30% this year.
  • Number of employees with deductibles ranging between $500-$999 more than doubled from 9% in 2000 to 21% this year.
  • The number of firms offering high deductible plans has remained the same over the past three years at 18% (phew)

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posted by Hanh Kim Quach | Permalink | 11:34 AM


 
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You knew there had to be a catch....

 
The America's Health Insurance Plans, the industry trade group, came out with a "Guaranteed Access'' proposal this week as a defense against state-level activity and national discussions about reforming the insurance market. (The New York Times writes a story about their proposal here.)

The good news is that the industry admits -- kind of -- that maybe some of them (maybe) have been a little overzealous with denying Americans coverage - and maybe that should change....
(Interesting factoid that I didn't know before -- 11% of those who apply for coverage are denied; however, 30% of the pre-Medicare age group, typically described as the early retiree set between 50-64, is denied when they apply)

On the flip side, insurers would only agree to cover "everyone'' if the states/taxpayers take on the most "high risk'' cases. So that means the patients they expect to be the sickest and most expensive should be insured by a state-run pool, subsidized by taxpayers. That way, insurers can continue to eek profits out of the remaining relatively healthy population.

It's a classic case of "socializing the risk, and privatizing the profits.''

Give me "socialized medicine'' anyday...

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posted by Hanh Kim Quach | Permalink | 10:38 AM


 
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Planning for the new year...

 
As we plan for the next year, the Senate Health Committee, chaired by the Senator Sheila Kuehl, is planning to meet on January 9th, to consider the following bills. (Letters due January 3rd):

SB 254 (Ashburn) – Emergency medical services: licensure
SB 365 (McClintock) – Out-of-state carriers
SB 389 (Yee) – Health care coverage: claims
SB 891 (Correa) – Health facilities: elective percutaneous coronary intervention pilot program
SB 1000 (Harman) – Substance abuse: adult recovery maintenance facilities
SB 1026 (Calderon) – Personal income and corporation taxes: credit: qualified health care provider

ABX1 1 (Nunez) is scheduled to be heard on January 16th. (Letters due January 10th).

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posted by Anthony Wright | Permalink | 10:31 AM


 
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The Season of Giving...

 

To the thousands of people that read this blog in the course of a week, we thank you for coming and being involved and engaged in the health policy debate in California. If this blog and the other work of Health Access has provided a service, a resource, or just an excuse to procrastinate, please consider making an end-of-year contribution to the Health Access Foundation. You can simply click here.

It's been an exciting year. We've been busy, and not just with "the year of health reform" and pushing as hard as possible for consumers on affordability, cost containment, and other key health issues. We've also been working on the SCHIP and children's coverage, timely access to care and other regulations to oversee HMOs, assisting language access and medical interpretation, implementing our new law against hospital overcharging, working to watchdog both government agencies and the health industry on behalf of California consumers, and keeping alive the vision of universal single-payer health care in the midst of the battles of the moment.

Next year, we'll need your support and contributions, as we gear up a major campaign against health care buddget cuts, continue the work around both immediate and long-term health reform, and work to make health care a major issue in the campaign season.

The more support we have, the more we can do. Any contribution would be greatly appreciated.

For individuals who want to make a tax-deductible contribution to research, education, and organizing work, click here:
http://www.health-access.org/hafcontibution.htm

For organizations who want to join Health Access California as a organizational member for 2008, click here:
http://www.health-access.org/joinhac/organization_signup.htm

Thank you for your consideration and contribution this holiday season.

Labels:


posted by Anthony Wright | Permalink | 1:30 AM


 
a


The Return of the Ed Boards...

Wednesday, December 19, 2007
 
Here's some of the editorial boards starting to weigh in on the health reform plan:

Los Angeles Daily News: Health Care Deal Isn’t Perfect, But It’s the Best One So Far
Los Angeles Times: California’s Health Care Plan
North County Times: Caution, Politicians At Work
Orange County Register: Health Plan – A Step Down The Wrong Road
San Jose Mercury News: Schwarzenegger’s Insurance Plan – A Dose Of Cynicism Is Healthy
Contra Costa Times: Analyze Health Reform
San Diego Union -Tribune: Heed Perata

Some positive, some negative (although predictably), and many take a very editorial-board-ish let's wait for the details and the financial analysis.

Labels: ,


posted by Anthony Wright | Permalink | 9:40 PM


 
a


Arnold should ask for a recount...

 
With the Hollywood writers' strike, I've been missing David Letterman's top ten list. And I know you have too.



So here's the top ten health policy stories of 2007, as prepared by the Commonwealth Fund. I would have a different list, but it's interesting reading.

Labels:


posted by Anthony Wright | Permalink | 8:19 PM


 
a


Passing the SCHIPs...

 
Unable to come to an agreement with a veto pen-wielding President, the Congress has passed a short-term extension for SCHIP, the children's coverage program, through March 2009. We understand this postpones a decision by MRMIB to disenroll children because of a lack of federal funds, at least in the near-term.

This doesn't solve the problem in the long term, or for those children who are now uninsured, but that would get health coverage through the proposal health reform proposal. It doesn't address the President's effort to cap any expansions above 250% FPL, just as the Assembly passes a bill that includes an expansion for children up to 300% FPL. But we live to fight another day.

Labels:


posted by Anthony Wright | Permalink | 8:00 PM


 
a


Resources...

 
Here's the Governor's description of AB x1 1, the Health Care Security and Cost Reduction Act:
http://www.fixourhealthcare.com/plan

For the official text of the bill, the detailed floor analysis, and the vote count, go to the Assembly website under "AB x1 1":
http://www.assembly.ca.gov/acs/acsframeset2text.htm

Here's Speaker's Nunez's press release:
http://democrats.assembly.ca.gov/newsline/releases/20071217ad46pr03.htm

Here's more from the California Health Reform website of the California HealthCare Foundation
http://www.calhealthreform.org/content/view/22/39/

And here's a short two-pager from the California Budget Project:
http://www.cbp.org/pdfs/2007/071218_ABX11Writeup.pdf

As always, more to come...

Labels:


posted by Anthony Wright | Permalink | 1:06 AM


 
a


How does it end?

 
I witnessed the press conference that Frank Russo reported on at the California Progress Report, and saw lots of coalition partners there: CALPIRG, Consumers Union, California Pan-Ethnic Health Network, Latino Issues Forum, California Primary Care Association, and many others, including allies who spoke from the 100% Campaign of children's groups like Children's Defense Fund, AARP, as well as AFSCME, SEIU, and some other unions.

All folks that are still pushing for health reform in the next few weeks, albeit in different ways. Some are downright cheered by the passage of the Assembly bill, and the press attention, coalition interest, and general momentum it provides.

Others, already concerned about the prospects on the ballot, now see a potential obstacle in the Senate. (Senator Perata's "DOA" comments have been clarified, suggesting there's still hope right after the holidays.)

This process is like a bad action movie, in more ways than one. Some of the Governor's health team are holed up in a back room of the Capitol, with movie posters filling the wall space... many from films that starred their boss.

The "Year of Health Reform" was an Arnold Schwarzenegger movie, with lots of hype and buzz, and an opening sequence that was a blockbuster in terms of getting attention. Like in most movies, the protagonist was left for dead many, many times. And then, just at the climatic ending (Republicans legislators blockade any taxes), there's a cliffhanger...

The special session is the sequel, and it's not over yet. But like buzzworthy films (Back to the Future? Pirates of the Californian?), they planned a trilogy, with the third act as the ballot campaign for financing.

My point is that everytime the press calls the health reform effort dead, it seems to come back to life. Just like the hero in an action movie. Or the villain. Actually, the times that I have been most optimistic is when the media says that it is stalled. So I think the process will continue.

I've seen Indiana Jones get out of worse situations

Labels:


posted by Anthony Wright | Permalink | 12:20 AM


 
a


Who benefits?

Tuesday, December 18, 2007
 
Who gets helped in the current framework of AB x1 1?

Here's a preliminary list, as we work through the possibilities:

* Virtually all uninsured children (800,000) who would get good, comprehensive Healthy Families-level coverage.
* Medi-Cal recipients (6.8 million children, seniors, and people with disabilities) would get better access to doctors and hospitals, due to an increase in Medi-Cal rates.
* Adults and parents up to 250% FPL ($25K for an individual, $50K for a family of four) who would get comprehensive with minimal cost-sharing.
* Many of those 250-400% FPL ($41K for an individual, $82 for a family of four) who would get the security of not having to pay more than 5.5% of their income for premium, and could pay less. (Many pay far more for coverage now.)
* Those who don't get group coverage who would be denied because of "pre-existing conditions," (an estimated 650,000+), who would now have access to coverage, and eventually not have a higher rate because of it.
* Employers who provide health care to their workers, but find that they compete against some who don't.

posted by Anthony Wright | Permalink | 2:32 PM


 
a


Balancing roles...

 
All year, we at Health Access have been balanced multiple goals in the "Year of Health Reform."

The first is to provide the information, the reporting, and the policy analysis to help our member and allied organizations be involved in the health policy debate. A primary role is to provide the best possible resources so that groups can most effectively advocate for their members and constituencies. This blog has been part of that effort, and we hope advocates and activists have found it useful, in addition to our direct work to influence policy, as organizers and advocates.

The other balancing act has been to be *for* reform and keep the momentum for reform up through the course of the year, while at the same time being vigilant in our consumer advocacy role of protecting our constituency from--which are all of California's health care consumers--all 36 million of them.

The Governor's original plan made that a significant challenge, since it included some good reform elements but with untenable burdens on some consumers, and other issues of concern.

I am far more enthusiastic about AB x1 1 as a framework, but we will continue to solicit assurances as we move forward, not just to clarify policies for consumers, but to assure voters at the polls, which will be very important.

Our continued advocacy on specific issues like affordability is in the context of actively supporting the overall reform, and moving it forward--the sad and sagging shape of the status quo demands it. But this means our work isn't done. Not by a long shot.

Labels: , , ,


posted by Anthony Wright | Permalink | 1:58 AM


 
a


More on the debate...

 
HEALTH ACCESS UPDATE
Monday, December 17, 2007


ASSEMBLY PASSES HISTORIC HEALTH EXPANSION AND REFORM PROPOSAL

* Agreement between Governor Schwarzenegger and Speaker Nunez passes first hurdle
* Proposal would extend health coverage to nearly 4 of 5 million uninsured Californians.
* Would be largest expansion of coverage since the creation of Medicaid and Medicare.
* Latest amendments include tax subsidies for families earning up to $82,600 (family of four) to help buy coverage, and for early retirees not yet eligible for Medicare.

New on the
Health Access WeBlog: More on the Assembly vote and reaction; Sen. Perata's LAO request; Analogies; More on the content on AB x1 1. Budget blues.


The California state Assembly Monday, on a 46-31 party line vote, approved an historic expansion of health care, which could ultimately provide health coverage to more than 95 percent of California residents.

“California is taking a giant step forward,’’ said Gov. Arnold Schwarzenegger, calling the Assembly’s passage of AB x1 1 “courageous.” Schwarzenegger spoke at a news conference flanked by Assembly Speaker Fabian Nunez and a phalanx of Democratic Assembly lawmakers. Also present were “groups who normally are opposed to one another” -- representatives from a broad range of health care interests: from small businesses, large businesses, physicians, labor unions, consumer groups, community of color organizations, hospitals and insurance companies.

AB x1 1 (Nunez/Perata) is the latest measure of nearly a half a dozen comprehensive health reform measures introduced in Schwarzenegger’s so-called “Year of Health Reform.’’

Schwarzenegger, over the past five years has vetoed or opposed major coverage expansions, including children’s coverage, single-payer universal coverage and an employer mandate. However, this year, Schwarzenegger and legislative leaders volleyed bills back and forth all aimed at reducing the ranks of uninsured in California , numbering up to 5.1 million continuously without coverage. Nearly one year after Senate Leader Don Perata and Nunez introduced separate health reform packages, legislative leaders and the governor have agreed on a package in AB x1 1.

WHAT’S IN THE BILL: In a nutshell, ABx1 1 does the following:

For individuals:
* Expands public programs to all children below 300% of poverty ($62,000 for a family of four) and their parents.
* Expands coverage to parents and adults without children at home to 250% of poverty ($25,525 for an individual; $34,225 for a couple).
* Increases the reimbursement for providers who care for Medi-Cal patients.
* Extends tax credits to families between 250% and 400% of poverty (up to $82,000 for a family of four), so that the cost of coverage does not exceed 5.5% of income.
* Extends tax credits to early retirees with higher incomes could also receive tax credits, as adults between ages 50 and 64 have the highest health care premiums because of their age and health status.
* Allows every Californian to purchase health coverage without being denied because of “pre-existing’’ conditions.
* Requires every Californian to have health coverage, unless by appeal to the state, they can show that the cost of health coverage would pose a financial hardship.

For employers:
* Requires businesses to spend between 1% and 6.5% of payroll on health coverage for workers.
* Requires businesses to set up Section 125 cafeteria plans, which enable employees to use pre-tax dollars to pay for premiums.
* Creates a statewide purchasing pool that they can pay into (rather than buy separate coverage), allowing the state to negotiate large group rates for their employees.

In the health care industry:
* Imposes new rules on insurers, requiring them to provide coverage to all Californians, regardless of pre-existing conditions.
* Requires health plans to dedicate 85 cents of ever premium dollar toward patient health services.
* Requires strategies to rein in health care costs, including disclosure of cost and quality information by providers, bulk purchasing of prescription drugs, preventive care and chronic disease maintenance, electronic health records and the creation of a public insurer to compete with private health plans.

ABx1 1 would not take effect until an accompanying ballot measure is passed by voters in November 2008. That measure would contain many of the measures that would pay for the $14 billion program – including:
* 4% hospital provider fee, that would bring in federal matching funds
* Employer contribution of between 1% to 6.5% of payroll
* Tobacco tax of between $1.50 and $2 per pack.
* Counties share of caring for medically indigent.

To read a more detailed analysis, click here.

ABx1 1 was heard in Assembly Appropriations committee before being voted on by the full house.

SUPPORT AND OPPOSITION:

Those supporting the measure in Appropriations Committee was the Service Employees International Union (SEIU), 100% Campaign of children's groups, AARP, Kaiser Permanente, the American Cancer Society, Health Net, Blue Shield, American Federation of State, County and Municipal Employees (AFSCME), and Carpenters Union.

Other consumer and community groups appeared at a press conference with the Governor and the Speaker at the end of the day. (Click here to read Health Access' "support if amended" letter on ABx1 1).

Taking no position on the measure was the California Labor Federation, which said it did not have time to adequately analyze and weigh the bill and was reluctant to take a position on the measure without seeing ballot initiative language. They emphasized that they were not opposed, as had been reported. California Federation of Teachers and the State Building Construction Trades echoed those concerns.

Opposition that testified in committee included the California Nurses Association, a representative of the UFCW and Teamsters unions, a representative of the CA School Employees Association, the National Federation of Independent Businesses (NFIB), and Blue Cross of California, the state's largest insurer and longtime opponent of reform this year.

COMMITTEE DEBATE: With recent news about a $14 billion project deficit for the fiscal year, many lawmakers questioned whether this was the right time to pass such an expansive reform.

To such inquiries, Nunez and the Department of Finance both said the bill was “revenue neutral,’’ meaning that while the entire program would cost approximately $14.4 billion, it would bring with it its own sources of money (seven of them) from employers, workers, the federal government, tobacco taxes, hospitals, counties and state savings totaling $14.56 billion, which would cover the costs of the program.

Republican Assemblywoman Mimi Walters asked Nunez and the Department of Finance whether they were certain financial projections would come through. AB x1 1 relies on $4.5 billion in federal dollars in addition to other revenue sources. Department of Finance staffer Tom Sheehy said one provision in ABx1 1 would not be implemented unless the Director of Finance declared that money to pay for the program was in hand and in state coffers.

Assemblyman Mark Leno, Democrat chairman of the Appropriations committee, followed up with questions about whether the program could be turned off if money did not come in as expected. Nunez’ staff responded that ballot initiative would contain provisions to assure that insufficient funds would trigger a series of events to pull back the program, including the individual mandate and the market reforms. It would first allow the governor and legislature to fix any fiscal imbalances. If lawmakers and the governor did not act, then the pieces of the legislation would be repealed, including the public program expansions and tax credits, returning the state to the status quo.

Nunez also emphasized that ABx1 1 could be amended by future legislatures on a majority vote should unintended consequences arise, or more direction or clarification is needed for the state board that would be in charge of implementing the program.

Democrat Assemblyman Jose Solorio said he was worried about consumers who would be required to buy coverage, but unable to afford it. Nearly 90 percent of uninsured Californians earn less than 400% of poverty, according to the California Health Interview Survey. Nunez assured him that the vast majority of the Californians who would be newly mandated to have coverage under his plan would be receiving state subsidies (as tax credits) or enrolled in public programs, which have low premiums and cost sharing. Additionally, families will be able to ask for an exemption from coverage if it would create a financial hardship.

Republican Assemblyman Doug LaMalfa asked how many undocumented immigrants would benefit from this plan. In this plan, all children – regardless of immigration status – would receive coverage. But workers whose employers paid into the system would receive benefits, said Nunez, who said he didn’t want the state program to become an arm of the federal government’s immigration department.

Assemblyman Ted Lieu explained why he needed to vote for ABx1 1. “The relevant question is, ‘Does this bill do better than the status quo?’ The status quo is not working for millions and millions of people.” The status quo, for one of Lieu’s constituents, means a slow death from cancer. Linda, Lieu’s constituent, works, but does not receive health care through work. Her daughter, at age 18, cannot buy health care because of a prior heart condition. And now the constituent, herself, has been diagnosed with cancer. “What is horrific is that in one of the most advanced civilizations, we let people like Linda waste away. At the end of the day, this bill is going to save lives. For people like Linda, I look forward to going to her and saying, ‘Help is on the way.’’

Leno, from San Francisco, remarked that he would prefer a single-payer universal health care system, as has been introduced and passed nearly every year for the past five years in SB840 (Kuehl). The governor, however, vetoed that bill last year, and has promised to do the same if it reached his desk again. “My internal debate is, knowing that the governor is not going to sign a single payer bill, should we sit on our hands and say, ‘we tried?’ when we have stories of people in our districts suffering on a daily basis? Do we wait for the perfect? Or do we do something in the meantime. We will have the opportunity to make fixes in the years to come,’’ said Leno whose committee passed the bill on a party line vote.

FLOOR DEBATE: Debate on the Assembly floor echoed debates of the past year. Republicans continued to question why their proposals for Health Savings Accounts were not a proper mechanism for reform (even though they promote high-deductible plans and underinsurance) and conjured up the image of health care rationing in countries with single-payer systems--which AB x1 1 is not. Democratic legislators made the case for action immediately. More on the floor debate will be posted on the Health Access WeBlog.

PROCESS: The Legislature could not fully pass the financing elements of ABx1 1 because Republicans in the Legislature have – for most the past decade – signed a pact against “increasing taxes.’’ They view the hospital fee and employer contribution as taxes, as well as the tobacco tax. Because of that constraint, supporters of this measure will have to collect signatures and put the financing of this proposal on the ballot.

In order to have enough time to collect signatures by June for the November ballot, such a ballot measure, as a companion to ABx1 1, would need to be submitted to the Attorney General's office in the next few weeks.

For a read of this year’s health care debates, visit
http://www.health-access.org/labels/Updates.htm.

Labels: , , ,


posted by Anthony Wright | Permalink | 1:53 AM


 
a


Some initial attention...

 
Some initial reporting on the Assembly vote by Samantha Young at the AP, Jordan Rau in the Los Angeles Times, Tom Chorneau at the San Francisco Chronicle, and Aurelio Rojas in the Sacramento Bee.

Labels:


posted by Anthony Wright | Permalink | 12:50 AM


 
a


Assembly passes...

Monday, December 17, 2007
 
With new amendments published today, the Assembly passed the bill, AB x1 1 (Nunez), 46-31, on a party line vote, with the Democrats in support, and Republicans against.

Senator Perata put out a statement that asked the LAO to give an analysis about the "budget neutrality" of the proposal.

So we'll see what happens.

FYI, Health Access California put out a "support if amended" letter on AB x1 1 (Nunez), asking to move the bill forward, but conditioning full support on seeing the ballot language on financing, and getting clarifications on affordability for consumers.

Here's our letter: ABx1HACasmfloor.doc

Here's our statement:

"This proposed framework will not just offer affordable coverage to millions of uninsured Californians, but also provide security for those with insurance, to ensure access to coverage in the case of job loss, retirement, divorce, or other changes in life situation. We continue to seek clarifications and assurances on affordability for consumers in the Senate, and look to evaluate the full proposal when we see the financing elements in order to take a final position."

"This proposal removes many of the barriers that people face in getting coverage, whether it is lack of on-the-job benefits, restrictive eligibility for public programs, or insurers being able to deny for 'pre-existing conditions.' The issue is not that people don't want coverage, but that there are availability, affordability, and administrative hurdles to getting coverage. This proposal doesn't remove every barrier, but significantly improves the status quo in health care, which is rapidly deteriorating without any reform. In the context of a individual requirement to have coverage, policymakers can no longer ignore this issue, and they have an obligation to remove those barriers, now and into the future."

Labels:


posted by Hanh Kim Quach | Permalink | 6:08 PM


 
a


 

HEALTH ACCESS UPDATE
Monday, December 17, 2007


ASSEMBLY PASSES HISTORIC HEALTH EXPANSION AND REFORM PROPOSAL

  • Agreement between Governor Schwarzenegger and Speaker Nunez passes first
    hurdle
  • Proposal would extend health coverage to nearly 4 of 5 million
    uninsured Californians.
  • Would be largest expansion of coverage since the
    creation of Medicaid and Medicare.

Latest amendments include tax subsidies
for families earning up to $82,600 (family of four) to help buy coverage, and
for early retirees not yet eligible for Medicare.

New on the Health Access WeBlog: More on the Assembly vote and reaction; Sen. Perata's LAO request; Analogies; More on the content on AB x1 1. Budget blues.


The California state Assembly Monday, on a 46-31 party line vote, approved an historic expansion of health care, which could ultimately provide health coverage to more than 95 percent of California residents.

“ California is taking a giant step forward,’’ said Gov. Arnold Schwarzenegger, calling the Assembly’s passage of AB x1 1 “courageous.” Schwarzenegger spoke at a news conference flanked by Assembly Speaker Fabian Nunez and a phalanx of Democratic Assembly lawmakers. Also present were “groups who normally are opposed to one another” -- representatives from a broad range of health care interests: from small businesses, large businesses, physicians, labor unions, consumer groups, community of color organizations, hospitals and insurance companies.

AB x1 1 (Nunez/Perata) is the latest measure of nearly a half a dozen comprehensive health reform measures introduced in Schwarzenegger’s so-called “Year of Health Reform.’’

Schwarzenegger, over the past five years has vetoed or opposed major coverage expansions, including children’s coverage, single-payer universal coverage and an employer mandate. However, this year, Schwarzenegger and legislative leaders volleyed bills back and forth all aimed at reducing the ranks of uninsured in California , numbering up to 5.1 million continuously without coverage. Nearly one year after Senate Leader Don Perata and Nunez introduced separate health reform packages, legislative leaders and the governor have agreed on a package in AB x1 1.

WHAT’S IN THE BILL: In a nutshell, ABx1 1 does the following:

For individuals:

  • Expands public programs to all children below 300% of poverty ($62,000 for a family of four) and their parents.
  • Expands coverage to parents and adults without children at home to 250% of poverty ($25,525 for an individual; $34,225 for a couple).
  • Increases the reimbursement for providers who care for Medi-Cal patients.
  • Extends tax credits to families between 250% and 400% of poverty (up to $82,000 for a family of four), so that the cost of coverage does not exceed 5.5% of income.
  • Extends tax credits to early retirees with higher incomes could also receive tax credits, as adults between ages 50 and 64 have the highest health care premiums because of their age and health status.
  • Allows every Californian to purchase health coverage without being denied because of “pre-existing’’ conditions.
  • Requires every Californian to have health coverage, unless by appeal to the state, they can show that the cost of health coverage would pose a financial hardship.

For employers:

  • Requires businesses to spend between 1% and 6.5% of payroll on health coverage for workers.
  • Requires businesses to set up Section 125 cafeteria plans, which enable employees to use pre-tax dollars to pay for premiums.
  • Creates a statewide purchasing pool that they can pay into (rather than buy separate coverage), allowing the state to negotiate large group rates for their employees.

In the health care industry:

  • Imposes new rules on insurers, requiring them to provide coverage to all Californians, regardless of pre-existing conditions.
  • Requires health plans to dedicate 85 cents of ever premium dollar toward patient health services.
  • Requires strategies to rein in health care costs, including disclosure of cost and quality information by providers, bulk purchasing of prescription drugs, preventive care and chronic disease maintenance, electronic health records and the creation of a public insurer to compete with private health plans.
  • ABx1 1 would not take effect until an accompanying ballot measure is passed by voters in November 2008. That measure would contain many of the measures that would pay for the $14 billion program – including:
    * 4% hospital provider fee, that would bring in federal matching funds
    * Employer contribution of between 1% to 6.5% of payroll
    * Tobacco tax of between $1.50 and $2 per pack.
    * Counties share of caring for medically indigent.

To read a more detailed analysis, click here.

ABx1 1 was heard in Assembly Appropriations committee before being voted on by the full house.

SUPPORT AND OPPOSITION:

Those supporting the measure in Appropriations Committee was the Service Employees International Union (SEIU), 100% Campaign of children's groups, AARP, Kaiser Permanente, the American Cancer Society, Health Net, Blue Shield, American Federation of State, County and Municipal Employees (AFSCME), and Carpenters Union.

Other consumer and community groups appeared at a press conference with the Governor and the Speaker at the end of the day. (Click here to read Health Access' "support if amended" letter on ABx1 1).

Taking no position on the measure was the California Labor Federation, which said it did not have time to adequately analyze and weigh the bill and was reluctant to take a position on the measure without seeing ballot initiative language. They emphasized that they were not opposed, as had been reported. California Federation of Teachers and the State Building Construction Trades echoed those concerns.

Opposition that testified in committee included the California Nurses Association, a representative of the UFCW and Teamsters unions, a representative of the CA School Employees Association, the National Federation of Independent Businesses (NFIB), and Blue Cross of California, the state's largest insurer and longtime opponent of reform this year.

COMMITTEE DEBATE: With recent news about a $14 billion project deficit for the fiscal year, many lawmakers questioned whether this was the right time to pass such an expansive reform.

To such inquiries, Nunez and the Department of Finance both said the bill was “revenue neutral,’’ meaning that while the entire program would cost approximately $14.4 billion, it would bring with it its own sources of money (seven of them) from employers, workers, the federal government, tobacco taxes, hospitals, counties and state savings totaling $14.56 billion, which would cover the costs of the program.

Republican Assemblywoman Mimi Walters asked Nunez and the Department of Finance whether they were certain financial projections would come through. AB x1 1 relies on $4.5 billion in federal dollars in addition to other revenue sources. Department of Finance staffer Tom Sheehy said one provision in ABx1 1 would not be implemented unless the Director of Finance declared that money to pay for the program was in hand and in state coffers.

Assemblyman Mark Leno, Democrat chairman of the Appropriations committee, followed up with questions about whether the program could be turned off if money did not come in as expected. Nunez’ staff responded that ballot initiative would contain provisions to assure that insufficient funds would trigger a series of events to pull back the program, including the individual mandate and the market reforms. It would first allow the governor and legislature to fix any fiscal imbalances. If lawmakers and the governor did not act, then the pieces of the legislation would be repealed, including the public program expansions and tax credits, returning the state to the status quo.

Nunez also emphasized that ABx1 1 could be amended by future legislatures on a majority vote should unintended consequences arise, or more direction or clarification is needed for the state board that would be in charge of implementing the program.

Democrat Assemblyman Jose Solorio said he was worried about consumers who would be required to buy coverage, but unable to afford it. Nearly 90 percent of uninsured Californians earn less than 400% of poverty, according to the California Health Interview Survey. Nunez assured him that the vast majority of the Californians who would be newly mandated to have coverage under his plan would be receiving state subsidies (as tax credits) or enrolled in public programs, which have low premiums and cost sharing. Additionally, families will be able to ask for an exemption from coverage if it would create a financial hardship.

Republican Assemblyman Doug LaMalfa asked how many undocumented immigrants would benefit from this plan. In this plan, all children – regardless of immigration status – would receive coverage. But workers whose employers paid into the system would receive benefits, said Nunez, who said he didn’t want the state program to become an arm of the federal government’s immigration department.

Assemblyman Ted Lieu explained why he needed to vote for ABx1 1. “The relevant question is, ‘Does this bill do better than the status quo?’ The status quo is not working for millions and millions of people.” The status quo, for one of Lieu’s constituents, means a slow death from cancer. Linda, Lieu’s constituent, works, but does not receive health care through work. Her daughter, at age 18, cannot buy health care because of a prior heart condition. And now the constituent, herself, has been diagnosed with cancer. “What is horrific is that in one of the most advanced civilizations, we let people like Linda waste away. At the end of the day, this bill is going to save lives. For people like Linda, I look forward to going to her and saying, ‘Help is on the way.’’

Leno, from San Francisco, remarked that he would prefer a single-payer universal health care system, as has been introduced and passed nearly every year for the past five years in SB840 (Kuehl). The governor, however, vetoed that bill last year, and has promised to do the same if it reached his desk again. “My internal debate is, knowing that the governor is not going to sign a single payer bill, should we sit on our hands and say, ‘we tried?’ when we have stories of people in our districts suffering on a daily basis? Do we wait for the perfect? Or do we do something in the meantime. We will have the opportunity to make fixes in the years to come,’’ said Leno whose committee passed the bill on a party line vote.

FLOOR DEBATE: Debate on the Assembly floor echoed debates of the past year. Republicans continued to question why their proposals for Health Savings Accounts were not a proper mechanism for reform (even though they promote high-deductible plans and underinsurance) and conjured up the image of health care rationing in countries with single-payer systems--which AB x1 1 is not. Democratic legislators made the case for action immediately. More on the floor debate will be posted on the Health Access WeBlog.

PROCESS: The Legislature could not fully pass the financing elements of ABx1 1 because Republicans in the Legislature have – for most the past decade – signed a pact against “increasing taxes.’’ They view the hospital fee and employer contribution as taxes, as well as the tobacco tax. Because of that constraint, supporters of this measure will have to collect signatures and put the financing of this proposal on the ballot.

In order to have enough time to collect signatures by June for the November ballot, such a ballot measure, as a companion to ABx1 1, would need to be submitted to the Attorney General's office in the next few weeks.

For a read of this year’s health care debates, visit: http://www.health-access.org/labels/Updates.htm

Labels: ,


posted by Hanh Kim Quach | Permalink | 5:48 PM


 
a


Analogies...

 
Blue Cross, in their undenying opposition to health reform, were the first to make the comparison that health care reform is like "energy deregulation."

For my out-of-state readers, that's an curse word, given the rolling blackouts that resulted.

But I am confused by the comparison. Wasn't the big issue with energy deregulation that it was... deregulation?

Health care is a largely unregulated market now... we let insurers deny people because of pre-existing conditions, employers not offer coverage to their workers, and hospitals and doctors to not disclose cost and quality data.

That would change under these proposals. This is about placing more oversight, not less, over the health industry.

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posted by Hanh Kim Quach | Permalink | 3:34 PM


 
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Assembly Appropriations Committee voted...

 
...just now to pass AB x1 1 (Nunez) to the full floor vote.

The full Assembly is in session, and the Democrats are in caucus.

More to come.

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posted by Hanh Kim Quach | Permalink | 1:35 PM


 
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More information...

Saturday, December 15, 2007
 
To add to our update yesterday that had our preliminary analysis of the new amendments of a health care deal out of the negotiations between Governor Schwarzenegger and Speaker Nunez, here's some more information about the framework for the financing:

EMPLOYER CONTRIBUTION: The minimum employer contribution would scale up to 6.5%. All employers would need to contribute
* California employers with payrolls of up to $250,000 a year would have to spend at least 1% on healthcare for their workers.
* Those with payrolls from $250,000 to $1 million would have to pay 4%.
* Those with payrolls of over $1 million up to $15 million would have to pay 6%.
* All larger employers of payrolls of over $15 million that would have to pay 6.5%.

Employers would have the choice of providing coverage privately, as they do now, or paying a fee of this amount to the statewide purchasing pool. The expectation is that employers who provide coverage now, with no requirement, would continue to do so, just as employers pay more than the minimum wage, but the minimum creates a floor from which workers can bargain up from.

TOBACCO TAX: The other news on financing is that the additional funding will be the tobacco tax, rather than the leasing of the lottery. The additional amount will probably be from $1.50-$2.00.

MIDDLE-INCOME SUBSIDIES: We expect that amendments on Monday to also detail the subsidies for folks over 250% of the federal poverty level. Families earning between 250% and 400% of the federal poverty level ($82,600 for a family of four) would be subsidized so that their premium costs will not exceed 5.5% of their incomes. We understand that this would be tied to to a premium for a middle-tier product, rather than the minimum benefit (or top-tier plan). This would mean that those families could choose to spend less than 5.5% for a minimum policy, or a set amount more for a comprehensive policy with little cost-sharing.

EARLY RETIREE CREDITS: There is also planned to be a tax credit for people who retire before they qualify for Medicare at age 65 from 400-700%FPL ($71,000 for a single person and $145,000 for a family of four) so that they would not spend more than 10% of their savings income on insurance.

ARTICLES: There's more in the articles today from Jordan Rau in the Los Angeles Times, Tom Chorneau in the San Francisco Chronicle, Mike Zapler in the San Jose Mercury, Aurelio Rojas in the Sacramento Bee, and Laura Kurtzman at the AP.

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posted by Anthony Wright | Permalink | 3:23 PM


 
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Different messaging, on bills and budgets...

Friday, December 14, 2007
 
The Governor has had different press events today. Both have big implications for health reform.

One was a press conference on health reform in Long Beach. At the same time, advocates were poring over the legislative language. Lots of issues raised by the specific language--much of it may be easily resolvable, but we'll see.

On the same day, the Governor sent the signal that he would declare a fiscal emergency in January, in order to start making mid-year cuts, given the "$10 to $14 billion deficit." This really isn't going to be pretty.

Kevin Yamamura of the Sacramento Bee had a background story this morning, where I recount some of the proposed cuts of yore.

For folks who want the gory details of the kinds of cuts that were proposed by both Governors Davis and Schwarzenegger, here's a link to a Health Access Budget Cuts Scorecard from 2005, that also provides some of the history of proposed health cuts from the last budget crisis of 2001-05. Eligibility cuts for children and adults, rate cuts, benefit cuts, etc. We need to be prepared.

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posted by Anthony Wright | Permalink | 4:44 PM


 
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A first look at the new legislation...

 
HEALTH ACCESS UPDATE
Friday, December 14th, 2007


NEW AMENDMENTS TO HEALTH REFORM RELEASED
* Governor, Assembly Speaker Continue Negotiations
* Possible Vote Next Week; Deadline Nears for Going to November 2008 Ballot

New on the
Health Access WeBlog: More on the Special Session; State Budget Blues; Blue Shield and Health Net Fines; Tobacco’s Revenge; Louise Jones, RIP; The Clinton-Obama Mix-Up on Mandates; Transparency; ER Overcharging; 90 Years of Health Reform History; Why We Can Win at the Ballot; MRMIB and SCHIP Update; A $1.2 Million Hospital Bill; The Need for a Safety Valve; Health Systems in Other States and Countries; Cost Containment; Middle-Income Uninsured; The Light at the End of the SCHIP Tunnel?; Presidential Plans That Don’t Even Help the Candidate; Cultural Competency; A Fortune on Health Reform?; Attack Ads Already?; Health Wonkery…


In the December of the “year of health reform,” there are continued negotiations by Governor Schwarzenegger, Assembly Speaker Nunez, and others to see if there is an agreement on a comprehensive health proposal that can be considered by the Legislature, starting with the Assembly on Monday.

Yesterday, Speaker Nunez convened an Assembly Democratic Caucus to brief Assemblymembers on the progress with negotiations. Some of the agreed-upon amendments to the current vehicle, AB x1 1 (Nunez), were released today, and more amendments are expected on Monday. The full text of the bill is available at: http://www.leginfo.ca.gov/cgi-bin/postquery?bill_number=abx1_1&sess=CUR&house=B&author=nunez

PROCESS: Even if an overall agreement can be worked out, that is the beginning, not the end, of this health reform effort. An agreement would need to go through the legislative process, perhaps starting with a vote in the Assembly on Monday. It is unclear when the Senate would vote on the measure. Senate President Pro Tem Don Perata has indicated he wants to review issues around the growing budget deficit because committing to a health reform effort.

It is expected that some or all of the proposal would not be enacted unless a companion ballot measure that included the financing for the proposal passes in November 2008. Ballot measures are usually filed before the end of the year preceding a November election to allow appropriate time for signature collection.

The legislative proposals by the Governor and the legislative leaders have many similarities, and the most recent weeks have seen several issues get closer to being resolved. The amendments released today confirm that.

This is a preliminary analysis. Health Access will continue to put out information and commentary on this proposal as it becomes available, in fact sheet form and on our blog, at www.health-access.org/blogger.html.

OPEN ISSUES REMAIN: However, there are still remaining open issues—and ones that will determine the support or opposition of many stakeholder groups. Also, language has not been drafted for the companion ballot measure.

They are the issues that provide confidence that the reform is workable and pencils out; and that determine whether a proposal would provide a benefit or a burden to many California consumers.

AREAS OF AGREEMENT: There continue to be major areas of agreements in concept, although with important details continuing to be worked out. In any compromise being discussed, the proposal would include several major steps forward in making coverage more available and affordable for Californians:

* The biggest public program coverage expansion since the creation of Medicare and Medicaid 40 years ago.
* The proposal would expand Medi-Cal and Healthy Families to lower-income children, parents, and even adults without children at home who currently have no access to public program coverage. All children up to 300% federal poverty level would be guaranteed coverage; the coverage expansion for adults goes up to 250% FPL (around $25K/year for an individual, or $50K for a family of four).
* The proposal would also streamline these programs so that they are easier to get on and to stay on. This includes the elimination in Medi-Cal of the depravation test, and the asset test.
* The proposal would improve these programs by increasing Medi-Cal reimbursement rates, so even the six million Californians on Medi-Cal now have better access to providers.
* Mentioned in the bill and expected in the ballot measure is additional financial assistance, through tax credits and/or subsidies, for people from 250-400% FPL (up to $80K for a family of four), and for early retirees of higher incomes, but who have particularly high premiums.

* The establishment of a minimum employer contribution for health care, of the similar import to the creation of a minimum wage 70 years ago. Providing more security the majority of Californians who get employer-based coverage but who are concerned about losing it, the bill would sets a standard for a minimum employer contribution to spend a percentage of payroll on health benefits, either by paying into the purchasing pool or by expending the funds on health insurance or other health benefits. (This section is proposed to go into the ballot measure rather than the bill, and there’s no specification, but the belief is that the minimum employer contribution would be a scaled amount up to 6% or 6.5% of payroll for most larger employers.)
* This statewide purchasing pool could create a new affordable option for employers to cover their workers, initially for employees and dependents of employees that choose to use the purchasing pool. The pool would offer subsidized coverage for all workers of employers who pay into the pool.

* New oversight over the insurance industry would especially help individuals and small businesses who don't have the market power of large group purchasers of coverage. The proposal would have:
* Reforms of the individual insurance market so that coverage is available to anyone who wishes to purchase it, by establishing “guaranteed issue” rules to prevent insurers from being able to deny people based on “pre-existing conditions.” The guaranteed issue would start immediately; “community rating” rules to prevent insurers from pricing people differently because of health status would be phased in fully in four years. There would also be a limit, determined by regulators, to the difference that insurers could price on age.
* An organization of the individual insurance marketplace, so all insurance products get classified in five tiers, with benchmark plans in each, to allow consumers a better sense of the value of the product they are buying, and to facilitate price and benefit comparisons.
* Other efforts, including reinsurance and risk adjustment, to ensure than insurers compete on price, quality and service, rather than on avoiding people who may actually need care.
* A requirement that premium dollars go to patient care, and a 15% limit on the percentage of premium dollars that an insurer collects go to administration, marketing, and profit.
* Some reforms of the small group market, extending protections that now exist for those small businesses up to 50 workers to mid-size employers with up to 100 employees as well.

* A more secure and more fairly financed health system would be bolstered through shared responsibility from multiple different funding streams, including minimum employer and individual contributions, reinvested country and state savings from public program expansions, a hospital fee, a unspecified tobacco tax, and strategies for bringing in California's fair share from the federal government, to:
* Bring in almost five billion dollars in new federal matching funds to California ’s health system, by getting matching Medi-Cal funds for these expansions of public programs and employer contributions.
* Offer workers new tax savings, by providing the ability to pay premiums, or share-of-premiums, with pre-tax dollars through Section 125 plans, for a savings of 15-40%.

* Several cost containment strategies, which, working together, can slow the growth in health costs. The coverage expansions and financing provisions will help, by themselves, reduce the "hidden tax" that results from not having all employers provide coverage to their workers, and for having the uninsured go without cost-saving preventative care. Other cost-control efforts would include:
* Preventing Californians from getting sicker by helping patients to affordably treat chronic diseases such as asthma and diabetes.
* Funding “community makeover” grants to build healthier neighborhoods.
* Requiring transparent public reporting on health care costs, and the quality of services, which would enable health purchasers and consumers to make wiser decisions about their care and the best way to spend their money.
* Requiring the adoption of health information technology, which could help avoid duplication and costly errors; and encouraging E-prescribing.
* Helping foster public insurer options for consumers out of county efforts, allowing these low-overhead, not-for-profit agencies to have regional networks and better compete.
* Allowing bulk purchasing of drugs for the new purchasing pool.


OUTSTANDING ISSUES: Consumer advocates, including Health Access California , are reviewing the proposal; it is clear that there are many elements of the proposals that we have long advocated for; that we didn’t get everything we wanted, and we need to see if we get everything we need.

While millions of both insured and uninsured Californians would be helped by this framework, there’s still a need to review the whole proposal—including the ballot measure—to ensure that no group of consumers is worse off under the proposal. Many consumer groups have adopted a “do no harm” standard.

* THE INDIVIDUAL MANDATE AND AFFORDABILITY continues to be a major issue of negotiation. The measure does have an individual requirement to have coverage, with a combination of public program expansions and subsidies, as well as affordability and hardship exemptions. Many consumer, consumer, and constituency organizations insisted that any requirement to have coverage needs to have protections to ensure the availability and affordability of such coverage, and will need to evaluate the proposal in this light.
* The amendments would expand public programs up for children, adults, and families up to 250% of the federal poverty level ($25K for an individual, $50K for a family of four) for those who qualify; the mandate effectively exempts those under 250% who do not qualify for those public programs.
* Those without employer-based coverage between 250-400% FPL would have the ability to go to the purchasing pool and get a tax credit/subsidy to assist with getting coverage. The mandate is contingent on these subsidies.
* Over 400%FPL ($40K/year for an individual; $80K for a family of four), there may be subsidies available for early retirees (who by virtue of age have some of the highest premiums).
* There would be a process at the MRMIB board to provide temporary and permanent exemptions to the mandate based on affordability and hardship.
* Benefits and cost sharing of the coverage offered are different depending on income. Those in public programs up to 250% FPL have fairly comprehensive benefits and low-cost sharing similar to Medi-Cal or Healthy Families. In the individual market and the purchasing pool, regulators would organize and “tier” the market, setting a minimum benefit that everybody would have to buy, that would include doctor, hospital, and preventative care, as well as four tiers of products above that minimum that people could purchase from.

These issues of affordability also have an impact on the finalizing of individual insurance market reforms, particularly the requirement on insurers to provide guaranteed issue. Both the Governor and the legislative leaders have been committed to reforming the market so that people with “pre-existing conditions” have access to buy insurance. But insurers balk at any exemptions that would allow sicker people to get coverage but allow healthier people not to contribute. By extending the subsidies and narrowing the affordability standard, few people would be exempted at first, allowing all those in the individual market to have guaranteed issue.

Another outstanding issue is one of a “safety valve,” to protect people from the mandate in the future with government shortfalls or rising costs. While the vast majority of uninsured would be significantly helped in meeting the requirements of the mandate, at biggest risk are some middle class Californians just over 400% FPL. They do get some benefit: this population would have guaranteed issue access to products, and most workers will have access to a Section 125 plan to get a significant discount (potential 20-40%) off of a premium by using pre-tax dollars. The vast majority of those already have insurance—less than 15% of the uninsured is over 400%FPL. However, if health costs rise, they will need either additional help or subsidies, or greater need for exemptions from the individual mandate. New language includes a periodic evaluation of the program.

* PURCHASING POOL STRUCTURE: There continues to be an issue about the financing of the pool. Most of the attention has been about the exact level of the employer contribution: the Legislative leadership has a 6.5% minimum employer contribution; the Governor has a 5.5% level. Both also have lower levels for some small businesses with differing definitions of “small” business, between $250,000 and $1 million in payrolls: both the levels and the cutoffs remain the subject of discussion.

The pool would include those who have public program coverage up to 250% of the federal poverty level; those who are eligible for a tax credit or subsidy between 250-400%, as well as early retirees; and all workers of those employers who pay the fee. It also includes other workers whose employer chooses to set up a Section 125 plan through the pool.

* FINANCING: While there’s substantial agreement on these elements of a health reform proposal, there is not language on a proposed companion ballot measure, which would include much of the financing. The ballot measure is likely to include the substance of the employer fee, the hospital fee, the county share-of-cost, and probably a tobacco tax of some amount.

Obviously, the more subsidies that are needed to make coverage affordable, the more financing that is needed. With additional financing, it would be possible to use this framework to improve the benefits for low- and moderate-income families, and to extend subsidies beyond 400% FPL.

FUTURE FIGHTS: Other items of interest for health advocates would also be left for future discussion, either in the next few days, or in future regulatory or legislative arenas. Insurance regulators, for example, will determine the variation allowed for insurers to be able to charge premiums based on different ages. And then there’s other possible legislative additions: for example, there’s significant interest by some advocates in allowing the self-employed to be able to use the purchasing pool, but there was not enough time to develop the concept.

DETAILS TO DISCUSS: Many organizations are waiting to see the rest of the proposal, most particularly the ballot measure with the financing, as well as the second round of amendments to this bill that are expected to come out early next week. The bill also includes some language that remain “open issues” between the Governor and the Speaker, so it continues to be subject to change.

INITIAL OVERALL COMMENT: This is a framework that would provide significant help to the vast majority of Californians in getting coverage they need and want, both for the insured and uninsured. While it includes many elements that health and consumer advocate have long fought for, we continue to seek more assurances about affordability for consumers, especially for very specific populations. Consumer and health advocates will be vigilant in reviewing additional amendments and the ballot measure on behalf of California patients. However, with the rapidly deteriorating status quo in health care, the urgency for reform is real for millions of Californians.

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posted by Anthony Wright | Permalink | 12:37 PM


 
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It's public....

 
Legislative language agreed to by the Governor and legislative leaders is available now. Click this link if you want the full 220 pages.

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posted by Hanh Kim Quach | Permalink | 9:41 AM


 
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Momentum...

Thursday, December 13, 2007
 
The Assembly Democratic Caucus met today to discuss the outlines of a health care plan. The deal is not made, but they are getting closer. Today's San Francisco Chronicle editorial suggests other details.

Amendments and language will start to come out tomorrow, Friday, and another round on Monday. We'll put out an analysis ASAP, but as this Ventura County Star article by Timm Herdt indicated, the issues are affordability, financing, and the scope of the mandate.

There's a possible vote on the Assembly floor early next week, possibly as early as Monday. It is unclear what the Senate will do, or when. Senate President Pro Tem Perata put out a statement late today, stating that he wanted to evaluate the budget crisis first.

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posted by Anthony Wright | Permalink | 10:36 PM


 
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What's a state budget?

 
The bad budget news keeps piling up. A $14 billion deficit. Across-the-board cuts to all parts of the state budget.

At some level, the reports that focus on "the state budget" disguise the actual impacts of these cuts with that antiseptic phrase. I once heard that states really only do three things: "educate, medicate, and incarcerate."

And that's actually pretty true. Education is close to half the budget; health care and related social services are around a third, and public safety, including corrections, is the next biggest area. The other departments are relatively small in comparison.

I think some of the same people who want to make the "state budget" smaller would be more alarmed about the notion of across-the-board cuts to education, health care, and public safety.

Only if we are clear about the real impact of these cuts is there going to be the possibility and political will to raise revenues and taxes as opposed to make even deeper cuts. That's the challenge for next year.

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posted by Anthony Wright | Permalink | 10:12 PM


 
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Falling off a cliff

 
The Department of Insurance has accused Blue Shield of illegally rescinding coverage for more than 200 Californians, according to a Los Angeles Times today. Insurance Commissioner Steve Poizner is seeking a $12.6 million fine.

The other insurance regulator -- Department of Managed Health Care -- is still reviewing Blue Shield's cancellation practices. If violations are found, DMHC could impose additional fines on the company.

This is the third health insurer in the past year found to have improperly rescinded policies of their enrollees. The practice involves insurers retroactively cancelling policies on patients, who seek treatment for illnesses believing they are covered. After their policies are cancelled, patients and providers are on the hook for hundreds of thousands in unpaid medical expenses.

Blue Cross and Health Net were other insurers, either fined by the state, pursued in lawsuits, or both. Court documents showed Health Net was able to avoid nearly $36 million in medical expenses, and gave bonuses to those who helped the company avoid paying to treat patients' illnesses.

I wouldn't be surprised if more big insurers were nailed to the wall for this practice in the coming months, year.

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posted by Hanh Kim Quach | Permalink | 11:19 AM


 
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Budget blues, redux...

Wednesday, December 12, 2007
 
The recent news about a growing budget deficit is alarming, with the debate now about whether the deficit is at $10 billion or $14 billion for next year. Word is that legislation that costs any money won't be getting Appropriations Committee next year.

As with five years ago, health care advocates are bracing for big cuts, at exactly the time when people need help the most. Health care is counter-cyclical: more people need Medi-Cal and other health programs at exactly the economic times when budget cutters want to scale them back.

The hope of health reform is that it can raise the revenues needed to fund both current and expanded health care programs. If there is no money raised from health reform, we are simply looking at cuts for the next few years.

We already have children's enrollment and prescription drug programs zeroed out last year, and we should expect other cuts to be proposed by Governor Schwarzenegger; the question is will he challenge those in his party to raise revenues as well? We have always been for a balanced solution to the budget crisis, one that includes both cuts and revenues.

As Dan Walters and the folks at Calitics have said, a sizable portion of that deficit is the $6 billion from the car tax that Governor Arnold Schwarzenegger campaigned against and cut. So it seems only appropriate to raise revenues by at least $6 billion as we figure our way out of this hole.

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posted by Anthony Wright | Permalink | 1:26 AM


 
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More on (individual) mandates...

Tuesday, December 11, 2007
 
In the national debate about mandates, many are making mountains out of molehills.

To recap from earlier posts on this blog: Even though their plans are incredibly similar, Clinton and Edwards are making a big deal that Obama's plan doesn't include one element, an individual mandate, even though he has said repeatedly that he would consider including an individual mandate later.

Obama says he wants universal coverage and would accept a mandate, but first wants to focus on making coverage available and affordable. Clinton and Edwards say they will make coverage available and affordable (through largely the same mechanisms), and then place a mandate to ensure everyone is in the system.

I am in agreement with Robert Laszewski at the Health Policy and Marketplace Review, in his analysis when he says: "So, when the day is done, I don't see much real difference here."

Some, fairly progressive health policy folks, including those who support single-payer, criticize Obama for not including a mandate. This includes Jonathan Cohn at The New Republic, and Maggie Mahar of HealthBeat, in perhaps the best of the recent articles, who quotes Princeton professor Paul Starr.


“The secret power of the mandate is that it is as much a mandate on government as it is on individuals. It is a mandate on government to make coverage available and affordable. For it would be patently unacceptable to demand that people have coverage and then provide no practical way for many people to get it.”

Having the mandate as a challenge to policymakers to make coverage available and affordable is a good thing--unless the policymakers don't meet the challenge. Governor Schwarzenegger clearly came to the health reform conversation out of a belief in an individual mandate, and as a result he did some--but not all--of the things that a mandate would require. For example, his original plan only had subsidies that were limited to folks up to 250% of the federal poverty level.

Leave it to Ron Brownstein of the National Journal (formerly of the LA Times) to cut through some of the clutter. He appropriately finds the geneology of the individual mandate and recognizes the critique from both sides of the aisle (including yours truly), but he also identifies that the issue is not ideological, but practical:

Although Republicans raise mostly ideological objections to an individual mandate, Democrats express more-concrete concerns. For liberals, notes Anthony Wright, a California health care advocate, the key issue is whether the government subsidies are sufficient to ensure that uninsured families can afford the coverage that a mandate compels them to buy...

It is on this front that Hillary Clinton faces the toughest questions today. She responds to concerns about the mandate's affordability by noting that her plan (like Edwards's) would cap the share of income that individuals must contribute to premiums, with government subsidies covering the rest. But, wary of providing a target for opponents, her campaign won't say what that cap will be. Although Clinton has promised generous funding for the public subsidies, it's difficult to see how uninsured families can judge her proposal without knowing even roughly how much of their income it would require them to contribute to buying insurance.
The mandate muddle masks the real question: how much actual help does the health plan provide people?

I would much rather that the candidates were competing on the level of subsidies they were providing low- and middle-income Americans, on how much they were going to use group purchasing power to bargain down the cost of coverage and drugs, etc. That's what we should use to rate one proposal superior to another. That's how any California health reform plan should be evaluated.

People want coverage: the question is what does any plan do to help them get the coverage they want and need--and whether that is sufficient for specific populations.

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posted by Anthony Wright | Permalink | 1:15 AM


 
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The fight is just heating up...

Monday, December 10, 2007
 
The tobacco companies have begun robo-calls against a possible increase in the cigarette tax to help fund health care, at least according to one Assembly office. It's reported by Bill Ainsworth in the San Diego Union-Tribune news blog.

Given the fact that even smokers support tobacco tax increases, it's hard to see the point... other than placing the spotlight on a disliked industry and its practices.

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posted by Anthony Wright | Permalink | 5:41 PM


 
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Louise Jones, R.I.P.

 



I went to the funeral of Louise Jones today, who passed away peacefully last Wednesday. She was battling a medical condition that led her to leave her
job as our Administrative Assistant here at Health Access a few years ago.

Knowing she was terminal, she left a lovely note that was distributed at the service that described her incredible life, from being born in the Bronx of West Indies background, to her large and growing family of which she clearly was the matriarch, her move to California, and even her advocacy for rent control in East Palo Alto.

The note from beyond expressed her pride in working, for the past 12 years, for advocacy organizations for the homeless, for children's causes, and for health care for all Californians. It was clear she cared about these issues, and her large family that clearly gave her great purpose and love. She will be missed.

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posted by Anthony Wright | Permalink | 4:48 PM


 
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The transparency revolution...

Sunday, December 09, 2007
 
It hasn't been the sexiest issue, but "transparency" could be the sleeper section of health reform that really breaks the mold in terms of decreasing costs while improving quality.

The issues are laid out in this guest editorial in the San Francisco Chronicle by the CEOs of AARP, Consumers Unions, and Pacific Business Group on Health. The distingished groups represented include the publishers of two of the most-circulated magazines in the country, Consumer Reports, and Modern Maturity. Health Access has been working with them in support of this important goal.

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posted by Anthony Wright | Permalink | 6:07 PM


 
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Those with the least get charged the most...

Saturday, December 08, 2007
 
For years, we've made the case that the uninsured actually get charged *more* than anybody else in the health care system. Because they don't have the group purchasing power of an insurer or a public program, those typically with the least get charged the most--the "sticker price" which the insurers and public programs always pay less than.

Our advocacy over the past few years has been to correct this with regard to drugs (last year's AB2911) and hospital bills (last year's AB774). And now there is some movement on doctor's visits. Barbara Feder at the San Jose Mercury News reports on a new lawsuit against ER doctors.

When we did our work against hospital overcharging, we found that uninsured patients would typically get several bills from an emergency room visit, not just from the hospital but from the ER doctor, any specialist that was involved in the care provided, the ambulance company, etc. While the hospital bill was by far the biggest bill (and because these smaller providers seem to be more aggressive in billing and collections), patients were likely to pay the smaller bills first, without realizing it was also inflated.

Lieff Cabraser, the law firm, had done some of the previous class actions against hospital chains like Sutter and Catholic Healthcare West, which resulted in settlements for consumers. So this is no frivolous lawsuit.

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posted by Anthony Wright | Permalink | 5:49 PM


 
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One hundred years in the making...

Thursday, December 06, 2007
 
Bill Ainsworth at the San Diego Union-Tribune comes up with the keen insight that Governor Schwarzenegger is continuing his role as actor in playing different parts as previous Governors, including Gov. Pete Wilson (as a ballot-box warrior) and Gov. Pat Brown (as an infrastructure-builder). He even neglected Gov. Hiram Johnson (as a refomer, at least in rhetoric) and Gov. Gray Davis (as a hirer).

He mentions that his current incarnation is Gov. Earl Warren, who he inducted into the California "Hall of Fame" last night. Warren came within one vote of passing universal health care in California--a tantalizing tidbit from the long history of hope and heartbreak on health reform in this state.

To provide current context to the current fight, a new report has summarized most of the health reform efforts over the course of the past 100 years, done comprehensively by Michael Dimmitt at the California Research Bureau. There's also an archive of all the past efforts at health reform for the past century. It's an impressive resource.

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posted by Anthony Wright | Permalink | 1:25 PM


 
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The Doctor is (not) in ..Well, maybe.

 
The Orange County Register has an interesting article about medical practices that have stopped accepting any insurance -- HMO or PPO -- because of low reimbursement rates and the hassle of getting claims filled.

Dr. Felice Gersh, a gynecologist and medical director of Irvine's Women's Medical Group, recently sent 10,000 letters to patients telling them that they'd have to pay cash for visits from now on. Prices range from $75 for a visit with a nurse practitioner to $200 for an annual well woman exam with a doctor.

While these so-called "concierge'' or "retainer'' medical practices aren't typical (and fortunately, don't seem to be growing at such a rapid pace), the tangle of causes and effects that culminated with this medical group spurning insurance companies underscores the problems in our current system.

A Wall Street Journal Story in February reported that providers and insurers -- together -- spend $20 billion annually in admistrative and associated costs to recover -- or fight -- claims. (Think of how much health care we rededicated that $20 billion!) The agony of wrangling with insurers, and the poor reimbursement rates, understandably aren't worth it to providers.

But doctors will get paid. So will insurers, who will continue to recruit new enrollees.
It's consumers who suffer most here.

As a baseline, whether their doctor's take insurance or not, the consumer medical experience is getting worse, not better. Consumers are being asked to wait longer for appointments, facing more limited benefits, or being asked to pay more when they go to the doctor.

A doctor who refuses to take coverage layers on additional complications for consumers; they'll either have to find a new one that does accept their insurance card, uprooting years of medical history or pay up front, and hope for quick reimbursement later.

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posted by Hanh Kim Quach | Permalink | 12:42 PM


 
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Ballot box balancing act...

Tuesday, December 04, 2007
 
Mike Zapler of San Jose Mercury News has a downer of an article about the hurdles of winning health care reform on the ballot. He writes about the odds of any ballot measure, especially those with a funded opposition. The history on health reform isn't pretty either. In the early 1990s, two such measures, Prop 166 and Prop 186, got 32% and 27% of the vote, respectively.

THE CASE WE CAN WIN: But as my colleague Beth Capell says in the article, we've been through a lot of campaigns since then, and we've learned a lot. The two most recent ballot measures that would have expanded health coverage were much, much closer. Prop 72 in 2004, to expand on-the-job coverage, got 49.2% of the vote--so health reform went from double-digit trouncings to a less than one percent gap. Prop 86 in 2006, a tobacco tax that partially went to expand children's coverage, got 48.2%--a similarly narrow margin. The public has seemed much more willing to support health reform, even with heavy spending against these measures, and is seeming more inclined by the moment. While these weren't victories, the trends are in the right direction.

And Steve Maviglio at the California Majority Report notes, after recounting the potentially significant opposition, what might take a health reform measure over-the-top: A broad-based coalition that includes unlikely allies and broad constituencies, and that includes Governor Schwarzenegger. Governor Schwarzenegger was against both Prop 72 and 86--he campaigned against Prop 72 and was featured the attack ads. If you believe that the Governor has an influence on more than 2% of the electorate, then you can see how health reform can be put over the top.

ONLY WITH US: But the Governor can help, he can't do it alone. His failed special election effort showed that. In order for this to work, it needs to be a proposal that a broad constituency can get behind, which includes the over 100 consumer, community, and labor groups that have been active in the Its Our Healthcare! campaign this year, and that are that traditional base of health reform.

Essential to the passage of any ballot measure is something that our members, and the voters in general, can support. That includes strong assurances on affordability, which is one of the biggest differences between Governor Schwarzenegger's proposal and the Democratic leadership.

When the Governor decided to veto AB8 and any proposal confined to what was possible with a majority vote in the legislature, he forced not just the financing but the full proposal to be part of this ballot strategy. That gave the drafters of a compromise some more flexibility with some additional funding--and, in fact, AB x1 1 is a better policy as result, providing more help to more people. But it raises the odds.

But that also raised the bar in terms of what is needed to come to a deal. For the various constituencies, the question is no longer what is tolerable in a health care package, but what package can excite and turn out voters, and mobilize organizations to actively campaign for it. The issue is no longer just what is good policy, but what is good politics with the voters. For example, in the course of legislation, it is typical to leave some questions up to regulators. In the case of the ballot, any measure will need to give some specific answers to voters.

This has empowered those representing consumer interests, because the questions and issues that voters will have are the same that consumer and labor groups have been raising all year, on affordability, cost containment, and access to care. The question is whether we can finance such a package while maintaining a broader coalition, that includes providers, health insdustry, employers, and yes, the Governor.

It's not worth putting together a deal that not going to win on the ballot. On the other hand, what is worth the effort is putting together a package that does right by voters and patients, that has the support of major stakeholders including consumer groups and labor, that is good policy that pencils out, and that has a good shot of winning. That's a lots of needles to thread, but that's the challenge of the moment.

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posted by Anthony Wright | Permalink | 1:36 AM


 
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Some delays are good...

Monday, December 03, 2007
 
Good news. The Managed Risk Medical Insurance Board has delayed the decision to start disenrolling children from the Healthy Families program for the time being. However, unless the President backs down from his continual veto threat, there's the votes to override the veto, or there's a deal made, children will start to lose coverage, and soon.

Here's the post from the MRMIB website:

DECEMBER 5TH MEETING CANCELLED

NOTE FROM EXECUTIVE DIRECTOR LESLEY CUMMINGS:

Given anticipated Congressional action, Board Chair Cliff Allenby instructed me to cancel the December 5th Board meeting. To date, Congress has authorized 2008 funding for Healthy Families using 2007 funding levels, providing California funding only through December 14; however, we expect that Congress will address SCHIP funding needs prior to its holiday recess which would change our situation in California. So I recommended that the Board delay consideration of making program reductions at this time. If Congress and the President continue to provide funding at the 2007 funding level, staff will come to the Board at a future meeting with proposals to ensure that the Board meets its fiscal stewardship to manage enrollment to available resources.


To read between the lines: if we only get 2007 level funding, California will still have to disenroll hundreds of thousands of children. We have work to do!

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posted by Anthony Wright | Permalink | 5:11 PM


 
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The rhetoric of reform...

 
In the discussion over the individual mandate among the presidental candidates, blogger Ezra Klein, NY Times columnist Paul Krugman, and others with good liberal credentials are making the progressive case for an individual mandate, and even making it a litmus test for a serious health proposal.

ARE INDIVIDUAL MANDATES A MUST? The argument goes like this: progressives believe in social insurance, where everybody needs to participate. If there isn't a requirement that we all need to contribute to health care, you undermine the fabric of social solidarity, the concept of universality. There's something to that.

Other commentators don't see the "individual mandate" issue as the defining issue, including Matt Ygleisa at The Atlantic, Kevin Drum at the Washington Monthly, Richard Eskow at the Sentinel Effect (including an interview with Obama's health advisor), Timothy Noah at Slate, and even former Labor Secretary and UC Professor Robert Reich (and Ezra's editor at The American Prospect), albeit all for different reasons. (I also posted a reply to Ezra's first and most recent posts.)

All of these commentators seem to indicate that the Clinton (or Edwards) plans, with an individual mandate, would be far better than the status quo. In the context of a good proposal, they don't make individual mandates something to attack; but they don't believe the individual mandate is the essential dividing point between Clinton and Obama, or between a workable or progressive proposal and one that is not.


FRAMING THE QUESTION: Some have seen the individual mandate not as a liberal but as a conservative construct, and not just because of it origins with moderate Republicans like Senator Chafee in the early 1990s, and Governors Romney and Schwarzenegger more recently. Under this belief, the individual mandate enforces a more conservative point of view, that of personal responsibility.

As Health Access put forward in our critique of an individual mandate from 2006, an individual mandate implies that the issue is that people need to be required to take up coverage, rather than acknowledging and addressing the real barriers that exist for people to get they coverage they actually want. The Health Access paper was responding to previous legislative proposals, including those by former Assemblyman Keith Richman (R), which did not propose to do much to address those barriers.

This year, Governor Schwarzenegger took the implications of the individual mandate seriously, meaning putting in place significant subsidies, a minimum employer contribution, and insurance market reforms so that people had a chance to meet the mandate. And there is where the common ground has been, on providing people the help they need to get the coverage they want. Our critique has been that the Governor's plan did not provide sufficient help to many low- and moderate-income populations facing the mandate--and that's what the negotiations continue to focus on as we speak.


MAKING THE MANDATE MOOT: At the same time, Health Access, in that very same critique and elsewhere, was clear about the fact that we don't oppose the notion of individual responsibility, whether it's a payroll tax to finance a single-payer system, or a worker requirement to take-up coverage offered by an employer, as long as it is deemed affordable.

The Democratic presidential plans--by Clinton, Edwards, and Obama, with and without an individual mandate--are in that vein: they largely rely on expanding group coverage, through public programs, employers, or purchasing pools. To the extent that it exists, the individual mandate is incidental, to bring in people and automatically enroll them. Obama actually doesn't even argue against an individual mandate--he says he would consider it, but only after his plan has provided available, affordable coverage. It seems Clinton and Edwards are there as well, providing assurances to people that coverage won't be more than a certain percentage of their income.

So is an individual mandate a liberal or conservative idea? Does it matter? People want health coverage--to get the care they need, and to protect them against financial risk. If coverage is available, affordable, and automatic, then the question is moot.

The real issue is what are the policies in place to provide for coverage that is available and affordable for all Americans. That's what I hope the candidates spend more time debating.

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posted by Anthony Wright | Permalink | 1:55 PM


 
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A BIG, unfortunate and expensive illustration for health reform

 
The Wall Street Journal had this tragic story last week about a Merced man -- who was insured -- but still socked with a $1.2 million hospital bill (not counting thousands in doctor's office bills also).

What happened to Jim Dawson, of Merced, that landed with debt that could bankrupt him is a textbook example of what health consumer advocates have been fighting to reform for years.

Dawson had a good job with Valero Energy Corp., a big oil refinery. He had Valero-sponsored comprehensive health insurance policy, and a regular primary care physician who knew his medical history, *should* not have been vulnerable to medical-financial angst. That's at least what many think. But Dawson's story shows how anyone can be vulnerable.

First thing that went wrong: His primary care physician, and subsequent specialists were not able to diagnose a staph infection until six months after his first doctor's visit -- and by that time, the infection had ended up in his blood stream.

Next: He ran up against a lifetime cap on his health coverage -- a max of $1.5 million (which, incidentally is considered generous. Most policies have a cap of $1 million, but where set in the 1970s when the purchasing power was equal to $6 million today, according to WSJ)

Lastly: Dawson and his wife, in combing through their hospital bills, realized the hospital had inflated various items at tens and hundreds of times their actual cost on the street. For instance, stockings for $791, when they could have purchased them for $12; oxygen for up to $6,675 PER NIGHT, when it could have been rented for $250. All those numbers added up to "Disneyland numbers,'' admitted the hospitals chief medical officer.

The Dawson case highlights a number of issues:

*DISCLOSURE OF QUALITY AND COST:

Dawson visited many providers who were unable to accurately diagnose him at first. Still, Dawson (or his insurance) paid all these providers full price for their conjecture. If providers were asked to account -- or disclose -- for why Dawson's staph infection went undiagnosed for so long, then
  1. Dawson's infection would not have spread as far or been as costly and
  2. Other consumers could decide whether or not to see that provider.

* LIFETIME CAPS:

The fact that lifetime caps have not been reset since the 1970s, combined with costly medical technologies that are used in health care will mean that more and more Americans will reach their lifetime caps.

* HOSPITAL OVERCHARGING

Even the chief medical examine at Dawson's hospital admitted his bill amounted to "Disneyland numbers.'' Given that Dawson's hospitalization occurred earlier this year, he should qualify for a discounted rate under AB774 (Chan), which was enacted in January. It requires hospitals to offer the Medicare-negotiated rate for patients who are uninsured, or spend more than 10 percent of their annual income on health costs.

Unfortunately, until this is sorted out, the Dawsons are making $30 payments to various hospitals. At that pace, with at least $1.2 million in the red, I estimate it will take them 3,333 years to pay off (not including interest).

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posted by Hanh Kim Quach | Permalink | 1:50 PM


 
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Primary fights over secondary issues...

Saturday, December 01, 2007
 
The Los Angeles Times reports on the debate among the Democratic presidential candidates over the so-called individual mandate. It been strange seeing this play out nationally, within the very vague terms of presidential campaign position papers… while we’ve been grappling with the nuts-and-bolts of these same issues here in Sacramento.

I'm a little confused about the fuss. The three proposals, by Edwards, Obama, and Clinton, are all very similar. Edwards and Clinton are trying to make a distinction with Obama, in that they have a individual mandate, and Obama doesn't. But Obama does not say he oppose the individual mandate--he said repeatedly that he would consider it, but his first goal is to make coverage affordable.

At the same time, Clinton and Edwards both propose to do similar things as Obama to make coverage affordable, providing certain assurances and subsidies (such as saying that premiums won’t be above a certain level of income.) So there's not much difference in terms of the help actually offered to voters: all would significantly expand public programs, bolster employer-based coverage, and offer new public insurance options for folks.

When Clinton attacks Obama for not being universal, Obama responds that their proposals aren't either, unless they are proposing onerous enforcement. All three of them rely on automatic enrollment mechanisms, especially at work, to get folks covered. All of them get pretty close to universal.


So why they are making such a deal about a relatively small items. And if they are going to spotlight their health care plans, why are they having an argument about the burdens, rather than the significant benefits, of health care reform?

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posted by Anthony Wright | Permalink | 12:51 AM


 
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Strange bedfellows

 
Insurance agent Alan Katz responds on his blog to my recent post about the need for an affordability standard in the context of an individual mandate. In my comments, I did mistakenly lump him in with the Governor and some insurers, who have publicly taken a hard-line "no exemptions" position. Unfortunately, they don't have blogs I can link to like Mr. Katz does.

He concurs that there's needs to be a "safety valve" for consumers--as well as in other parts of the reform package. We agree. Now only if we can get the Governor there.

I hope that this article by the AP's Laura Kurtzman on the individual mandate and affordability helps.

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posted by Anthony Wright | Permalink | 12:01 AM


 
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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.