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Where's your vote...

Thursday, January 31, 2008
 
Health Access doesn't endorse candidates, but we'll help you analyze where candidates are on health reform as we finish up our comparison in the next day, and compare presidential candidate plans to the ill-fated ABx1 1 legislation.

In the meantime, check out this really cool assessment of candidates at http://www.healthcentral.com/healthcare08/

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posted by Hanh Kim Quach | Permalink | 2:42 PM


 
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Reactions...

Tuesday, January 29, 2008
 
Lots of reaction today on the health reform...

The press coverage included:
* Tom Chorneau in the San Francisco Chronicle,
* Aurelio Rojas in the Sacramento Bee
* Mike Zapler in the San Jose Mercury News
* Bill Ainsworth in the San Diego Union-Tribune
* Jordan Rau in the Los Angeles Times
* Jesse McKinley and Kevin Sack in the New York Times
* Christopher Lee in the Washington Post
* Ayesha Thomas at News10 in Sacramento
* and a summary on California Healthline.

Statements in reaction by:
* Governor Arnold Schwarzenegger
* Speaker Fabian Nunez
(There's a major compilation of ABx1 1 information on his website.)
* Senate President Pro Tem Don Perata
* Senate Health Committee Chair Sheila Kuehl

Blogs in reaction:
* Sacramento Bee’s Daniel Weintraub
* Calitics
* Several at the California Progress Report (including those by Frank Russo, Rose Ann DeMoro, and my assessment on the impact in other states)
* Alan Katz has lessons learned.
* A Healthy Blog in Massachusetts sends condolences.
* Ezra Klein continues his health care obsession.
* Helenann on DailyKos.
* The Urban Institute has comments.
* Karen Tumulty at Time.com's Swampland, from her national perch, calls it the "most underplayed story of the day."

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posted by Anthony Wright | Permalink | 11:40 PM


 
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Schwarzenegger on Next Steps

 
Earlier today, I spoke at a press conference with Governor Schwarzenegger, Speaker Nunez, and many different stakeholders in the health care field, with the message that we aren't going to give up on health care reform. Video from that press conference is available at the Governor's website, at:
http://gov.ca.gov/

The Governor answered some questions, but he gave longer ones earlier in the day at the Sacramento Press Club. Here's a transcript on his answers on health reform, which give some insight into what he's thinking as we move forward...


Q: George Skelton, LA Times. Is there anything about the present, or the killed health care plan, that you would like to preserve and maybe make some incremental steps, instead of making the big comprehensive program, waiting and doing that? Or would you just do children, for instance, or would you do requirement for 85 percent patient care, that kind of thing?

GOVERNOR: Well, first of all, it's a good question because normally that's what you would do. But in health care we have found that it doesn't work, because what happens is, if you take on health care reform in incremental stages, in incremental ways, the whole thing is so interconnected. For instance, let's take children. You go and you take out the children. You say it will cost 500 million dollars to insure the children. Where do you get the 500 million?

We, in our proposal, have put together a pot of money which was 14.7 billion dollars that we knew, with shared responsibility, we can raise that money and get that money, which was through the hospital administration and through the tobacco tax and through employers' responsibility and individuals, and the state, and the federal government with its matching funds, and so on and so forth. So a part of that money was for the children, as much as there was part of that money for prevention, and a part of that money for Medi-Cal, 4 billion dollars for Medi-Cal, and on and on and on.

And our package also increased the risk pool, so therefore you can go to insurance companies and say, now, since you have a bigger risk pool, you've got to go, by law, insure everyone. And you can't cancel anyone anymore. Because we want to make sure that no matter who it is, if you're 80 years old or if you're 20 years old, that you get insurance. We wanted to make sure that no matter what your medical history is, that you can get insurance.

So those things are interconnected. So when you do it in fragmented ways and piecemeal it, then it becomes kind of the special interests going to say, I’m going to go lobby now the legislators to change this one thing that really will benefit me, and no one else. And that is the problem that has been, in the history of health care, it all has been done incremental, and so what you have now is a mishmash of different things that ends up being disastrous for the people of California.

But if there would have been a way, of course I would have gone that way. But we saw it, as we got in there, we saw how interconnected it all was, and the more and more experts we talked to on the national level and on the state level all said you've got to do the whole thing over, rather than just trying to do the piecemeal approach. So that's why.

But to answer your other question which you had, should we throw out this whole thing now because it didn't work in the Senate? No. Let's assume for a second that means that we're not 100 percent there. Someone in the Senate thought that we're not 100 percent there, or several. Whoever it was felt that, otherwise they would have passed it. So I just say, okay, let's go back. Let's go back to the Senators, let's go back to the Assembly, let's bring all the stakeholders together.

Because I tell you one thing, that it is remarkable of what I have witnessed this last year, the way people came together that were way on the right and way on the left. I mean, there were labor leaders that all of a sudden threw out that idea that they would never vote for anything that has to do with mandatory health care insurance, with individual mandate. And they changed, and they came to the center. It was wonderful to watch the business guys agree to a certain fee. It was wonderful to see the Hospital Association say okay, put a fee on us. We're more than happy, because we are going to benefit if this is reformed. So there were tremendous changes by everyone, by advocate groups and by doctors, by the Hospital Association, by labor leaders, by business leaders, by everyone coming together. That was really amazing. So I'll try to keep that together and just iron out, and see what the problem was, look at that list of things that they had a problem with and then continue on working towards it.

And I think that all of you are a very important component of this, because the more you talk about it is absolutely necessary not to give up, it is absolutely necessary to continue on, and to look at that as a marathon run and that is the last mile, and we've got to do it -- because otherwise you get into a situation where we have already read today that one of the Senators said, "You know something? It doesn't really matter, because hopefully we will have a Democratic president and then he will maybe, or she maybe, will do it. (Laughter).

See how I immediately corrected myself? (Laughter) Because imagine now tonight at 5:00 o'clock in the evening by wife sits there with this homework with the kids. She switches channels, and all of a sudden she sees me only say "He." It would have been disastrous. So I immediately made the corrections and fine tuned it all.

Anyway, so the key thing is that someone said the president will do it. Hopefully it will be a Democratic president and then they will take on health care, and that will then take care of everything. That's the wrong way of thinking, because what we are saying then is that we in California cannot do it, that we have to wait for Washington to babysit us, to teach us how to do it, when in fact it is the states that are supposed to teach Washington how to do it. We did not wait when we did our environmental issues, fighting global warming, AB 32. We are teaching Washington how to do it. We didn't say, well, we can't get it done. Let us have Washington show us how to do it. No. We want to lead. The same is in stem cell research. California moved forward and said we're not going to wait for this administration. We are going to do it. And the same thing should be in health care. We show the rest of the nation that we can do it. And we should show to Washington that we can do it, and here, copy us.

I think this is what you should do, is put the pressure on the legislators, Democrats and Republicans, to move forward and not to give up.

Q: One follow up on health care. Did you learn anything from this? Is there anything you would have done differently, or would do differently next time?

GOVERNOR: You know, it was a learning process, because I did not come in to this as a health care expert, trust me. So it was to me -- I knew when I came into office that I want to take on big issues that everyone said are impossible to do. And I said to myself, you know, why give up? Why just say it's impossible, and never tackle those issues? If it is infrastructure and rebuilding California, if it is the stem cell research, if it is redoing our Workers' Compensation reform, or any of those things -- health care was one of those things that I said to myself, "It's crazy that we have 6.7 million people uninsured, and we give up, and we say well, no one has been able to do it, so let's give up." So that's why we tackled it. And I went in there not knowing much about it at all. Just I had the will that we've got to get it done. And so as time went on and I started meeting all the experts, and we had meeting after meeting, and hundreds of meetings, I learned. And as this learning process went on I learned to make certain changes, and consider other things. Other people came on board, and there were a lot of stakeholders that came in and said have you ever thought about this, have you ever thought about that? And it was wonderful.

And I tell you, I want to compliment one person right off the top, before I forget, and that is Speaker Núñez. Because I tell you something, that guy was a jewel. He believed passionately, and he believes passionately, in health care reform. He sees, and he always painted this wonderful picture of the poor people that he represents that don't have health care, and he wants to get health care for them. It was wonderful to work with him. And here's like a situation, a Republican working with the Democrat -- again, a very unusual situation, as a Republican governor to be interested in this kind of reform, and in that way, to reform it in that way, and to go beyond the party principles, but to go just according to the people's principles, and to work with him on that. And we met in the middle. And so I want to congratulate him and I want to thank him for all the great work that he has done for the whole year of working with me, and working with the stakeholders, and bringing all of his constituents in there, and so on and so forth. Without him we wouldn't at all have gotten there.

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posted by Anthony Wright | Permalink | 11:14 PM


 
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Enabling My Mother

 
Here's reason #6,782 that the status quo just isn't working -- and it's purely personal.

My mother, a Buddhist in name only, cannot help but worry about everything. She worries that my 17-year-old geeky, mute brother will join an Asian gang. She worries my sister, an engineer, spent too much on a couch. And she worries I'll die commuting to work on my bike.

Now, she's worried that her retiree insurance coverage won't pay my father's recent hospital bill.

The hospital has sent a bill for about $90,000.
The anesthesiologist sent an $8,000 bill.
The physician's assistant another $1,200.

And they keep rolling in.....

She's not asking for free health care. In fact, her deductible is $1,500 with an out-of-pocket maximum of $4,000. She and my father are willing to pay every dime of that -- and continue paying the $650 a month for coverage, as long as she can be assured that the coverage actually works.

I'm sure she'll be okay, but for once, I can't say I blame her for worrying. Ordinarily, (or knowing her, maybe not) I'm not sure my mother would necessarily fret over these bills. But stories in recent years about rescissions, denial of claims, and people hitting their lifetime limits has left her feeling very unsure about whether the insurance she has will be there when she needs it. Sadly, that's how many Americans feel today.

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posted by Hanh Kim Quach | Permalink | 1:46 PM


 
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Over there

 
Here's an interesting little video clip about how the Netherlands' new health system works.

Until a few years ago, the Dutch had a patchwork healthcare system, like ours, with a mix of public coverage (65%) and privately purchased (35%) coverage. Now, through an individual mandate everyone is in insured by a private insurer, but insurance companies are heavily regulated -- required to issue coverage to all, and rewarded (or given extra money) for taking good care of sicker patients.

Employers pay, government pays and citizens pay. Subsidies are available for lower-income residents. Lots of cost and quality control, through transparency, etc. (Sound familiar?). They implemented their reforms in spite of budget constraints.

In 2004, the Netherlands spent 9.2% of GDP on health care, versus the US' 15.3%.

The conversation to get there, however, took decades, including the implementation of primary and clinical care standards in the 1980s. So I guess all this is to say maybe we'll get there someday.

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posted by Hanh Kim Quach | Permalink | 12:18 PM


 
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The Fateful Vote

 
HEALTH ACCESS UPDATE
Tuesday, January 29th, 2008


SENATE HEALTH COMMITTEE FAILS TO PASS HEALTH REFORM
* Sen. Perata withdraws support for AB x1 1; Senators cite budget shortfall, LAO report
* Sen. Mark Ridley-Thomas casts the only "aye" vote in committee for ABx1 1
* Speaker, lawmakers urge efforts on health reform to continue
* ACTION ALERT: Call your Senator to express dismay at health reform failure!

New on the Health Access WeBlog: Much More on Senate Health Committee Vote, Commentary on California's Impact on Other States; Editorial Boards on AB x1 1; Mailers by Tobacco and Big Business; Health Wonk Review; Single-Payer Supporters for Strategic Steps

The Senate Health Committee on Monday failed to pass ABx1 1, which garnered one “aye’’ vote and seven “no’’ votes. Three Democrats abstained while three voted against the measure. Speaker Fabian Nunez declined to have the bill reconsidered saying he “got the message,’’ but issued a challenge to his colleagues:

“I would challenge members of the Senate to come up with a plan that stands up to the same kind of scrutiny and analysis, is doable, and is going to respond to the needs of those families that don’t have health care today,” he said.

The only yes vote for ABx1 1 on Senate Health Committee came from Sen. Mark Ridley-Thomas, who said, “I remain persuaded there is something to be embraced here, by the range of advocates and sponsors who are diverse in their own rights. This doesn’t suggest there isn’t more work to do.’’

ALERT: Call Your Senator TODAY to express your disappointment at the Senate's failure to come to agreement on health reform; and to urge them to take leadership on health reforms and expansions.

The phone numbers for Senator’s Sacramento offices are available on the California Senate website, at: http://www.senate.ca.gov/~newsen/senators/senators.htp

THE BILL: ABx1 1 would have expanded health coverage to approximately 3.6 million Californians who currently do not have health insurance. All told 95 percent of Californians would have had health coverage through the bill, which would have also required businesses to contribute to worker health care, required most Californians to have coverage, and made various reforms to the insurance market – including a prohibition on the practice of denying enrollees based on “pre-existing conditions.’’

It would have raised nearly $15 billion in tobacco taxes, employer contributions, hospital fees and federal funds to pay for it. (Follow the links to read Health Access’ Fact Sheet and analysis of Who Gets Help through AB x1 1.)

The failure of AB x1 1 leads Sacramento policymakers into a second year of the Year of Health Reform, which will likely be overshadowed – if not eclipsed – by the state’s staggering $14.5 billion budget deficit and cash flow problems.

STATED REASONS FOR NOT SUPPORTING

In 45 minutes, senators gave wide ranging reasons for why they could not support ABx1 1, including some statements that proponents believed were misrepresentations of the bill. The Sacramento Bee's Capitol Alert has the most detailed reporting of the Senators' statements at the hearing. Beneath the commentary and criticism were common themes.:

The economy and budget situation: A worsening economy, combined with the state budget deficit of $14 billion, would make passage of the bill seem imprudent. In the wake of the Legislative Analyst’s Office’s report outlining the potential risk of shortfalls in the program in later years, senators said they felt uncomfortable approving legislation that could put the state’s budget further at risk.

Question marks and readiness: Some questions regarding the health reform plan’s implementation were unanswerable at this moment – from the cost of premiums, to federal matching funds, to the makeup of the minimum credible coverage. Lawmakers saw those question marks as too risky to proceed.

Process and timing: Other senators felt pressured to act on deadline, and felt restrained by the November 2008 ballot initiative that was tied to ABx1 1 – as is. That meant making amendments to the bill, which senators thought were important, were impossible.

The Senate's concerns about ABx1 1 are outlined in this letter sent by Senate President Perata to Gov. Schwarzenegger and Speaker Nunez.

SOME SENATORS SAY KEEP ON MOVING

Sen. Darrell Steinberg, and two others elected to abstain on the measure, rather than vote against Ab x1 1. Steinberg, said, in spite of ABx1 1 incompleteness, “It’s not deserving of outright rejection …We should continue to work on it.’’

No matter their stance on ABx1 1, the bill’s failure on Monday many lawmakers and advocates insisted that it did not mean the death of health reform at large, echoing the sentiments of Senate President Perata, who said “More is yet to come, no one has lost heart,’’ who spoke at a press conference after the vote.

Perata, for his part, said he would not call the bill’s “a failure,’’ saying it took nearly a decade to get significantly less complicated reform–such as motorcycle helmet laws–passed. “I believe we got as far as we could get this year.’’

Even though the Year of Health Reform had captured the attention of political leaders in 2007, this was not the first year of health reform. In the past five years, other major expansions of health coverage have stalled, but efforts have continued:

* In 2003, then-Gov. Gray Davis signed SB2, a pay-or-play required employer contribution, which was subsequently repealed in a narrow 2004 vote (Prop.72).
* In 2005, AB772 (Chan), which would have guaranteed all California children coverage, but was vetoed by Governor Schwarzenegger. A similar measure was part of the tobacco tax in Prop 86 in 2006, which was narrowly defeated.
* In 2006, Gov. Schwarzenegger vetoed SB840 (Kuehl), which would have created the framework (but without the financing) for a universal single-payer system.
* In 2007, AB8 (Nunez/Perata) passsed the legislature. Governor Schwazenegger vetoed it, but negotiated with Speaker Nunez, and eventually supported a new version, AB x1 1 in 2008 (Nunez).

Perata said he hoped lawmakers would continue to work on elements of ABx1 1 that were “small but important,’’ and “yielded’’ health reform discussions to Speaker Nunez. While advocates expressed their commitment to continued efforts at health reform, the prospects are tough.

Many of the elements of health reform, including any expansion of coverage, would require new revenues, especially in light of the budget crisis. The action of the Senate effectively ended the effort around the ballot measure, that would have raised the bulk of $15 billion for coverage expansions. Instead, there is $0 of new dollars, in a budget-cutting environment.

Senate President Pro Tem Perata was clear that his attention was moving on to this year’s budget crisis, which looks to be more dire than those in years past, as Perata presaged. “I believe our attention will soon be turned to see how the state does not go insolvent in March and how we forestall serious problems if we do not pass a budget by July,’’ he said.

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posted by Anthony Wright | Permalink | 1:05 AM


 
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Overcoming California's unique health reform hurdles...

Monday, January 28, 2008
 
Part of last week I was with many of my fellow health and consumer advocates in Washington, DC. I learned about all the good and promising efforts they were embarking on in states like Minnesota, Oregon, Ohio, Colorado, Illinois, Maryland, Pennsylvania, Washington, Maine, Vermont, and yes, my previous home states in New York and New Jersey.

They were using the progress that we made in California in their own efforts. In one blue state, advocates are pushing the most progressive legislator in their StateHouse to improve his nascent proposal on the employer contribution, to be more like what was agreed to by Assembly Speaker Nunez and Governor Schwarzenegger.

Our efforts, in short, have already been helpful to my colleagues in other states. I know other states are already borrowing some of the policy elements that were developed in this exhaustive process.

But it's cold comfort for Californians, now that the bill has stalled. What is the implication for my colleagues in other states?

With apologies to my New York background, if we could have made it here, we could made it anywhere. It would have been a boon to efforts around the country and in DC.

But there's reasons why the opposite is not true.

California has all the obstacles that seem to frustrate federal reform, but without the flexibility or financing ability.

* National health reform is hard because health care has an enormous number of stakeholders that are impacted by any change, and it's hard to get a consensus, especially in a country so large and diverse, both in terms of the on-the-ground infrastructure, and in terms of ideology. On health care, Washington, DC has been polarized on any solution (see the SCHIP debate), which has resulted in either neglect or gridlock.

* It is because of this gridlock that the states have taken the lead with their own efforts. And while states have clear jurisdiction and responsibilities in many health areas, state health reform is hard because there's contraints in policy and process: Medicaid rules, ERISA, and the biggest of all, the ability to finance the system overall. States have balanced budget requirements and it's harder to raise revenues. (Among other things, we don't have a Bush tax cut to repeal, as is the suggestion of many Democratic presidential candidates.)

A nation-sized state, California has the size and diversity that makes consensus hard (think Berkeley and Bakersfield, Orange County and Oakland), and has one of the worst problems, with Californians more likely to be uninsured than in all but five states. As we have said before, Massachusetts, with 10% uninsured, had to close a gap; California, with nearly 20% uninsured, has to jump a chasm.

So California has all the obstacles at the federal level, with all the obstacles at the state level, plus some of California's very own--in particular the 2/3 vote rule to pass any revenues in a legislators (a threshold only Arkansas and Rhode Island share) that empowers a solid Republican blockade against taxes; and the ballot-box culture of initiatives and referendum.

Yet in spite of all this--look how far we have come.

In the past five years, the legislature has passed four measures to dramatically expand health coverage--SB2; AB772; SB840; AB8. Until recently, it was the Governor that was the obstacle. The Assembly and the Governor agreed on a fifth proposal, AB x1 1, and now it's the Senate.

Despite all the obstacles, it's clear that political will can make it happen, from Senate President John Burton in 2003 to Assembly Speaker Fabian Nunez and Governor Arnold Schwarzenegger in this special session.

We just don't yet have the needed political will. But that is something we can build, and change, and make happen.

I cringed when some Democratic Senators in committee made comments about the Legislature--talking about themselves!--being unable to functionally monitor and make adjustments to a health reform if they are needed. There are clearly constraints with health reform, but that sounded like abdicating leadership. Finding an excuse, rather than solving a problem.

If I learned anything in the past five years, it is that reform in California is possible, but that it takes political will and leadership from multiple sources, a major effort to engage and mobilize Californians to demand and expect results, and that it also takes multiple efforts and time to make it happen.

This wasn't the first year of health reform, and it won't be the last. We'll see to it.

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posted by Anthony Wright | Permalink | 7:20 PM


 
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Quick response...

 
Just got back...

The California Senate has failed millions of Californians that are struggling under high health costs, that are uninsured, that are insured but at risk of losing coverage, or those being denied for so-called pre-existing conditions.

NO EXCUSES: There's been lots of reasons given, about process and timing, but they are unconvincing. These Senators have no excuse for the many who suffer with the exisitng health care system--not timetables or the budget crisis or lack of revenues.
* There was over a year to negotiate, to be clear about what was needed and not needed to get the votes.
* Health reform is needed in good times and bad--and more acutely in bad times. It's not like the uninsured suddenly don't need health care during a recession. The need is still there.
* The proposed ballot measure would have raised $15 billion in additional assistance to California families--we certainly would have wanted more, but unless action is taken quickly, there won't be a cent now. The Legislature had full ability to adjust the program based on the revenues that came in, what they had to work with. So how is $0 better than $15 billion?

THE FIGHT CONTINUES: We'll keep working for reform. This wasn't the first year of health reform, and it won't be the last. We'll continue to fight for significant health reforms, because California consumers can't wait.

A WORD ABOUT NATIONAL IMPACTS: The need and urgency of the issue is real and ongoing. My consumer advocate colleagues in other states recognize that California has unique challenges in passing health reform, from our size, to the scope of the problem, to the structural obstacles to increasing revenues through the legislature or on the ballot.

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posted by Anthony Wright | Permalink | 5:52 PM


 
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Condolence of sorts

 
Sen. Perata has posted a letter on his website on his house' decision.

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posted by Hanh Kim Quach | Permalink | 3:54 PM


 
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It wasn't even close....

 
The final vote for ABx1 1 in Today's Senate Health Committee


1-Aye (Sen. Mark Ridley-Thomas)
7- Noes (Sens. Kuehl, Aanestad, Cox, Maldonado, Negrete-McLeod, Wyland and Yee)
3-Absentions (Sens. Alquist, Cedillo, Steinberg)

We're now awaiting Senate President Pro Tem Perata's Press Conference:

Listen here: http://www.senate.ca.gov/ftp/sen/committee/redalert.htm

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posted by Hanh Kim Quach | Permalink | 3:11 PM


 
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Steps backward?

 
This is a really painful hearing.
Sen. Aanestad somehow thinks ABx1 1, and providing coverage to 3.6 million Californians, increasing reimbursements to doctors who care for the poor, and placing limits on insurance companies, is a "step backward'' from the status quo.

The status quo means anywhere between 75,000 to 101,000 Americans die of preventable diseases annually. It means California will continue to pay its doctors who care for the poorest patients the least.

I'm not sure where he's coming from...but to each his own.

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posted by Hanh Kim Quach | Permalink | 2:57 PM


 
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Fact Check on Sen. Yee

 
Okay, Sen. Leland Yee should really know better. He just claimed that ABx1 1 would punish low income families by garnishing wages and placing liens on homes if families could not prove they had coverage.

That simply is not true. (How many times do we have to say that.)

ABx1 1 says nothing about this kind of enforcement. Additionally, such behavior by a state agency (ie. Franchise Tax Board) would not be permitted until a) the Legislature approves legislation on that issue and b) the Legislature approves funding for enforcement, which is unlikely given the existing funding shortfall.

What ABx1 1 does say is if a person does not have coverage after 62 days, they will be told of different options where they could find coverage (public programs, the state purchasing pool). If the individual does not act, they will be automatically enrolled in the least expensive policy. The state will then recover the costs of that coverage through the Franchise Tax Board, but no additional penalties are exacted.

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posted by Hanh Kim Quach | Permalink | 2:37 PM


 
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Look who wants KNOX KEENE!

 
Sen. Dave Cox just complained that ABx1 1 did not meet Knox Keene requirements because it did not include brand name prescription drug coverage.

First of all -- Knox Keene, the state's mandated guarantee of "basic health care'' -- does not provide any prescription drugs. Just doctors, hospitals, diagnostic and preventive health.

BUT -- we'd LOOOOVVVVVEEE to see prescription drugs guaranteed in that.

Do I hear a "mandated benefit'' coming from Sen. Cox -- demanding brand-name prescription drug coverage in California? This is only really funny because Sen. Cox and his Republican compatriots have repeatedly attempted to UNDO mandated benefits and kvetched ad nauseum about the state's "mandates'' that require health plans to cover childhood immunizations and cancer screening.

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posted by Hanh Kim Quach | Permalink | 2:11 PM


 
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The opposition...

 
Even though some of our allies have made noise on AB x1 1 and their opposition, let's remember that the real money in opposition to health reform is from the business, insurance, and tobacco lobbies.

Capitol Weekly has the scoop on mailers by the big business groups and the tobacco companies.

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posted by Anthony Wright | Permalink | 11:57 AM


 
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Pulling on the boxing gloves

 
The debate over ABx1 1 is being slugged out in today's editorial pages:

In the anti-ABx1 1 corner, we have:
  • The California Nurses Association with two op eds, one in the Sacramento Bee and one in the Mercury News, ruing
  • The Foundation for Taxpayer and Consumer Rights in the Sacramento Bee, bemoaning the use of an individual mandate and continuing its crusade for rate caps.

In the pro-ABx1 1 corner, we have:

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posted by Hanh Kim Quach | Permalink | 10:17 AM


 
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Analysis of the Analysis: LAO Agrees It Can Work, But Overstates Risk

 
HEALTH ACCESS UPDATE
Monday, January 28th, 2008


CA SENATE HEALTH COMMITTEE TO VOTE ON HEALTH REFORM TODAY;
NEW ANALYSIS PROVIDES ASSURANCES ON FISCAL IMPACTS
* LAO Agrees that Health Reform Can Pencil Out, But Overstates Risk
* Health Access Analysis Spotlights What LAO Neglected:
*Savings, Legislative General Fund Protections, Risk of Status Quo


* Health Access ALERT: Reform Can Work, Deserves a Chance to Succeed
Call Your Senator Today to Support AB x1 1

The Senate Health Committee is scheduled to vote this afternoon on the comprehensive health reform measure, AB x1 1, negotiated by Assembly Speaker Fabian Nunez and Governor Arnold Schwarzenegger.

The bill would dramatically reform the health care system through multiple efforts, including by significantly expanding public health programs, ensuring that employers contribute to their worker’s health coverage, and stopping insurers for denying people for “pre-existing conditions.”

ALERT: Call Your Senator TODAY and urge them not to lose the window of opportunity. The phone numbers for Senator’s Sacramento offices are available on the California Senate website, at: http://www.senate.ca.gov

NEW ANALYSIS: As California state Senators consider their vote, new information and analyses are coming out that provide more benefits and assurances for California consumers, taxpayers, and the state general fund.

A new analysis by Health Access California agrees with the Legislative Analyst’s Office’s verification of the ability for health reform, as proposed in AB x1 1, to pencil out for five years without any impact on the general fund. However, the Health Access analysis spotlights information where the LAO has:
* significantly overstated risk, especially with regard to the number of uninsured, the baseline premium price for coverage, and the ability to draw down federal funds.
* neglected to calculate significant savings, including a more realistic assessment of enrollment and crowd-out, the impact of cost containment provisions, and the impact of new federal funds on the health system;
* does not fully acknowledge the built-in general fund protections, especially through ongoing legislative oversight, and the ability to adjust the program over time; and
* ignores any comparison with the significant risks of the status quo—of not passing reform, and allowing the health system to further deteriorate.

The report is on the Health Access California website, and below.
http://www.health-access.org/advocating/docs/LAORESP012708.pdf

More analyses on health reform are available on our resource page on our website, at: http://www.health-access.org/

Report from today’s activities will be available on the Health Access California WeBlog, at: http://www.health-access.org/blogger.html

Here's the executive summary and report:

ANALYSIS: FISCAL PROJECTIONS FOR AB x1 1 AND LAO REPORT

SUMMARY:

AB X1 1 ADDS UP: The LAO analysis found that assuming a starting baseline cost for health coverage (of $250 per month per person), the health reform proposal pencils out for at least five years without general fund impacts.
* HIGH END ESTIMATES OF SPENDING OVERLOOKED: The modeling provided by the proponents assumes 95% enrollment in public programs and tax subsidies in early years of the program as well as maximum crowdout of employer spending. Neither is likely so spending is over-estimated.

DOWNSIDE RISKS OVERSTATED: The LAO overstates some of the downside risks, particularly with the baseline premium assumption, the availability of federal funds, and the estimate of the uninsured.
* BASE PREMIUM ASSUMPTIONS IN LINE WITH PUBLIC PROGRAMS: The $250 per member per month premium baseline is significantly higher than California ’s current public programs, including Medi-Cal or Healthy Families, even taking into account significant provider rate increases.
* FEDERAL FUNDS AVAILABLE: Every dollar of federal funds is based on a program element that is in place in other states. For example, 20 states have hospital provider fees and thirty states, including California , have nursing home provider fees.

LEGISLATIVE OVERSIGHT PROTECTS THE GENERAL FUND: The proposal includes ample legislative oversight, including recurrent appropriation authority plus an innovative approach that requires the Department of Finance and the Legislature to project spending and revenues three years out.

UPSIDES NOT CALCULATED: Unlike the presidential candidates, the LAO does not book savings from cost containment measures. The report also overlooks positive economic impacts of $4.4 billion in federal spending and enhanced productivity.

RISK OF INACTION: Failing to act also has significant budget risks. More uninsured means more general fund costs.


FULL REPORT:

LAO AGREES THAT AB x1 1 ADDS UP

The LAO analysis found that assuming a starting baseline cost for health coverage (of $250 per month per person), the health reform proposal pencils out for at least five years without ever using general fund dollars.

· In comparison, the original projections of the Massachusetts proposal was only projected to be balanced for the first two years, and claimed general fund dollars in the first year. In contrast, the design of this proposal is not to have a general fund impact.
· Also unlike Massachusetts , this reform relies on a diverse mix of financing, from at least seven different funding sources, which in itself provides some stability.

The Plan Adds Up Despite Aggressive Assumptions on Enrollment, Crowd-Out

The Legislative Analyst takes at face value the projections of enrollment in the purchasing pool and public programs but these were deliberately modeled at the high end in order to produce a cautious estimate.
· The Gruber modeling that serves as the basis for the analysis assumes full enrollment in public programs and tax subsidy in year three. This would be a far faster phase-in than either Medi-Cal or Healthy Families, and very few public programs ever reach 95%, even after many years of operation. This means that spending on coverage expansions and the tax credit are likely to be substantially lower in the first few years and even in later years.
· The modeling also assumes an upper bar for crowd-out: that is, the modeling maximizes the number of low wage employers not currently offering coverage which are projected to choose the purchasing pool. This will happen over time, generating larger surpluses in the early years of the program.
· These factors would create savings in the early years of the program, suggesting that the program could go longer than five years, without adjustments, and still have the general fund protected.

DOWNSIDE RISKS OF AB x1 1 OVERSTATED SIGNIFICANTLY BY LAO

As is its duty, the LAO does raise questions about some assumptions of the proposal, from the premium rate to the ability to draw down federal funds. As is its job, the LAO appropriately identified the areas where there is "risk" that the costs may be higher than anticipated: these include that the cost of care or coverage is more than expected, or rises more than expected; if we find that there are more uninsured than estimated; and if there's a major cut in federal funds (although the LAO acknowledges that of those booked in the proposal, "most federal funds are accessible under existing rules.")

Base Premium Assumptions Fully In Line With Public Program Experience:

According to the LAO Analysis, if the state’s new purchasing pool was able to negotiate a starting cost of $250 per month for premiums, the health reform effort would be fairly balanced and be financed for at least five years, without impacting the general fund. If the state, however, missed that target and negotiated a $300 per month cost, then by year five of the reform effort would cost $1.5 billion more than it took in annually.

The $250 per month figure seems more than attainable, even high, based on the California ’s experiences with public program coverage to date. The current negotiated rate for Medi-Cal is $103 per member per month. The proponents increased the Medi-Cal rate to $187/month to account for higher provider reimbursement rates, and then added another 30%. Healthy Families, a program that MRMIB has already successful negotiated contracts for, is able to buy coverage for only 10% above Medi-Cal. If anything, California ’s experience suggests that we can drive a better deal than $250 per member per month.

The LAO uses employer-based coverage as a point of comparison. Is this a fair basis? Would a purchasing pool with 2.5 million enrollees have more bargaining power than employers with 20 or 50 or even 1,000 employees? The purchasing pool would have more bargaining power than any single employer in California . A better comparison is with public programs like Healthy Families or Medicare. The rate of increase for Healthy Families, Medicare and other public programs is significantly lower than the rate of increase for commercial coverage, whether employer-based or individually purchased.

Other proponents also note that the state’s new purchasing pool would be covering a younger, healthier (read: less expensive) population overall and would be twice the size of CalPERS’ negotiating pool, which must leverage on behalf of older, sicker workers and retirees, making costs higher.

In committee, the LAO was asked why a comparison to public programs was not appropriate. Their answer was that the pool would need to negotiate a Knox/Keene benefits package. Both Medi-Cal managed care and Healthy Families provide at a minimum the basic Knox/Keene plan (doctors, hospitals, and preventive services) plus prescription drugs.

Finally, health plans have said they can do it. In committee, the Local Initiatives, which would be included as an option in the purchasing pool, testified that they could provide coverage to this population at $250 per member per month. We understand that since the LAO raised this concern, some health plans have done their own modeling, and believe that if they can negotiate Medicare-level rates with providers (which virtually all providers now take), they could meet the $250 per member per month target.

Federal Funds Largely Secure: Risks Overstated

Analyst Elizabeth Hill said she believed that while most of the federal funds were attainable through existing rules, she stated that about a quarter -- $1.1 billion of $4.4 billion in federal funding--was subject to risk. This definition of risk assumes that the federal government will deny California the same approvals that many other states have received.

Most of the federal funding is dictated by formulas that require the government to match the state’s investment into Medi-Cal and Healthy Families: the federal government literally has no choice but to match California’s spending unless basic Medicaid law dating back to the creation of the program in 1965 is changed.

Some of the federal spending also depends on California ’s ability to obtain a waiver from the federal government that would allow for the state to cover low-income adults without children living at home. A number of states already have received waivers from the federal government to cover childless adults.

California has existing provider fees on nursing homes, ICFs, and other Medi-Cal providers. Twenty states have hospital provider fees and thirty have nursing home provider fees. It is correct that the current hospital waiver precludes use of a provider fee but this waiver expires in a few years, as the new reforms take effect.

If the federal government does not allow some or all of the needed waivers, any necessary adjustments in the program would be made prior to implementation. Also, the federal funds that are not mandatory are part of California ’s baseline fund—and no state has ever lost baseline funding in recent memory. That includes in the current federal Administration, which has been more aggressive in cutting than most—and it is important to remember that this reform will be implemented under a new Administration.

The Legislative Analyst fails to acknowledge that California has for many years missed the opportunity for billions of dollars in available federal spending. The proposed reforms draw down over $4 billion in new federal funds.

Estimates of the Uninsured Come from Best Possible Source

We concur with the Analyst that if the number of uninsured is higher, costs would be higher.
However, there is no evidence to the suggestion that a different data source, the Survey of Income and Program Participation by the Census Bureau, may be more accurate. The methodology for this data source, the Census Bureau, explicitly states that it should not be used for state-level estimates because the sample is not drawn to be accurate at the level of a state, even one as large as California.

Most analysts in California, including the drafters of AB x1 1, rely on the California Health Interview Survey, done by UCLA, which has a much larger sample size than any of the Census Bureau surveys. This survey has been funded by the State of California precisely because the various federal surveys consistently underestimated enrollment in public programs, thus providing inaccurate estimates for budgeting purposes. That is, the federal surveys consistently overestimate the number of uninsured, especially at any given point in time. This is driven by differences in survey methodology, including the precise questions asked as well as the sample size.

AB x1 1 INCLUDES SIGNIFICANT GENERAL FUND PROTECTIONS, INCLUDING BOTH ADMINSTRATIVE AND LEGISLATIVE OVERSIGHT

ONGOING LEGISLATIVE APPROPRIATIONS AUTHORITY: The testimony in Senate Health Committee corrected a misperception that passage of this bill would be the only opportunity for legislative review.

To the contrary, the Legislature has full authority, and in fact responsibility, through appropriations and legislative oversight, to stop or modify the programs at any time. If the ballot measure with the financing is passed, the program cannot fully begin until the Legislature appropriates funding. The Legislature can continue to model projections, the status of negotiations with health plans and providers, and the benefits provided to Californians, and make adjustments as needed. AB x1 1 is amendable by majority vote.

TRIGGER ON /TRIGGER OFF: So then what happens if there is a shortfall projected? The measure provides for both "trigger on" and "trigger off" provisions, so the Department of Finance can warn that there are insufficient revenues to meet spending and so that the Legislature can act to provide Californians health care.

If the Legislature does not act by raising additional revenues, scaling back the program, controlling costs, finding new federal funds, or taking other actions, then the default is that most of the measure is repealed. This “safety valve” is for both the general fund and for Californians facing the individual mandate: the mandate is conditioned on the public program subsidies and guaranteed issue.

The LAO acknowledges this, although indicates that there would be "pressure on the General Fund" given the Legislature's likely interest in keeping the reforms in place. But that will be a decision by the Legislature to make. In the event of a shortfall where the $15 billion in new revenue is not enough to make the commitments of the bill, the more likely result is for the Legislature is to find ways to scale down the commitments.

POSITIVE POTENTIAL IGNORED

The LAO took into account some negative assumptions, and didn't take into account several positive assumptions, even acknowledging that the plan "contains several provisions that could help reduce health care costs over time."Cost Containment Not Calculated

A proposal that pencils out for five years would allow policymakers the time to see if the cost control provisions actually work--including the prevention and public health efforts, the impact of transparency efforts, the negotiating power of the purchasing pool, and even the impact of reducing the "hidden tax" of the uninsured.

The cost containment elements aren't "booked" as savings, because the LAO recognizes that they will take time to have an impact. We would note that most of the presidential candidates balance their reform plans by booking savings from cost containment measures, many of them included in this measure. Five years would give us that time, as well as to put forth and implement additional proposals to control and reduce costs.

Through these cost containment efforts and other provisions, AB x1 1 has tackled key cost drivers in the existing Medi-Cal program, so the potential savings is not just to the new programs, but is likely to generate general fund savings as well, savings that has not been factored into the equation.

The Employer Fee Brings in More Revenue Over Time

The scaled employer fee will produce increased revenue over time as payrolls increase. As wages rise over time, more employers will climb over the thresholds to pay a higher percentage of payroll climbing up over $250,000 to pay 4% of payroll instead of 1% in payroll and over $1 million to pay 6% instead of 4%. This escalation in the employer fee is built into the scaling. We cannot determine from the LAO report whether this natural increase in revenue was taken into account or what magnitude of increased revenue it provides.

Other Positive Economic Impacts

The proposal is estimated to bring $4.4 billion in new federal dollars into the California economy, and reduce federal income tax payments from California residents. Expansion of access to coverage under the proposal would have positive effects on business productivity. Expanding health coverage would reduce job lock and improve skills matches between employees and employers. It would also reduce the amount of work lost due to poor health. Finally, it would increase individual financial security, since lack of adequate insurance is a leading cause of personal bankruptcy.

THE SIGNIFICANT RISKS OF INACTION

As the LAO notes, “Any plan to reform the state’s health care system, by the nature of its complexity, will involve financial risk over the long term. Many of the risks discussed above would be shared by any health reform plans that attempt to maintain the current system of employer-provided coverage while expanding public programs to cover the uninsured."

What the LAO left unsaid was the clear financial risk of the status quo. As noted by the San Jose Mercury News, January 25 editorial, inaction is the more costly option.

The Legislative Analyst fails to consider the status quo where as health care costs increase, the number of uninsured climb, creating pressure on the general fund through Medi-Cal and costs to county government as well as the economic drag created by people living sicker and being one emergency room visit away from bankruptcy or homelessness.

The share of non-elderly Californian’s with coverage through an employer fell 5 percent points between 2000 and 2007, with a corresponding increase in uninsurance and public program enrollment. This ongoing decline in job-based coverage is most pronounced among lower and middle-income families but is spread across the income spectrum. When employers do not provide health coverage, part of the cost of care to the uninsured is borne by other firms in the form of higher premiums. The New American Foundation estimates this cost to be $14 billion a year. This is combined with the $14 billion in lost revenue that would be generated through the proposal.

Another major portion of the cost of declining job-based coverage falls on taxpayers. Costs are shifted to taxpayers through increased take-up of Medicaid and State Children’s Health Insurance Programs, increased use of public health facilities, and state and federal reimbursement to hospitals for uncompensated care. The combination of the cost containment mechanisms in the legislation and the creation of an employer contribution to the pool, with a credit for health spending will serve to help stabilize job-based coverage in the state and prevent a greater shift in costs onto the public.

The lack of health coverage also has a significant effect on workers’ health and labor force participation. Individuals without health coverage are more likely to skip and delay needed care, less likely to receive treatment for chronic conditions like asthma and diabetes, and more likely to experience a debilitating health condition.

There are real risks, both to the uninsured and insured, to the general fund and to the economy in general, of not taking these important steps for health reform at this time.

In conclusion, AB x1 1 has the ability to add up, and has significant potential to do so; and the risks have been overstated. In the event of shortfalls, there are significant general protections, including ongoing legislative oversight and authority to “right-size” the program accordingly. The alternative is to leave millions of Californians uninsured, and let the health system continue to decline, with all the general fund and economic risks that such a situation would imply.

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posted by Anthony Wright | Permalink | 10:14 AM


 
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Wonkery...

 
In all the excitement, I don’t want to neglect the new edition of Health Wonk Review, at e-CareManagement. Our comparison of California and Massachusetts is cited, along with some other good commentary, about in-store retail clinics, physician care, and problems and solutions for our health care system.

In light of the ongoing opposition to health reform by virtually the entire Republican delegation, I'll spotlight Joe Paduda's Managed Care Matters blog post, asking why Republicans aren't for universal health care...

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posted by Anthony Wright | Permalink | 1:43 AM


 
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All eyes on the California Senate...

Saturday, January 26, 2008
 
Some of us at Health Access are at the Families USA conference in Washington, DC, with health advocates from around the country.

It's true: the whole world is watching. They recognize that California moving on health reform helps move the national debate. There are groundbreaking elements of the California proposal that are not anywhere in the national political discourse, or in play in any other state. But the interest and even excitement is not even for the specifics of the legislation, but that health reform is moving.

We'll see what happens in the Senate next week.

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posted by Anthony Wright | Permalink | 9:36 AM


 
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They like it! They really like it!

Friday, January 25, 2008
 
It could have been my own cold-induced delirium, but I got a little teary this AM reading the op ed pages of the Sacramento Bee and San Jose Mercury News. Both editorial pages eloquently urge the Senate Health Committee to move ABx1 1 along on Monday. Both do so by showing the price of inaction.

From the Mercury News:

...the LAO wasn't asked by Senate President Pro Tem Don Perata to report on the impact of doing nothing.

If he had asked, he would have been told that employers already pay a hidden tax of about $14 billion to subsidize health care. And the average family of four with insurance also pays a hidden tax of about $1,200 a year to subsidize those who don't have insurance.

From the Sacramento Bee:

If the legislative analyst were to analyze the risks to the state's economy and budget by doing nothing, the results would be sobering. Imagine more hospitals closing, more employers dropping coverage for employees, more kids condemned to a lifetime of preventable diseases and less chance of controlling runaway medical inflation.

Given the alternatives, we'll take our chances with AB X1 1. So should Perata, the Senate president pro tem, who could determine the fate of this legislation.

It doesn't happen often that a Republican governor comes together with Democrats to craft a health care overhaul that is supported by hospitals, business coalitions, health care advocates and right-minded unions and consumer groups. This is an opportunity that the Senate, and the state, can't afford to pass up. Pass AB X1 1.

Don't blow this chance.


Also in the Sacramento Bee, small businessman and Small Business Majority executive director has an op ed about the need for reform.

To be "balanced" the San Diego Union Tribune continues its screed against reform.

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posted by Hanh Kim Quach | Permalink | 10:32 AM


 
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Single-payer supporters for strategic steps...

 
Los Angeles Mayor Antonio Villaraigosa just recently sent a letter to Senator Sheila Kuehl, from the point of view as a fellow supporter of a single-payer solution to health reform, to urge her to support AB x1 1 (Nunez/Perata). Here's a PDF version of that letter:
LAMayorKuehlAB1xSupport.pdf

I was pleased to be a co-signer of a similar letter with over a dozen prominent single-payer supporters, people who I deeply respect and who have dedicated their lives and work toward winning single-payer reforms. This includes activists, academics, and community leaders who led the Proposition 186 campaign, and gave years of their lives and even their bank accounts; and people who worked tirelessly on SB921 and SB840 in recent years, and fought to get it on the Governor's desk in 2006.

We continue to believe that this is not an "either/or" issue, but rather a "yes, and..." More than that, we believe AB x1 1 is the most effective and strategic step to get to single-payer, and that is a motivating factor behind our support.

Far from "settling" for AB x1 1, this is about locking in significant gains for the uninsured as a way to keep the movement and momentum active for broad reforms. Here's the PDF:
SinglePayerSupportABX11-011708.pdf

Here's the full letter:

Thursday, January 17th, 2008

Dear Senator Kuehl, and all legislators who support SB840:

Re: Single-Payer Supporters for Strategic Steps, for AB x1 1

We, the undersigned, write to you as strong supporters of universal health care. We also have a long history of advocacy for single-payer policy proposals. Many of us have been involved in the fight for single-payer health care for as long as two decades. Many of us were active in working for Prop 186 back in 1994, and many of us worked hard over the last few years in support of SB921, and to get SB840 on the Governor's desk in 2006.

As strong supporters of a truly universal health care system, we write to urge you to support AB x1 1 (Nunez), as a significant strategic step toward our shared goal. We strongly believe that health reform need not be an “either/or” situation, and that supporting this reform in front of us is consistent with being whole-hearted supporters of SB840 and single-payer.

We believe that AB x1 1 not only will do no harm — your appropriate minimum test for health legislation — but that AB x1 1 will also do a great deal of good and benefit millions of Californians.

Moreover, we believe that passage and enactment of AB x1 1 will be a strategic advance for the cause of single-payer because it will establish public programs that are the foundation of universal coverage, including a single-payer system.

AB x1 1 embodies policy elements of single-payer. Passage of this law would make it easier to enact truly universal coverage and to pass a single-payer system in the future, since it already includes:

• a major expansion of public program coverage to moderate-income Californians as well as low-income residents, setting the stage for truly universal coverage reforms, including single payer,
• the setting of a minimum employer contribution to health care, which is essential to funding universal coverage and an important part of the financing for SB840,
• the creation of a statewide purchasing pool that could be the beginnings of the huge
purchasing pool that could grow into a single universal system,
• an increase in Medi-Cal rates, helping providers realize that rates could be reasonable under a public program such as a single-payer system.

It also includes additional oversight over insurers. While some have criticized the notion of preserving the role of insurers, the proposal would significantly change the way insurers do business, including having to take all customers on a “guaranteed issue” basis, and having to negotiate with a large purchasing pool to access millions of California customers. The proposal creates a framework where insurers will either have to change their behavior, or face future reforms that impose further oversight on insurers or replace their function.

Like the proposals of the Democratic presidential candidates, AB x 1 1 does not undertake the massive transformation of the health care system that you propose and that we support. But it accomplishes important elements while providing security to those who have good coverage and want to keep it, while creating the framework to take extra steps. Just as passage of family leave legislation created a framework to come back and pass paid family leave, we believe this proposal creates political and policy tools to advance broader reforms.

Some fear that passage of any plan would stall the coming of SB840, as politicians declare their job done. We believe that the opposite is true. Failure begets failure, and if health reform is stalled now, political leaders may be discouraged from supporting any reforms of our health system (and certainly more far-reaching proposals like single-payer). They will likely move on to other issues.

On the other hand, success begets success: Passage and enactment of such a proposal would create a positive environment around health care reform, as politicians will continually seek to raise the bar above the last reform. The people of California are not satisfied with the health care system as it is, and they will want to see it change further to become a health care system worthy of our country and our state. After major reforms in areas like education and global warming, nobody thinks those issues are “done”; instead the interest in pursuing additional reform has stayed strong, and we believe that this will be the same for health care.

The comparison of AB x1 1 should not be with SB840, which we agree is a “gold standard,” but with the status quo in health care, where millions are uninsured, people are denied coverage because of “pre-existing conditions,” low- and moderate-income families face unlimited premiums and unlimited liability, and the situation is only getting worse. Does AB x1 1 provide all the protections we want to see in our health care system? No, but it provides protections that currently do not exist at all:

• it dramatically expands and assures coverage to increasingly desperate families and
individuals,
• it offers protection against the unaffordability of health insurance premiums,
especially for low- and moderate-income families;
• it establishes strong oversight of insurers, and
• it strengthens health care access of insured and uninsured Californians alike by more adequately funding health care providers, especially hospitals and doctors, whose current underpayment threatens their ability to provide emergency services for anyone and their willingness to serve low-income patients.

Under AB x1 1, there are millions of people, especially at the lower end of the income scale but also those with moderate incomes, that would get substantial help in getting the care and coverage they need. We have an obligation to meet their pressing needs. Asking them to wait is asking them to go without the access to care that those of us with insurance have. In addition, the more we can reduce the number of uninsured, the shorter the gap we have to bridge to get to universal coverage and a single-payer system. ABx 1 1 provides a solid foundation on which we can and will continue to advance additional health care reforms.

We will continue to be very active in support of truly universal coverage, but we urge you to consider this as a strategic step needed to win ultimate victory.

Thank you for your consideration.

Sincerely,

E. Richard Brown, PhD
Professor, UCLA School of Public Health

Michael R. Cousineau, PhD
Associate Professor of Research and Director, Center for Community Health Studies, University of Southern California Keck School of Medicine

Sherry Hirota
CEO, Asian Health Services

Henry L. “Hank” Lacayo
State President, Congress of California Seniors

Marty Lynch
CEO, LifeLong Medical Care

Jennifer Reifel Malin, MD
Current Member and Former Board Member, California Physicians’ Alliance

Maryann O’Sullivan
Founding Executive Director, Health Access California

John Roark, MD
Board Member and Past President, California Physicians’ Alliance

Steve Schear
Co-Chair, Universal Health Care Action Network

Joan Pirkle Smith
Chair, Health Committee, Southern California Americans for Democratic Action
Chair, Health Care Legislation Subcommittee, AFTRA


Roy Ulrich
Radio Host and Producer, KPFK

Nora Vargas
Executive Director, Latino Issues Forum, a co-sponsor of SB840,
and convenor of the Latino Universal Health Action Network


Anthony Wright
Executive Director, Health Access California

*All affiliations listed for identification purposes only

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posted by Anthony Wright | Permalink | 8:46 AM


 
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Time to take action on health reform...

Thursday, January 24, 2008
 
HEALTH ACCESS ALERT
Thursday, January 24th, 2008

HISTORIC HEALTH REFORM LEGISLATION HEARD IN SENATE COMMITTEE
* Panel meets for nearly 11 hours to scrutinize 200 page bill and ballot initiative
* Senate Health Committee postpones historic vote on ABX1 1 until Monday
* Report from the hearing, and much more, at the
Health Access WeBlog

ALERT: CONTACT YOUR SENATOR TODAY TO SUPPORT AB x1 1:
* Pass Health Reform, or Stay With Status Quo and Leave Millions Uninsured?

The Health Access WeBlog has our traditional report on the Senate Health Committee hearing today on AB x1 1, which heard long testimony about the measure. At the request of Senate President Pro Tem Don Perata, the Senate Health Committee delayed their vote until Monday afternoon of January 28th.

Health Access California and other health, consumer, community, children's and senior organizations are urging other health advocates to contact their Senators to commit to SUPPORT AB x1 1, and to take advantage of this window of opportunity to dramatically expand health coverage for the uninsured, secure coverage for those Californians with coverage, and build a base for future reforms.

CALL YOUR SENATOR TO SUPPORT AB x1 1, which will:
* expand public coverage to millions of Californians who are now (or will become) uninsured, and as a result live sicker, die younger, and one emergency away from financial ruin;
* provide more options and financial assistance to many insured Californians, who now struggle with having to deal with health costs;
* prohibit insurers from denying people because of "pre-existing conditions," and spending too much on administration, marketing and profit.

For a list of Senators and their contact information, including phone and fax numbers, in both their Sacramento and district offices, go to the California Senate website, at:
http://www.senate.ca.gov/~newsen/senators/senators.htp

MORE ON THE BILL

The bill dramatically expands coverage building on top of California’s current mix of private-employer-provided and public program coverage.

ABx1 1 is the culmination of more than 18 months intense attention from the state’s leaders, which began with the governor and legislative leaders each introducing their own proposals and gradually merging the measures. To read a thorough explanation of what ABx1 1 does, click here and here for previous Health Access updates, fact sheet, and analysis on the measure.

In summary, the measure would raise over $15 billion in new money to expand coverage through:
* Requiring employers to provide a minimum contribution toward their workers’ coverage;
* Getting individual contributions that are related to a family's income;
* Raising the tobacco tax to $1.75 per pack;
* Imposing a 4 percent hospital fee;
* Drawing down new federal matching funds;
* Reinvesting state and county savings

AB x1 1 would expand existing Medi-Cal and Healthy Families programs to cover an additional 1.5 million low- to moderate-income Californians. All in all, an additional 3.6 million Californians, who would otherwise be uninsured, would have medical coverage – 81% of whom would be in families earning less than 400% of poverty ($70,400 for a family of three)

A REPORT ON THE SENATE HEALTH COMMITEE HEARING is available at
http://www.health-access.org/2008/01/report-on-senate-health-committee.htm

Health Access will provide an update on events as they unfold, on the Health Access WeBlog and through these E-mail Updates and Alerts.

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posted by Anthony Wright | Permalink | 5:17 PM


 
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Report on the Senate Health Committee

 
REPORT ON THE COMMITTEE HEARING

Assembly Speaker Fabian Nunez and Health and Human Services Secretary Kim Belshe on Thursday appealed to the 11-member Senate Health Committee to pass ABx1 1 (Nunez/Perata), which could extend health coverage to nearly three-quarters of the state’s uninsured population.

Heading into the hearing, none of the four Republicans on the committee were in support of the bill. Two Democrats – Sens. Sheila Kuehl and Leland Yee had indicated their intent to vote against the measure, potentially leaving ABx1 1 one vote short of passage. A previously scheduled vote for the measure has been postponed until Monday afternoon.

The bill dramatically expands coverage building on top of California ’s current mix of private-employer-provided and public program coverage.

Nunez and Belshe tried to focus committee members and witnesses for and against the measure to consider – not what they’d like to have ideally, but against the current system. “There are poor children walking around California without health insurance. While this isn’t the perfect solution, it’s the right solution because it’s going to provide them with the health insurance they need,’’ Nunez said. ABx1 1 would cover California ’s remaining 800,000 uninsured children, and around 3 million adults. Belshe reiterated: “The status quo is not an option.”

ABx1 1 is the culmination of more than 18 months intense attention from the state’s leaders, which began with the governor and legislative leaders each introducing their own proposals and gradually merging the measures. To read a thorough explanation of what ABx1 1 does, click here and here for previous Health Access updates, fact sheet, and analysis on the measure.

In summary, the measure would raise over $15 billion in new money to expand coverage through:
* Requiring employers to provide a minimum contribution toward their workers’ coverage;
* Getting individual contributions that are related to a family's income;
* Raising the tobacco tax to $1.75 per pack;
* Imposing a 4 percent hospital fee;
* Drawing down new federal matching funds;
* Reinvesting state and county savings

AB x1 1 would expand existing Medi-Cal and Healthy Families programs to cover an additional 1.5 million low- to moderate-income Californians. All in all, an additional 3.6 million Californians, who would otherwise be uninsured, would have medical coverage – 81% of whom would be in families earning less than 400% of poverty ($70,400 for a family of three)

FISCAL ANALYSIS

In light of the state’s $14.5 billion deficit over the next two years, Senator Perata had insisted on obtaining an analysis from the Legislative Analysts’ Office. The nonpartisan budget analyst’s assessment can be found there.

Among many points, what received the most attention was the analysts’ thoughts on federal funding, and how much the state could drive down premium prices.

Federal funding: Analyst Liz Hill said she believed that while most of the federal funds were attainable through existing rules, she stated that about a quarter -- $1.1 billion of $4.4 billion in federal funding--was subject to risk. While most of the federal funding is dictated by formulas that require the government to match the state’s investment into Medi-Cal and Healthy Families, some of it also depended California ’s ability to obtain a waiver from the federal government that would allow for the state to cover low-income adults without children living at home. Proponents pointed out that a number of states (20) already had waivers from the federal government to cover childless adults, and expected the same treatment.

Negotiated premium costs: Much of the fiscal discussion focused on what price the state could actually negotiate for premiums. According to the LAO Analysis, if the state’s new purchasing pool was able to negotiate a starting cost of $250 per month for premiums, the health reform effort would be fairly balanced and be financed for at least five years, although a deficit of $300 million would start to arise in the fifth year. If the state, however, missed that target and negotiated a $300 per month cost, then the reform effort would cost $1.5 billion more than it took in annually.

Rebuttal: Secretary Belshe said she believed the $250 per month figure was attainable as it used Medi-Cal’s current negotiated rate -- $103/month – increased it to $187/month to account for higher provider reimbursement rates, and then added another 30%. Healthy Families, a program that MRMIB has already successful negotiated contracts for, is able to buy coverage for only 10% above Medi-Cal. The state would also have more bargaining power than most small and medium-size employers, which was used as the LAO’s basis for comparison. Other proponents also chimed in that the state’s new purchasing pool would be covering a younger, healthier (read: less expensive) population overall and would be twice the size of CalPERS’ negotiating pool, which must leverage on behalf of older, sicker workers and retirees, making costs higher.

Opponents and skeptics wanted assurances from health plans that a $250/month cost could be achieved. Blue Cross volunteered a figure of over $400/month in the CalPERS program, but Belshe again refuted that the pool population and benefit should be likened to Medi-Cal and Healthy Families, not CalPERS, which is a older population.

ELEMENTS OF THE BILL

The all-day hearing was too long to provide a comprehensive report of all the testimony, both in support and opposition. Following is a broad outline of the hearing and a summary of a few points of discussion made in each section.

INDIVIDUAL MANDATE AND MINIMUM CREDITABLE COVERAGE:
Many groups in support said they were accepting an individual mandate only with guarantees that coverage would be affordable (with limits on how much of a low- and moderate-income family’s income is spent on premium, and restrictions on insurers) and available (through guaranteed issue). Others, however, wanted more specificity on what kind of benefit package would be provided.

Some pointed to the the tax credit that allows middle-income Californians to buy coverage at around 5.5 percent of their income, is tied to a package that provides prescription drugs, doctors visits, preventive care and chronic disease management outside of any deductible.

Sen. Darrell Steinberg, D-Sacramento, asked how easy it would be for individuals – or classes of individuals – to seek an exemption from the mandate to have coverage if it proved too financially burdensome. Additionally, he and other lawmakers questioned how aggressive the state would be in enforcing the measure.

Opponents of the measure raised the spectre of wage garnishment and liens on homes. Proponents argued that ABx1 1 says nothing about this kind of heavy-handed enforcement. Additionally, such behavior by a state agency (ie. Franchise Tax Board) would not be permitted until the Legislature approved legislation on that issue and the Legislature approved funding for enforcement. What ABx1 1 does say is if a person does not have coverage after 62 days, they will be told of different options where they could find coverage (public programs, the state purchasing pool). If the individual does not act, they will be automatically enrolled in the least expensive policy. The state will then recover the costs of that coverage through the Franchise Tax Board, but no additional penalties are exacted.

PURCHASING POOL, COVERAGE EXPANSIONS AND PROPOSED TAX CREDITS: Many groups spoke in favor of the public program expansions, which would add nearly 2 million lives, representing the largest increase since the inception of Medicaid 40 years ago. Additionally, a new public pool would negotiate for coverage for an additional 2.5 million Californians, making it an even larger player on the market than CalPERS. A number, however, questioned how well the newly created state-run purchasing pool would work and whether employees would face fee increases if the Legislature is unable to obtain a 2/3rds vote to increase employee fees should funding shortfalls arise. Others were also concerned that out-of-pocket costs were not capped, putting consumers at risk of higher costs.

OUTSIDE THE PURCHASING POOL: Proponents cited the benefits of the plan to those who do not have coverage, including stabilizing the employer-based coverage that over half of Californians currently enjoy, and having the ability to weed out "junk insurance" by defining a minimum benefit. Opponents were concerned about populations that would not be able to join the statewide purchasing pool; Others expressed concern that employers would drop their health spending to the minimum. Proponents argued that like a minimum wage, the setting of a minimum standard doesn't mean that all employers drop wages to the minimum, but rather it sets a floor from which workers can bargain up from.

INSURANCE MARKET REFORMS: A broad cross-section of proponents embraced insurance market reforms, which include a requirement that health plans sell to all Californians, regardless of pre-existing conditions, and limited health insurers’ ability to charge rates based on health status. Some, however, cited concerns that a provision requiring health plans to dedicated 85 cents for every premium dollar earned on health care was not strong enough.

FINANCING: Aside from fiscal issues previously discussed, the employer mandate portion of the financing was most thoroughly discussed. A number of groups feared that the employer mandate, forcing businesses to pay for worker healthcare, would cause businesses to purposely misclassify their employees as “independent contractors’’ in order to avoid paying benefits, such as Unemployment Insurance and, now, health benefits. Proponents argued that state law already addresses the underground economy with a law that would impose a $20,000 penalty for businesses that willfully misclassify employees, and that could include jail time. Some groups, however, said that the state did not police that provision very aggressively. Businesses, as expected, argued that the employer mandate was too onerous.

MASSACHUSETTS AND BEYOND: The last parts of the hearing, though focused on different issues, often revisited portions that had previously been discussed. Lawmakers heard disparate views on the differences between California’s reform and Massachusetts. To read more about that, see Health Access’ analyses on Massachusetts and California. Lawmakers also heard about cost containment provisions, which were the crux issue for many provider groups, requiring disclosure of quality and cost, essentially shaming providers that did not do a good job to begin providing better service.

AND ON TO MONDAY:
Before closing, Speaker Fabian Nunez made one final appeal to senators.

“In no way, shape or form is AB1x a perfect bill. I never pretended that it was. But, at the end of the day, we have to be practical,’’ he said. “…There are things in here that I might not be too happy about, but it’s a compromise and it’s a darn good compromise…This legislation has a shot of getting the support of voters and will get the support of the governor.’’

The Senate Health Committee will meet Monday afternoon to vote.

Thanks to Hanh Kim Quach for reporting.

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posted by Anthony Wright | Permalink | 2:52 PM


 
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It's a wrap....

Wednesday, January 23, 2008
 
Senate Health Committee just adjourned its nearly 11 hour hearing on ABx1 1. I'm pretty amazed at the committee's stamina and feel fortunate that Sen. Kuehl urged committee members to restrain from speechifying until Monday afternoon, when they reconvene to vote on the bill.

Health Access will have our usual update following today's hearing at some point tomorrow or Friday.

To read up on previous analyses of the bill, check out:

http://www.health-access.org/2007/12/first-look-at-new-legislation.htm
and
http://www.health-access.org/2007/12/health-access-update-monday-december-17.htm
and
http://www.health-access.org/2008/01/health-care-hangs-in-balance.htm

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posted by Hanh Kim Quach | Permalink | 7:50 PM


 
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Bad Bosses

 
Sen. Sheila Kuehl just raised a good question, which is how ABx1 1 would handle businesses that "misclassify" or "reclassify" their workers as "independent contractors'' in order to avoid the employer mandate.

This is also known as the underground economy.

SEIU's Beth Capell responded:

Existing law – Unemployment Insurance Code Section 2101 – already addresses issues surrounding the “underground economy.’’ Specifically, the law says businesses cannot “willfully make a false statement or representation’’….that would reduce a worker’s “benefit or payment.’’

An employer that does so, would be fined $20,000 and could spend a year in prison, as provided under UI Code Section 2122.

California’s Economic Development Department has a division specifically dedicated to pursuing and punishing businesses that evade payroll obligations, and in recent months has pursued, arrested, fined, and imprisoned a number of businesses. ABx1 1 would be one of those obligations.

Additionally, Capell added that Kuehl's own SB840 did not include penalty provisions, but would also -- if passed -- be an employer obligation enforceable under this code section.

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posted by Hanh Kim Quach | Permalink | 4:29 PM


 
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Vote on Monday

 
After today's LOOOOOONNNNNNNGGGGGG hearing on ABx1 1, Senators will be able to go home, think about the bill, be lobbied, and return on Monday afternoon to vote, Chairwoman Kuehl said.

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posted by Hanh Kim Quach | Permalink | 1:37 PM


 
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Failure to comply with mandate

 
Many senators are asking about what would happen to those Californians who fail to -- or are unable to -- comply with the mandate.


It's a good question and it's a concern that has spun many rumors about some faceless bureaucrat -- knocking at your door, garnishing wages, putting liens on your house.

Here's the real scoop: ABx1 1 says nothing about this kind of enforcement. Additionally, such behavior by a state agency (ie. Franchise Tax Board) would not be permitted until

  • a) the Legislature approves legislation on that issue and
  • b) the Legislature approves funding for enforcement, which is unlikely given the existing funding shortfall.

What ABx1 1 does say is if a person does not have coverage after 62 days, they will be told of different options where they could find coverage (public programs, the state purchasing pool). If the individual does not act, they will be automatically enrolled in the least expensive policy. The state will then recover the costs of that coverage through the Franchise Tax Board, but no additional penalties are exacted.

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posted by Hanh Kim Quach | Permalink | 1:33 PM


 
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More death....

 
Sen. Leland Yee, who has announced his intention to vote no on the bill, is offended that proponents for ABx1 1 insinuate that a "no'' vote on the bill means they are tacitly allowing people to die.

“I resent the fact that if we don’t pass this bill, people will die. There are
other bills that would take care of the kinds of problems you guys are talking
about.’’


In his press release yesterday announcing his intention to vote against ABx1 1, Yee cites SB840, Sen Sheila Kuehl's single-payer bill as a good solution, and says he is "extremely skeptical of a law'' he characterizes ABx1 1 as allowing insurance companies to "charge any amount for the policy'' with "... no regulation of the costs of insurance..."

Setting aside his (lack of) accuracy, I find it interesting that rate regulation has become such a prime concern for Yee, since he actually voted abstained AB1554 (Jones), which would have regulated health insurance premiums last year, essentially killing the bill.

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posted by Hanh Kim Quach | Permalink | 11:03 AM


 
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Who dies when?

 
Sen. Darrell Steinberg and Elaine Alquist have rightly focussed on what happens to previously uninsured Californians, who obtain coverage through health reform, and then are cut off if the revenues for the program go south -- causing health reform to "trigger off'' and revert to the "status quo'' -- which means newly uninsured Californians are uninsured again.

This is particularly troubling if a person is in the middle of treatment for cancer.

Sen. Alquist raises this point:

“I’m hearing about safety valves to the state, but not safety valves for the
consumer. There will be people who die because they can’t get treatment during
that 12 or 14-month period’’ during which time health reform is “turned off.’’


But Health and Human Services Secretary Kim Belshe responds that people are dying now -- without coverage, and without this bill.

"I want to underscore a fundamental reality. People are dying
today because they don't have insurance. Lack of insurance means lack of
access. Lack of access means diminished health outcomes. Diminished health
outcomes mean people die.''

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posted by Hanh Kim Quach | Permalink | 10:54 AM


 
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"The Status Quo is not an option"

 
The "most thorough hearing'' on ABX1 1 has begun. You can listen to testimony in the Senate Health Committee throughout the day here, and click on Room 4203.

Secretary of Health and Human Services is now giving her opening remarks on the legislation, following Assembly Speaker Fabian Nunez. Both have emphasized the need to reform the system -- now. Both admit that while this bill may not be perfect, the fall back is the status quo.

"Voting for this bill makes greatly needed progress. Voting against the bill is keeping the status quo,'' Nunez said. "Keeping the status quo does harm. Keeping the status quo tells the uninsured -- who live sicker and die younger -- that they have to wait. Keeping the status quo tells 800,000 kids they have to wait. "

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posted by Hanh Kim Quach | Permalink | 9:34 AM


 
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Hearing day...

 
So today's the big day of the Senate Health Committee to hear AB x1 1. There's suspense, given the indications that Senator Leland Yee has indicated he may vote against the measure.

We'll try to post what we can through the day. It might take some time to get our full report on the proceedings out, onto this blog and via E-mail, but we'll do the best we can.

Later in the week, we'll provide updates from Washington, DC, and the Families USA conference. Stay tuned...

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posted by Anthony Wright | Permalink | 12:29 AM


 
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More on the LAO...

Tuesday, January 22, 2008
 
The LAO analysis found that assuming a starting baseline cost for health coverage (of $250 per month per person), the health reform proposal pencils out for at least five years. (In comparison, the Massachusetts proposal only balanced in their original projections for the first two years.)

That's five years to see if the cost control provisions actually work--including the prevention and public health efforts, the impact of transparency efforts, the negotiating power of the purchasing pool, and even the impact of reducing the "hidden tax" of the uninsured. The cost containment elements aren't "booked" as savings (like the presidential candidates do in their plans), because there is a recognition that they will take time to have an impact. Five years would give us that time, as well as to put forth and implement additional proposals to control and reduce costs.

As is its job, the LAO appropriately identified the areas where there is "risk" that the costs may be higher than anticipated: these include that the cost of care or coverage is more than expected, or rises more than expected; if we find that there are more uninsured than estimated; and if there's a major cut in federal funds (although the LAO acknowledges that of those booked in the proposa, "most federal funds are accessible under existing rules.")

So then what happens if there is a shortfall projected? There's "trigger on" and "trigger off" provisions, so the Deparment of Finance can warn that there's a problem. If the Legislature does not act--by raising additional revenues, scaling back the program, controlling costs, finding new federal funds, or taking other actions--then the reforms are largely repealed, and we go back to the status quo. The LAO acknowledges this, although indicates that there would be "pressure on the General Fund" given the Legislature's likely interest in keeping the reforms in place. But that will be a decision by the Legislature to make.

(In my mind, that's better than the status quo, where health costs go up, the number of uninsured go up, and the Legislature can just let that happen, without a hearing, never mind an action.)

It's too bad that the LAO took into account some negative assumptions, and didn't take into account several positive assumptions, even acknowledging that the plan "contains several provisions that could help reduce health care costs over time."

The report begins to hint at the right context: that any reform will have questions as you look into the future:

"Any plan to reform the state’s health care system, by the nature of its complexity, will involve financial risk over the long term. Many of the risks discussed above would be shared by any health reform plans that attempt to maintain the current system of employer-provided coverage while expanding public programs to cover the uninsured."

What the LAO left unsaid was the clear financial risk of the status quo.

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posted by Anthony Wright | Permalink | 7:23 PM


 
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Not so bad, after all...

 
The LAO is out with its assessment of the health reforms in AB x1 1 and the related ballot measure.

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posted by Anthony Wright | Permalink | 7:09 PM


 
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Hot off the Presses -- For the Nerdiest in Nerdland

 
Exciting news. The Federal Register today released its 2008 Poverty Level Guidelines. For most people, this means nothing. But for those who work with/around public programs, these numbers dictate who's in and who's out for Medicaid, SCHIP, food stamps, and other public programs.

Find them here: http://aspe.hhs.gov/poverty/08poverty.shtml

Also, Health Access likes to do a spreadsheet that shows annual and monthly income at different levels, which you can find here.

Our lobbyist Beth Capell likes to carry a miniature version in her wallet for quick reference, and has trained me to do the same.

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posted by Hanh Kim Quach | Permalink | 3:21 PM


 
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New website on hospital "fair pricing" policies...

 
On the eve of a vote on a major health reform, it's good to see reforms passed in previous years bear fruit.

There's a new website out today, that helps uninsured and underinsured hospital patients and health consumers, by allowing them to find the fair pricing and free care policies of any hospital in California, including those in their area.

A new California law, sponsored by Health Access California in 2006, now requires hospitals to make public their guidelines for their pricing policies, and this website will help in getting that information out to the public. Uninsured or underinsured hospital patients have long been charged several times what insurers and government programs pay for exactly the same service. The new law makes sure than low- and moderate-income Californians should not be overcharged, and that hospitals make public their eligibility policies about providing free or discounted care.

The website, even in "stage one" of its development, is a one-stop shopping, allowing people to use Google Maps to identify hospitals in a given area, and then have access to the "fair pricing" eligibility policies, financial assistance applications, and the contact person of a key contacts at each hospital. It is expected to include the information for all 400 hospitals in California.

This will be a big boon to those who get a big hospital bill, and are looking for what financial assistance might be available.

The Web site, sponsored by the Office of Statewide Health Planning and Development (OSHPD), can be accessed at:
www.oshpd.ca.gov/fairpricing

The bill, AB774(Chan), sponsored by Health Access Californian and signed into law in 2006, states that self-pay patients under 350% of the federal poverty level (around $72,000 for a family of four) should not have to pay more than the Medicare or Medi-Cal rate for hospital services. It also requires that uninsured and underinsured hospital patients get information about their consumer rights and financial options, and that hospital make public their policies of who qualifies for financial assistance, including fair prices, reduced prices, and free care. Along with a New York law also passed in 2006, it is the nation's strongest in preventing hospital overcharging.

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posted by Anthony Wright | Permalink | 2:36 PM


 
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The Lessons of 1994...

 
Ezra Klein at the American Prospect has a new, long article on the lessons of 1994, from the experience with the Clinton health care debate. There are plenty of parallels with our current California conversation...

http://prospect.org/cs/articles?article=the_lessons_of_94

Will we have learned?

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posted by Anthony Wright | Permalink | 2:26 PM


 
a


Register and Vote...

Monday, January 21, 2008
 
Tomorrow, Tuesday, Janaury 22nd is the deadline to register to vote for the Presidential Primary in California, which is Tuesday, February 5th.

There's ballot measures and much more. Health and a lot of other key issues are in play. If you aren't already, please register, and vote.

For more information, go to the Secretary of State's website:
http://www.sos.ca.gov/elections/elections_vr.htm

posted by Anthony Wright | Permalink | 2:02 PM


 
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The Education of Arnold Schwarzenegger...

Saturday, January 19, 2008
 
I was intrigued that the Governor provided such candor to the LA Times editorial board that he admitted he made mistakes, especially early in his term.

But it seems to me he didn't go far enough in his assessment. There are several areas where the Governor, with his current goals and agenda--on the budget, health care, and other issues--is hamstrung by his previous policy stances.

* Many have made the point that today's budget crisis yielding $10 billion in budget cuts is a direct result of his early actions. He reduced the vehicle license fee, which in the current budget year creates a $6.1 billion hole (booked as state spending because of the county backfill). There's another $3 billion that we are paying to service the debt he create with his bond package--a decision he made rather than to either raise revenues or make additional cuts. So that's over $9 billion right there. If he had made different decisions, he wouldn't be in the whole he is in today.

* When he was facing the budget crisis last year, he toyed with the idea of reducing the 2/3 vote requirement for budgets and taxes. He would not have had the 50+ day budget standoff if he helped to pass Prop 56--he actually campaigned against it. He would have had an easier time passing budgets with the passage of Prop 56, which would have changes the supermajority requirement to pass a budget or taxes to 55%.

* On health care, he would already be along the way to his goal of covering all Californians with his health plan if Prop 72 (health coverage for workers of large employers) and Prop 86 (tobacco tax to fund hospital care and children's coverage) had passed. Both were defeated narrowly--by less than two percentage points. The Governor was against them--he was likely a decisive factor. Now, the health plan he supports does include revised version of those elements. He has been clear he supports these elements only in the context of a broader reform, but it might have been easier to have those measures pass in the first place. Now it all comes down to a vote in the legislature in the next two weeeks, and a vote of the people in November.

The education of Governor Schwarzenegger has been fascinating to watch, and it seems he has more learning to do. But to the extent that he has evolved, he is hamstrung by his past positions and actions.

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posted by Anthony Wright | Permalink | 12:52 AM


 
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Payroll Impact Report finalized

Thursday, January 17, 2008
 
The UC Berkeley Labor Center has finalized its report on the impact of ABx1 1 on payroll costs, which I wrote about earlier this week. Their report can be found here.

Another report, analyzing the impact of ABx1 1 on total operational costs will be forthcoming.

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posted by Hanh Kim Quach | Permalink | 5:40 PM


 
a


Republican bills: Revived, then Rejected

 
The Senate Health Committee heard a number of Republican bills on Wednesday. All but one failed. The special session bills were resurrected from 2007, where many either failed or were not heard in committee. Following is a list of the bills, purpose, and outcome:

  • SBx1 5 (Cox): Would redirect First Five tobacco tax funds to pay for health care services. FAILED
  • SBx1 9 (Runner): Directs state to issue licenses to open more clinics, including in retail locations. FAILED.
  • SBx1 10 (Maldonado): Would create a tax credit for those who have Health Savings Accounts, which are used with high-deductible health plans. Efforts to conform state and federal tax laws on Health Savings Accounts have failed the past two years because tax credits through them are predicated on the fact that individuals are underinsured. FAILED
  • SBx1 16 (McClintock): Allows out-of-state insurers to offer health coverage in California, essentially negating the voter-approved HMO Patients Bill of Rights guaranteeing 23 protections such as cancer screening and children’s immunizations. FAILED
  • SBx1 21 (Cogdill): Creates a tax credit for providers practicing in rural areas. FAILED
  • SBx1 23 (Ashburn): Creates a tax credit for businesses that set up a Section 125 account for their employees, which enables use of pre-tax dollars for health expenses. PASSED

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posted by Hanh Kim Quach | Permalink | 2:56 PM


 
a


1-Stop Shopping on ABx1 1

 
Here's a list of resources on health reform and AB x1 1, for your perusal:

* Text of bill (with history and analyses), AB x1 1 (Nunez/Perata)
http://www.leginfo.ca.gov/cgi-bin/postquery?bill_number=abx1_1&sess=CUR&house=B&author=nunez
* Actual Initiative, filed at Attorney General's Office
http://www.calhealthreform.org/pdf/2008initiative.pdf

* Fact Sheet on AB x1 1 from Speaker's Office
http://www.health-access.org/advocating/docs/ABx1%201%20Fact%20Sheet%2001%2003%2008.pdf
* Fact Sheet on AB x1 1 from Governor's Office
http://www.fixourhealthcare.com/plan
* Assembly Floor Analysis on AB x1 1
http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_0001-0050/abx1_1_cfa_20071217_160631_asm_floor.html

* Health Access Letter on AB x1 1
http://www.health-access.org/advocating/docs/ABx1%201%2020080108.pdf
* Health Access Analysis: Who Gets What Help?
(Best document to find out how AB x1 1 would impact you and your family)
http://www.health-access.org/advocating/docs/ABx1%201%20Who%20Gets%20Help.pdf

* Gruber Analysis: Modeling on Populations Movements and Coverage
http://www.calhealthreform.org/pdf/GruberAnalysis011108.pdf
* Health Access Analysis: Comparing California and Massachusetts Reforms
http://www.health-access.org/advocating/docs/2008CA-MAReformComparison%2001%2014%2008.pdf
* UC-Berkeley Labor Center Analysis: Impact on Payroll Costs
http://www.health-access.org/advocating/docs/UCBEmployerImpactPrelim.pdf

* Q&A on AB x1 1 from Speaker's Office
http://www.health-access.org/advocating/docs/ABx1%201%20QA%20-%20Nunez.pdf
* FAQ on AB x1 1 from California Health Care Foundation
http://www.calhealthreform.org/content/view/63/

Happy reading!

Labels:


posted by Anthony Wright | Permalink | 12:03 AM


 
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The power of purchasing...

Wednesday, January 16, 2008
 
Lots of coverage today about a new report by CALPERS and the Pacific Business Group on Health, about the costs of hospital care. There's articles by Lisa Girion in the Los Angeles Times, Barbara Feder Ostrov in the San Jose Mercury, Victoria Colliver in the San Francisco Chronicle, and Gilbert Chan in the Sacramento Bee. Fascinating stuff, about the wide range of hospital charges between and within regions, and how hospitals largely charge "what the market can bear."

The study goes to one of my main points: in health care, charges are much more about purchasing power than the cost of care. An individual, with little market power, pays more for prescription drugs, hospital bills, and insurance that groups, and the bigger the group and the bigger the bargaining power, the less care costs.

What's the implications for health reform?
* This is why AB x1 1 has a purchasing pool--bigger than CALPERS--to negotiate the best possible deal with insurers and drug companies.
* Studies like this also point to the need for transparency--to identify the problems that we need to solve problems. PBGH was active is helping support the transparency language in the bill.

posted by Anthony Wright | Permalink | 11:32 AM


 
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Business impact of ABx1 1

 
Republicans have been caterwauling for more than a year about the inclusion of an employer mandate in health reform plans.

They call attempts to level the playing field between employers who provide coverage and those who don't a "tax'' that will crush businesses and cause an exodus of industry from the state.

UC Berkeley Labor Center is working on an analysis on the impact of ABx1 1 on business -- an update of an earlier analysis on various health proposals on business. They have shared a preliminary analysis, however, that shows the impact of ABx1 1 on payroll costs. You can find their preliminary analysis here.

Interesting findings:

  • Nearly half of all businesses (47.3%) will not have to pay anything more, having already met or exceeded ABx1 1 health care spending requirements.
  • Only 1.7% of businesses in all of California will bear an increase in costs (between 4% and 6.5%)

To the idea that small businesses, in particular will suffer:

  • 90% of very small firms (between 3-9 employees) will have their health care costs increased by less than 1%.
  • Nearly 70% of small firms (between 10-99 workers) will have their health care costs increased less than 1%.

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


 
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Reich on moving beyond mandates...

 
Robert Reich, former U.S. Secretary of Labor, and now at UC-Berkeley, makes a lot of sense: The individual mandate is the wrong thing to focus on in health reform. Those who are spending lots of time on this particular component, either promoting mandates or opposing mandates, are missing the main debate.

Read the whole article. He first makes clear: the three Democratic presidential candidates have very similar, comprehensive plans:

Mandates are a sideshow, and fighting over them risks turning away voters from the main event. In almost every important respect, all major Democratic plans are the same.

They require employers to "play or pay" -- either provide coverage to their employees or contribute to the cost of coverage. They create purchasing pools that will offer insurance to anyone who doesn't get it from an employer. They offer a public heath-insurance option. The plans preserve freedom of choice of doctors. They aim to save money through more preventive care, better management of chronic disease, and standardized information technology. All of them subsidize lower-income families. Despite some skirmishing over whose subsidies are most generous, the subsidies are about the same.


This description of the Democratic presidential candidates also mirror the pending California health reform, AB x1 1.

Reich effectively demolishes the notion that there's a major difference between Obama on one hand, and Clinton and Edwards on the other, with regard to the individual mandate:

Take a closer look and even the candidates' positions on mandates aren't all that different. John Edwards has proposed to automatically enroll people in health insurance on their tax returns, but has said this mandate won't apply until premiums are affordable. Hillary Clinton says she favors mandates, but isn't sure there should be a penalty for noncompliance. Barack Obama favors an immediate mandate for children, but doesn't include one for adults. He says he's willing to revisit the issue after making health insurance more affordable and enrollment easier, and is also considering an automatic enrollment with an opt-out for those who don't want to be included.

As a practical matter, the difference between Sen. Clinton's and Sen. Obama's approaches come down to timing and sequencing. Mrs. Clinton wants a mandate first, believing that enrolling the younger and healthier will help reduce costs for everyone else. Mr. Obama thinks forcing people to buy health insurance before it's affordable isn't realistic. He wants to lower health costs first, and is willing to consider a mandate only if necessary.

This fight is little more than a distraction, given that a mandate would matter only to a tiny portion of Americans. All major Democratic candidates and virtually all experts agree that the combination of purchasing pools, subsidies, easy enrollment and mandatory coverage of children will cover a large majority of those who currently lack insurance -- even without a mandate that adults purchase it.


Those who oppose the individual mandate and embrace Obama on that issue neglect that fact that Obama has not opposed the individual mandate; he merely wants to focus on affordability first. That's similar with the California proposal, which conditions the individual mandate on affordability, and provides for exemption if there isn't affordability.

As I have blogged before, the real issue is not the mandate--the vast majority of people want coverage--but what the proposal does to help people to get and afford the coverage in the first place.

In conclusion, Reich make the important point about the individual manaate.: "It's the least important aspect of what they're offering." The much more important issues are the expansions of public programs, the increased bargaining power of purchasing pools, the "guaranteed issue" regulation of insurers--those are the big deal. Those are the main issue, deserving of the marquee.

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posted by Anthony Wright | Permalink | 12:05 AM


 
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A looooong hearing agenda...

Tuesday, January 15, 2008
 
The Senate Health Committee has put out a tentative outline of the hearing, scheduled for next week, on AB x1 1 (Nunez).

Outline for Hearing on ABX1 1 (Nunez)

I. Author’s presentation, including presentation by Secretary Belshe or administration representative
II. LAO presentation of fiscal analysis
III. Testimony, by topic (order for each topic will be support, support if
amended or with amendments, concerns, oppose unless amended,
oppose)
A. Mandate to maintain minimum creditable coverage
B. Purchasing pool, coverage expansions, and proposed tax credits
C. Requirements for health coverage outside of purchasing pool
D. Health insurance market and regulatory reforms
E. Financing (including provisions of proposed initiative)
--Employer assessments
--Redirection of county funds
--Tobacco tax
--Hospital assessments
--Federal funds
--Individual contributions
--Contingencies in event of funding shortfall
F. Testimony on Massachusetts health plan
G. Scope of practice changes
H. Data collection and transparency and pay for performance provisions
I. Other provisions
--Hospital and physician rates
--IHSS worker provisions
--Electronic prescribing and medical records
--Healthy actions and incentive rewards
--Public insurer provisions
--Diabetes, obesity and smoking provisions
--Prohibition on hospital balance billing
--Other
IV. Author’s close

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posted by Anthony Wright | Permalink | 3:04 PM


 
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More on Massachusetts, and comparing to California...

 
HEALTH ACCESS UPDATE
Tuesday, January 15, 2007

NEW ANALYSIS: PENDING CA HEALTH REFORM WOULD GO WELL BEYOND MA
* Fundamentally Different in Financing, Cost Containment, and Other Concepts
* Broader Benefit in Providing Premium Relief, Insurance Market Reform
* California's Proposals Learns Some of the Lessons from Massachusetts
* Senate Health Committee to Hear AB x1 1(Nunez) Next Wed, Jan 23rd, 9am

New on the Health Access WeBlog: LAO on the Budget; California in Health Wonk Review; A Single-Payer Supporter for AB x1 1; More on the SF Court Case; U.S. Health Rankings;


The Senate Health Committee, chaired by Senator Sheila Kuehl, has postponed the hearing considering AB x1 1 (Nunez), the current health reform proposal negotiated with Governor Schwarzenegger, as they await the analysis by the Legislative Analyst's Office. The hearing will now be next Wednesday, January 23rd, starting at 9:00am and is expected to last all day. The deadline for letters of support or opposition on the measure are due this Wednesday.

NEW MODEL: As the Senate Health Committee awaits a financial analysis, the California Health Care Foundation has released another analysis, showing the results of modeling of AB x1 1 and the related ballot measure. The report, by MIT Professor Jonathan Gruber, shows how 3.6 million Californians would have coverage under the proposal, mostly through expanded public programs, a new subsidized purchasing pool, and greater availability of on-the-job coverage. The report is at the Cal Health Reform website, at:
http://www.calhealthreform.org/pdf/GruberAnalysis011108.pdf

NEW ANALYSIS: Health Access is also releasing a new analysis today, comparing AB x1 1 (Nunez) with the recent reform in Massachusetts . This new comparative analysis shows that the pending California Health Security and Cost Reduction Act, AB x1 1 (Nunez), takes major steps in health reform far beyond the much-discussed Massachusetts reform of 2006.

A full copy of the 8-page analysis is available at the Health Access website, at: http://www.health-access.org/advocating/docs/2008CA-MAReformComparison%2001%2014%2008.pdf

The analysis, entitled "Health Reform in California and Massachusetts : Different from Start to Finish," concludes that AB x1 1 would provide a broader benefit to California consumers than what was passed in Massachusetts . In addition, the California proposal has a much more stable financing structure of significant new dollars to improve the state's health care system, and goes far beyond Massachusetts in trying to control health care costs.

The report lists "top ten" major differences between the California 's AB x1 1, and the health reform law, Chapter 58, passed in 2006. In contrast with Massachusetts, the California proposal includes:
1) New, Broader Financing, including a Tobacco Tax
2) A More Meaningful Employer Contribution
3) General Fund Protection
4) Significant Cost Containment
5) Subsidies up to and above 400% of the federal poverty level
6) Key Differences in the Individual Mandate, Affordability and Enforcement
7) A Transition to Guaranteed Issue
8) Medical Loss Ratios and Increased Insurer Oversight
9) Not Just a Connector, but a Negotiator
10) New and Improved Public Health Care Options

The report shows that while there are similarities in the framework, California's pending proposal goes far beyond Massachusetts in numerous areas. At the same time, even with their more limited reform, Massachusetts has taken the major step of covering over half of uninsured--over 300,000 people through public program expansions--in a short amount of time, and is on path to close the gap further. The biggest critique is that this success in signing up patients quickly has led to higher-than-expected general fund costs.

The report explains how the Massachusetts plan never raised significant new revenue--it mostly redistributed existing state and federal funds, and relied on new funding from the general fund. In stark contrast, the California proposal would raise $15 billion in new funding, to be in a lock-box protected from the general fund, and vice versa. The new funds raised are from a much more meaningful employer contribution, individual contribution, a hospital fee, significant new federal matching funds, reinvested savings from county and state governments, and a tobacco tax.

In fact, research into the history of the Massachusetts law shows the California's proposal is much more like the ballot measure originally proposed by the consumer and community advocates, which included significant employer contributions, middle-income subsidies up to 400% FPL, and a tobacco tax--none of which made it in the final Massachusetts package, but is included in the pending California plan. The study goes into the details of the different iterations of these measures.

The conclusion of the report is that Massachusetts and California start from different places, and the plans are different enough, that they will end up having different results. Critiques of the Massachusetts plan simply do not apply to California 's reform.

Again, a full copy of the 8-page analysis is available at the Health Access website, at: http://www.health-access.org/advocating/docs/2008CA-MAReformComparison%2001%2014%2008.pdf

To view other resources from the Year of Health Reform, visit our website,at:
http://www.health-access.org/advocating/2007_healthdebate.html.

CALL TO ACTION: With the new hearing time, letters are due into the Senate Health Committee TOMORROW, Wednesday, January 16th, in order to be included in the committee analysis.

Health Access California has sent a letter expressing support, while also seeking amendments to get clarifications on affordability and benefits. The letter is available on our website. Letters of support should be sent to the Senate Health Commitee at:

The. Hon Sheila Kuehl
Chair, Senate Health Committee
State Capitol, Room 2191
Sacramento , CA 95814
FAX: 916-324-0384

Advocates should also write letters to the individual members of the Senate Health Committee:

Senator Sheila Kuehl (Chair); Senator Samuel Aanestad (Vice Chair); Senator Elaine Alquist; Senator Gilbert Cedillo; Senator Dave Cox; Senator Abel Maldonado; Senator Gloria Negrete McLeod; Senator Mark Ridley-Thomas; Senator Darrell Steinberg; Senator Mark Wyland; Senator Leland Yee

Health Access will continue to provide updates on ABx1 1, the initiative and other health reform efforts, including late-breaking developments that will be posted on our blog, at:http://www,health-access.org/blogger.html

To view other resources from the Year of Health Reform, visit our website, at:http://www.health-access.org/advocating/2007_healthdebate.html.

This includes a new analysis, "Who Gets What Help?" so that California consumers can find out how they would be helped under the proposal in getting health coverage.
http://www.health-access.org/advocating/docs/ABx1%201%20Who%20Gets%20Help.pdf

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posted by Anthony Wright | Permalink | 10:37 AM


 
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Balancing Hardships

 
Proponents and opponents of health reform point to the vast amounts of human suffering that will ensue should something not pass -- or pass. I have no doubt that both sides are correct, but I would point everyone to Pages 28-31 in the recent San Francisco decision, where the judges wrote eloquently about the "balance'' of hardships imposed various sectors under the Healthy San Francisco Program -- or lack thereof.


I'm going to summarize their words more bluntly, but you can read the more graceful version by clicking on either of the links posted above.

If Health San Francisco did NOT go forward:

  • Patients who just started treating their diseases would stop going to the doctor, stop taking drugs, and risk death or serious illness.
  • The city would incur costs -- as it does now -- because sick (and now, uninsured) patients would cram into the city clinics and public hospitals and the city would not have enough dollars from employers -- or other sources -- to help offset the costs for caring for the uninsured.
  • For the "public interest"... well.... wouldn't you want to know the person who is handling your food is healthy?

If Healthy San Francisco DOES go forward:

  • It would be a big administrative pain in the rear for businesses, and it'd cost them money because they'd actually have to provide health care for their workers.

This "Balance of Hardships" perfectly frames our remaining year(s) of health reform. Given those pros and cons, wouldn't you want health reform?

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posted by Hanh Kim Quach | Permalink | 10:30 AM


 
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First take by the LAO...

Monday, January 14, 2008
 
...on the budget.

The Legislative Analysts' Office came out today with its first review of the Governor's budget. It didn't have a major concern with the numbers, but with the decisions.

The major beef: Not all state programs are equal, and so a 10% cut does not recognize the priority of the programs, or the impact of the cuts on the program's effectiveness. The LAO also calls for additional revenues, not just cuts. She also casts a skeptical eye on the Governor's "reforms."

On the analysis section, the section in entitled, "Economic and Revenue Forecasts Appear Reasonable, but Some Downside Risk." Even though the LAO had a better projection just a few weeks ago, they are ready to predict the worst. Very LAO. Expect something similar with the analysis on health reform: it can pencil out, but here's the risks that it won't. Nothing definitive, but pointing to "downside risks."

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posted by Anthony Wright | Permalink | 4:51 PM


 
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The never-ending year of reform...

 
FYI, the Senate Health Committee hearing on ABX1 1 (Nunez) has been now been rescheduled to Wednesday, January 23rd. It will start at 9:00am in room 4203.

That does mean that groups have a new opportunity to get in their comments to the committee, including additional or updated letters of support or opposition, by Wednesday, January 16th.

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posted by Anthony Wright | Permalink | 12:23 PM


 
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When you come to a fork in the road...

 
Here's an important post on the California Progress Report, an argument about why supporters of single-payer should support AB x1 1 (Nunez).

It's written by Steve Schear, who is a long-time single-payer activist, active in the fight for Proposition 186, one of several founders of Health Access California 20 years ago, and until recently served on our board. He helped create the notion of the Health Care Options Project effort, which helped jump-start the current effort. He is still active, and currently co-chairs the Universal Health Care Action Network, a national group.

His arguments make sense to me, and mirror some of my thinking. Even though we work on a wide range of health issues, Health Access is a long-time, avowed single-payer organization, from developing the proposal that eventually became Proposition 186 15 years ago, to most recently in 2006, when we devoted our field organizing staff full-time to getting SB840 on Governor Schwarzenegger's desk, and continuing to be active this year, in keeping SB840 in the conversation.

I recognize that the notion that AB x1 1 is a strategic step toward single payer may be a selling point for some, but not for others. But here's the point: if I am hitchhiking from Bakersfield to Sacramento, and there's a vehicle that will take me to Fresno, I'm taking it. The vehicle might stop in Fresno, or maybe I can convince the driver along the way to go further, to Stockton, or all the way to Sacramento. Maybe not, and we will decide at Modesto to go our separate ways. The goal is still Sacramento, but it's better to get moving, rather than the status quo of staying in Bakersfield. (No offense to those in Kern County.)

Steve isn't alone on this one.

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posted by Anthony Wright | Permalink | 1:01 AM


 
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West Coast Wonkery...

Saturday, January 12, 2008
 
There's a new Health Wonk Review at the always interesting Health Care Policy and Marketplace Review. And I don't just say that because Bob Laszewski included our post on the presidential candidates' health plans, and said, "if you are following California reform, you need to keep an eye on this site." After all, readers of this blog already know that.

There's just so many interesting posts, I could fill this blog with responses, especially since so many of the issues are California-centric. This includes:
* Brian Klepper's critique of the current reform proposal in California (which was cross-posted to The Health Care Blog, where I responded);
* A take by the Colorado Health Insurance Insider on the recission controversy in California, (which bizarrely suggests more underwriting, rather than just getting rid of the practice);
* A HealthBlawg post on the ERISA lawsuit in San Franscisco (which had to be updated for the most recent, positive decision by the Appeals Court); and
* A couple of posts (on InsureBlog and HealthBeat) on the Nataline Sarkisyan situation, the complicated and tragic issue of a 17-year old denied for a liver transplant by Cigna, who died just after hours public pressure was succesful in getting an approval.

Happy reading!

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posted by Anthony Wright | Permalink | 12:07 AM


 
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A classless budget...

Friday, January 11, 2008
 
Lots of coverage of the budget cuts, by Tom Chorneau and John Wildermuth in the San Francisco Chronicle (with a separate health cuts article by Elizabeth Fernandez), Mike Zapler in the San Jose Mercury News , and Dan Smith and Judy Lin in the Sacramento Bee.

These articles place some emphasis on the health cuts: provider cuts, eliminating dental and other benefits, additional paperwork burdens, increased costs for children and seniors, AIDS services cuts, etc.

But it is remarkable how broad the cuts really are. In my advocacy career, I've become used to austerity budgets that took the biggest whack at the most vulnerable, especially health and social services for those who are low-income. But this has something for everybody to hate, regardless of income or ideology: cuts to schools, closed parks, released prisoners, hospital rate reductions. It's hard to see who would *not* be impacted in one way or another.

Some cynics (or is it optimists?) believe the Governor is setting the stage to get a tax increase. I'm not sure I believe the conspiracy theory--after all, if he is sincere about "no new taxes," what other choice does he have?

But those commentators are right that this budget, unwittingly or not, creates a large coalition looking for an alternative solution to the budget crisis.

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posted by Anthony Wright | Permalink | 11:29 PM


 
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Deja Vu

 
One of the striking thing about the health budget cuts is that we've seen them before. Provider rate cuts; benefit cuts, including dental; even quarterly status reports.

Jeez. It's like the writer's strike has come to Sacramento... all we are getting is reruns.

And it's not even the good ones. It's turkeys... more "BJ & The Bear" than "Seinfeld." Here's for a different program in 2008.

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posted by Anthony Wright | Permalink | 3:08 PM


 
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The dirty details on the budget...

Thursday, January 10, 2008
 
HEALTH ACCESS UPDATE
Thursday, January 10, 2008


GOVERNOR ANNOUNCES BUDGET CUTS; HEALTH CUTS WOULD IMPACT MILLIONS
* $14.5 billion deficit surfaces 10% reductions across state programs and departments
* Governor revisits health budget cuts previously rejected as too severe
* Cuts include major provider rate cuts; benefit cuts, including dental; QSRs
* Health reform proceeds, offers argument against cuts, for revenues

New on the Health Access Weblog: More on the budget, SF court case; Status of AB x1 1; etc.


Gov. Arnold Schwarzenegger returned to his pre-post-partisan days Thursday, unveiling an austere 2008-09 budget that attempts to address a $14.5 billion deficit, and calling a fiscal emergency.

THE BUDGET IN BROAD STROKES

Next year’s $141 billion budget would close parks, cut education funding, and cancel advance payments of budget borrowing from previous years. The budget reduces most state departments and programs by 10 percent, across-the-board.

“Now, some might say that it sounds easy to just cut across the board by 10%, but let me tell you… I can see every single person hurt by those cuts, and I understand how difficult they will be for many, many people,’’ Schwarzenegger said.

Nevertheless, Schwarzenegger revisited familiar fiscal territory, proposing cuts that both he and former Gov. Gray Davis had proposed, but were rejected by lawmakers as too extreme. In addition, Schwarzenegger re-proposed a so-called budget "reform," which had twice failed in previous years: automatic, across-the-board cuts to programs when spending grows ahead of revenues.

Democratic legislative leaders immediately disavowed the budget. “The budget proposed today is what a cuts-only budget looks like and the proponents of a cuts-only approach need to own it,” Speaker Núñez said. “This budget isn’t going for an up or down vote today. Clearly if passed as written, it would cause a lot of permanent harm.”

THE MOST PROMINENT HEALTH CUTS

The health cuts themselves would reduce access to care, cut covered benefits, and raise costs for millions of low-income California children, parents, seniors and people with disabilities. These are cuts that have been considered before, that previous Legislatures have rejected as too extreme. For a look at Health Access’ budget cuts scorecard from the previous budget crisis, click here.

Three areas of reductions with the biggest dollar value are provider rate cuts, cuts to benefits, and quarterly status reports that would serve to discourage access to care. Other cuts include increased costs and reduced benefits in Medi-Ca, Healthy Families, and other programs. The impacts include:

* PROVIDER RATE CUTS ($720.9 million): Cuts to provider rates will significantly reduce access to doctors, hospitals, and specialists for the over six million Californians with Medi-Cal coverage, and many others. California already has among the worst reimbursement rates in the nation, and over half of the state's doctors don't take Medi-Cal.

* BENEFIT CUTS, INCLUDING ADULT DENTAL ($133.9 million): The millions with Medi-Cal coverage will also lose several health benefits. Three million low-income parents, seniors, and people with disabilities will lose dental coverage under this proposal.

* MORE PAPERWORK LEADING TO LOWER ENROLLMENT ($92.2 million): While the proposal does not seek to directly cut eligibility to public programs, it imposes paperwork burdens--so-called "quarterly status reports" (QSRs) on low-income families with the purpose of having over one hundred thousand Californians fall off coverage.

IMPLICATIONS FOR HEALTH REFORM

Gov. Schwarzenegger maintained that his goal of reforming the state’s health care system was not contrary or inconsistent with the severe cuts proposed to programs that would be expanded in health reform.

During his State of the State, the Governor conjured up President Franklin Delano Roosevelt, who presided over the Depression era, “he did not just wait and hope for something to happen. He was acting; he was making a move. He started building bridges...highways…buildings and all this. All the things we stil enjoy today. He did not say, ‘Because this is a temporary problem, people should suffer permanently because of it. No. He wanted to do things, and that’s what we have to do.’’

ABx1 1 (Nunez) and its accompanying ballot measure could address and provide a needed infusion of cash -- nearly $15 billion -- to provide health coverage. The arguments made for health reform in the past year can be used to argue against cuts like the ones Schwarzenegger proposed Thursday.

Medi-Cal provider fees: The proposed budget seeks to cut provider fees by 10%, even though the Governor has made clear that doctors and hospitals in California that care for the neediest patients are paid some of the lowest rates in the nation, which creates access issues for those on Medi-Cal, and a "hidden tax" on the rest of us. Health reform would raise rates as much as 20% in some cases and not cost the state additional general fund money. The money would come from a 4% hospital fee increase that the state’s California Hospital Association has approved. (It is worth noting that nursing homes did not suffer a proposed rate reduction because their rates are largely self-funded, having imposed a 6% fee on themselves in 2004.)

Federal matching funds: The proposed budget would cut Medi-Cal by $1.1 million, which means that California would lose another $1.1 million in federal Medicaid matching funds. The Governor has argued that our lack of investment in health care has meant that we have left billions of dollars of federal matching funds on the table in Washington, DC. Health reform would enable the state to pull down additional federal matching dollars because the state would be paying more into Medi-Cal (drawing down a dollar for dollar match) and Healthy Families (which draws down $2 for every $1 state dollar spent).

Reductions in uncompensated care costs: The proposed budget would decrease Medi-Cal caseload through the imposing of the quarterly status reports, and leave more people uninsured, and increase the "hidden tax" for the rest of us. The Governor has argued that expanding coverage to 95% of Californians under health reform – either through work or public programs – will mean more patients would be able to pay, or have a source pay, for their care. This reduces the losses for hospitals and providers, and puts them less at risk of closure.

HEALTH BUDGET CUTS: THE NITTY GRITTY

Following is a rundown of major health programs in California and the cuts sustained.

MEDI-CAL, which serves the state’s poorest Californians – most with incomes up to $17,170 for a family of three, will suffer a $1.1 billion blow, which would reduce their benefits and make it harder for them to access care.
2007-08: $37 billion ($14.1 billion general fund),
2008-09: $36 billion ($13.6 billion general fund)

PROVIDER RATE CUTS ($720.9 million) – the reductions will be divided as follows.
Ø -$602.4 million: Doctors, hospitals, managed care plans, other providers
Ø -$56.8 million: Rates to long-term Care facilities
Ø -$30 million: Non-contract hospitals
Ø -$34.4 million: Funding reductions to public hospitals
Ø Noted: Nursing home provider rates were not reduced because of a 6% nursing home fee increase imposed in 2004.

BENEFITS CUTS ($133.9 million): Proposal would reduce benefits that the federal government considers “optional.”
Ø -$115 million: Adult dental benefits
Ø -$19 million: Chiropractic care, incontinence creams and washes, acupuncture, audiology, optometry, opticians and optical labs, podiatry, speech therapy and psychology.

BUREAUCRATIC BARRIERS THAT REDUCE ENROLLMENT ($92.2 million): Requires Medi-Cal recipients to file paperwork every three months to determine eligibility for the program. The Governor’s office expects this alone would result in a decreased enrollment of 73,900 children and adults falling off of Medi-Cal. Currently, children who qualify are insured for an entire year. Parents need to file semi-annually.

OTHER CUTS ($157 million)
Ø -$24 million: Reduction in pay to hospitals which incur uncompensated care costs. These hospitals care for high numbers of uninsured patients and Medi-Cal recipients.
Ø -$50.1 million: Medicare Part B premiums for elderly who do not qualify for Medi-Cal share of cost.
Ø -$83.1 million: County, administrative and other reductions.


HEALTHY FAMILIES, which provides coverage to low- to middle-income children on a sliding scale for families up to 250% of poverty ($51,625 for a family of three) will also endure changes. Families who are enrolled will have to pay higher premiums and co-pays, which will vary by income.
2007-08: $1.1 billion ($393.6 million general fund), 888,450 enrollees
2008-09: $1.1 billion ($387.8 million general fund), 954,252 enrollees

Ø -$6.3 million: Limiting dental benefits to $1,000 annually
Ø -$3.4 million: Increasing co-pays for non-preventative services from $5 per visit to $7.5- per visit for families with incomes higher than 150% of poverty ($25,758 for a family of three)
Ø -$11.1 million: Increasing premiums for families with incomes higher than 150% of poverty. Premiums would range from $9 to $19 per child. One family would pay no more than $57/month in premiums.
Ø -$22.4 million: A 5% reduction in payments to health plans that participate in Healthy Families

MRMIP, (Managed Risk Medical Insurance Program), provides health coverage for high-risk, medically uninsurable individuals who are denied health care in the private, individual market. The program currently has 339 Californians on a waiting list to obtain coverage and more than 8,000 enrollees, according to the director Lesley Cummings on Thursday.
2007-08: $40 million
2008-09: $36 million

To view the governor’s budget, visit www.ebudget.ca.gov.

WHAT'S NEXT

The Legislative Analysts Office will pore over each line of the budget and release a thorough analysis to lawmakers in mid-February. Soon after, Legislative budget subcommittees will begin vetting each section of the budget and eventually the Legislature will produce a counterproposal to the governor's budget. Schwarzenegger, in the meantime, will revise his budget in May, using the latest revenue and spending numbers available.

In the interim, ABx1 1 (Nunez) is scheduled to be heard in the Senate Health Committee on January 16.

For more information, contact the author of this report, Hanh Kim Quach, at hquach@health-access.org.

For more information about the Year of Health Reform, visit http://www.health-access.org/advocating/2007_healthdebate.html.

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posted by Anthony Wright | Permalink | 8:25 PM


 
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A shout out to the health nerds

 
First thing's first -- if you want to see it for yourself, the Ninth Circuit's ruling to suspend the lower court Judge Jeffrey White's stay on the Healthy San Francisco Plan, click here.

The ruling is interesting in light of the work being done this year to reform health care and expand health coverage statewide -- in part -- through an employer mandate. In fact, when the ruling came down against the San Francisco plan right after Christmas, there was no shortage of Scrooges in the streets, praising the decision that would have left 26,000 middle-income San Franciscans uninsured.

(Background: Golden Gate Restaurant Association sued to prevent an employer-mandate piece of the Healthy San Francisco Plan from going into effect, saying the ordinance violated the federal ERISA law. ABX1 1, a measure that will be heard in the Senate Health Committee next week and has been agreed to by both the Speaker and Governor, contains an employer mandate as part of a package to extend coverage to more than 3 million uninsured Californians).

Reasons the Ninth Circuit ruled against the Restaurants and for the City:


  • The ordinance does not require businesses to adopt any specific kind of health plan, it merely sets a spending threshold that employers would have to meet, therefore, it does not violate ERISA. (ERISA was intended to assure that employers would not have to contend with a hodgepodge of different benefit laws etc in each and every city, county, state they operated. This has nothing to do with levels of expenditures)
  • If an employer does not meet the spending requirements, they pay money to the city -- again, with no reference to benefit structure of a health plan for which they will pay.
  • The ordinance doesn't require employers who already provide coverage to provide certain benefits (thereby altering their ERISA plans.)
  • Lastly, there is no additional burden to complying with the ordinance, as employers would be tracking this information anyway.

On top of the technical details, the court also found the hardships borne by San Francisco residents would be far greater than those borne by businesses. Approximately 20,000 San Francisco workers would be harmed, including "human suffering" -- contrasted with economic injuries.

While ABx1 1 is not exactly the same as the San Francisco ordinance, the arguments used by opponents against an employer mandate (which IS part of ABx1 1) are essentially the same. This ruling should put that hollering to rest -- until the next court ruling...

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posted by Hanh Kim Quach | Permalink | 6:23 PM


 
a


Initial comment on the big budget cuts

 
Our Headlines:

HEALTH BUDGET CUTS TO REDUCE ACCESS AND CARE FOR MILLIONS
* Big Cuts to Provider Rates, Medi-Cal Benefits (Including Dental for 3 Million Adults);
* Retread of Proposals Rejected by Previous Legislatures as Too Severe
* Magnitude of Cuts Show Need to Balanced Solution to Budget, Including Taxes
* Health Reform Needed More Than Ever; Logic of Reform Argues Against Proposed Cuts



THE BIG PICTURE: The health cuts would reduce access to care, cut covered benefits, and raise costs for millions of low-income California children, parents, seniors and people with disabilities, and further erodes the health system on which we all rely. This shows why we need a balanced solution to the budget crisis, that includes not just cuts but revenues to prevent the worst of the cuts, and allows people to get the care they need.

THE IMPACT OF THE BIG CUTS: These are cuts we have seen before, that previous Legislatures have rejected as too extreme. The three cuts with the biggest dollar value are provider rate cuts, cuts to benefits, and quarterly status reports to discourage access to care:

* PROVIDER RATE CUTS ($720.9 million): The provider cuts will significantly reduce access to doctors, hospitals, and specialists for the over six million Californians with Medi-Cal coverage. California already has among the worst reimbursement rates in the nation, and half of the state's doctors don't take Medi-Cal.
* BENEFIT CUTS ($133.9 million): The millions with Medi-Cal coverage will also lose several health benefits. Three million low-income parents, seniors, and people with disabilities will lose dental coverage under this proposal.
* MORE PAPERWORK LEADING TO LOWER ENROLLMENT ($92.2 million): While the proposal does not seek to directly cut eligibility, it imposes paperwork burdens on low-income families with the purpose of having over one hundred thousand Californians fall off coverage. These 'quarterly status reports' are cynical attempts to reduce enrollment at a time when we want and need to increase enrollment.

HEALTH REFORM CONNECTION: The budget shows we need health reform more now than ever, but we also need to follow the logic of health reform, to invest rather than cut into our health system.
* The Governor is right that are Medi-Cal rates are too low, and impose a cost of all of us even with insurance. Yet the budget makes further cuts to Medi-Cal.
* Just as the Governor says that we need to bring in more federal funds through health reform, he should recognize that cutting over a billion dollars in Medi-Cal means that we lose another billion dollars in federal matching funds.
* And while we support the Governor's effort to raise revenues to fund health coverage expansions that are desperately needed, it would make sense to also raise the funds needed to ensure that Californians keep the coverage they have. We need to balance these cuts with new revenues as well.

We have our work cut out for us.

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posted by Anthony Wright | Permalink | 2:58 PM


 
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Cuts, cuts, cuts....

 
The cuts are released, and no surprise, they are bad. They are familiar to those who went through the previous budget crisis. Many of them are cuts that previous California legislatures rejected as too extreme. It's like a horror film where the monster won't stay dead.

Budget-balancing reductions in Medi-Cal and related programs include:
* PROVIDER RATES CUT: The proposal would reduce most provider rates by 10 percent. This includes reducing rates for physicians, medical service providers, and managed care plans, and shifting federal Safety Net Care Pool payments from designated public hospitals to other programs, allowing a corresponding reduction in General Fund spending. This also includes reductions in reimbursement rates for hospitals that do not contract with Medi-Cal; payments to certain long-term care facilities; payments to Medi-Cal Disproportionate Share Hospitals.
* MEDI-CAL BENEFITS CUT: The proposal eliminates certain optional Medi-Cal benefits, including dental for adults, chiropractic care, incontinence creams and washes, acupuncture, audiology, optometry, opticians and optical labs, podiatry, speech therapy and psychology, for the 6.6 million Californians in Medi-Cal.
* INCREASED MEDI-CAL SHARE-OF-COSTS: The proopsal ends payment of Medicare Part B premiums for Medi-Cal share-of-cost beneficiaries, who are lower-income seniors and people with disabilities.
* ADDITIONAL PAPERWORK, LOWER ENROLLMENT: The proposal reinstates quarterly status reports for Medi-Cal eligibility, increasing the administrative burden on Medi-Cal patients and making it harder for them to stay on coverage.
* COUNTY ENROLLMENT CUTS: The proposal also reduces Medi-Cal payments to counties.
* HEALTHY FAMILIES CUTS: The 800,000+ children in the Healthy Families program will be impacted by reductions in rates, increased premiums and co-pays, and establishing an annual cap on dental benefits.
* OTHER CUTS IN ACCESS TO CARE PROGRAMS: There will be 10 percent reduction in provider payments for California Children Services (CCS) Program, the
Genetically Handicapped Person Program, Child Health and Disability Prevention
Program (CHDP) and the primary care and rural health programs. There will also be a 10 percent reduction in county case management of CHDP and CCS clients, and grants and
payments to safety net clinics.

More later.

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posted by Anthony Wright | Permalink | 12:34 PM


 
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Health Care Hangs in the Balance

 

Health Access Alert

Thursday, January 10, 2008

HEALTH CARE HANGS IN THE BALANCE

  • Letters of Support for AB x1 1 Due to Senate Health Committee Today
  • Court Rules to Allow Healthy San Francisco, with Employer Contribution, to Continue
  • Advocates Await Announcement Today of Budget & Health Care Cuts

In the next several days, health care in California hangs in the balance, in multiple venues. Health advocates need to take action today in the next few weeks, in order to preserve the health coverage people have, and to expand it to those that don't have coverage.

BUDGET: Later today, Governor Arnold Schwarzenegger will announce his proposed mid-year cuts, for the current fiscal year of 2007-08, as well as a proposed budget for the budget year of 2008-09. In the previous budget crisis, Governors Davis and Schwarzenegger proposed cuts to enrollment (including outreach, retention, and eligibility), to benefits, and to reimbursement rates to providers.

We expect that the Governor will propose the equivalent of a 10% across-the-board cut throughout the budget, including to health care. He has also said that he seeks to resolve the budget crisis solely by cuts, rather than proposed a balanced solution that includes taxes and other revenues as well.

Health and consumer advocates will actively work to prevent cuts that decrease access to health care, and for the revenues needed to prevent such cuts. Health Access will post a quick analysis of the health budget proposal today on our blog, at http://click.icptrack.com/icp/relay.php?r=1012041699&msgid=3703366&act=XIOO&c=5484&admin=0&destination=http%3A%2F%2Fwww.health-access.org%2Fblogger.html&l=3, and then a more detailed report shortly afterwards via this E-mail Update/Alert.

HEALTH REFORM: One area where the Governor has agreed to support additional revenues is in the context of health reform and coverage expansions. He has agreed to support a proposed negotiated with Speaker Fabian Nunez that is both a legislative proposal and a ballot measure, that combined would raise $15 billion, to fund a major public program expansion for low-income California families, for health subsidies for middle-income and working Californians, and for a Medi-Cal provider rate increase.

Health Access just produced a new ANALYSIS, included BELOW, that describes the type of assistance that various California families will get from the reform package. Entitled "California Health Reform (AB x1 1): WHO GETS WHAT HELP?" the paper shows how AB x1 1 would provide distinct but significant help to low-, moderate-, and even higher-income Californians; to both the insured and uninsured; and to those who get coverae through on-the-job benefits; to those in public programs, and to those who buy insurance in the individual market.

The bill is expected to be heard in Senate Health Committee, chaired by Senator Sheila Kuehl, on Wednesday, January 16th. However, Senator Kuehl indicated in committee today that if the report by the Legislative Analyst's Office is not available by then, she would postpone the hearing for a week, until January 23rd. On either day, she plans to have an extensive hearing, going through the bill section by section.

CALL TO ACTION: If the hearing does happen next Wednesday, then letters are due into the Senate Health Committee TODAY, Thursday, January 10th, in order to be included in the committee analysis. Health Access California has sent a letter expressing support, while also seeking amendments to get clarifications on affordability and benefits. The letter is available on our website. Letters of support should be sent to the Senate Health Commitee at:

The. Hon Sheila Kuehl
Chair, Senate Health Committee
State Capitol, Room 2191
Sacramento, CA 95814
FAX: 916-324-0384

Advocates should also write letters to the individual members of the Senate Health Committee:

Senator Sheila Kuehl (Chair)

Senator Samuel Aanestad (Vice Chair)

Senator Elaine Alquist

Senator Gilbert Cedillo

Senator Dave Cox

Senator Abel Maldonado

Senator Gloria Negrete McLeod

Senator Mark Ridley-Thomas

Senator Darrell Steinberg

Senator Mark Wyland

Senator Leland Yee

COURT RULING: Health reform efforts in California, and at the state and local level around the country got a boost yesterday, when the Ninth Circuit Court of Appeals unanimously ruled to allow San Franscisco to continue its health reform effort, including with a minimum employer contribution.

In late December, a lower court had struck down the employer contribution element of the Healthy San Francisco plan, citing it as a violation of federal law under ERISA. San Francisco appealed the decision, and the appeals court stayed that decision until that appeal is decided upon, citing after a preliminary hearing that there is a "strong likelihood" that the lower court decision would be overturned.

This is good news for those in San Francisco who will now be able to get better access to care as a result; it also illuminates an opening, that state and local governments can enact state and local health reform that do not violate the restrictions under federal law and ERISA.

Health Access will continue to provide updates on ABx1 1, the initiative and other health reform efforts, including late-breaking developments that will be posted on our blog, at:http://click.icptrack.com/icp/relay.php?r=1012041699&msgid=3703366&act=XIOO&c=5484&admin=0&destination=http%3A%2F%2Fwww%2Chealth-access.org%2Fblogger.html&l=15.

To view other resources from the Year of Health Reform, visit our website, at: http://www.healthaccess.org/advocating/2007_healthdebate.html.

As promised, here's the new analysis of the bill, "California Health Reform (AB x1 1): WHO GETS WHAT HELP?"

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posted by Hanh Kim Quach | Permalink | 12:00 PM


 
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Before the budget battles begin...

Wednesday, January 09, 2008
 
So tomorrow, this year's budget battles win begin in earnest. And they will be ugly.

But before the budget battles begin, I would like to respond to those who question why we support a single-payer health care system and public program expansions, at the very same time we are actively engaged in fight over the bad decisions and priorities that elected officials sometimes make with regard to public health programs.

The question is comical, since it pre-supposes that we are naive, thinking somehow that everything that government does is right. That's far from the truth.

The answer is in the process we are about to go through. By all accounts, Governor Schwarzenegger will propose ugly cuts tomorrow. And he will propose those cuts rather than put forward a balanced approach that includes fighting for additional taxes and revenues to prevent the worst of those cuts.

But then these cuts will be evaluated in a public process, analyzed, considered by a legislature, and negotiated throughout. Various constituency groups will make their points about the impact of the cuts. And however, tough and ugly the budget process will be, there will be a resolution.

We may or may not like the final result. (In previous budget efforts, we've won some and lost some.) But at least there was public discussion and oversight.

In health care, what's the alternative? For those not on public programs, consumers have their premiums increased, their benefits cut, deductibles raised, their choices restricted and they often have no say. Those decisions are made by employers and insurers, in private boardrooms and executive suites. Not in public, not by elected leaders who are accountable for their decisions.

Many who support single-payer believe that if everybody is in the same health system, the public pressure will be there for a system to balance keeping cost-sharing low but quality high. In countries with universal health care systems, this is a active issues: In Canada, Britain, or elsewhere, elected officials compete on how they will improve their health systems.

Reforms like AB x1 1 place more public oversight over health insurers and the health sector, so that some issues, such as what a minimum benefit should include, are debated and decided in public, rather than in private. That's much better than the status quo.

So even when Health Access and other groups are fighting budget cuts, don't be mistaken: we support a system that allows us to have the fight in the first place.

And that's why we'll also fight some of the so-called budget reforms, to allow unilateral or automatic cuts, that seek to remove that public process. That's a consistent principle through all our work.

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posted by Anthony Wright | Permalink | 10:13 PM


 
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Charmingly Third World

 
I know we have very talented smart, physicians, scientists and researchers in this country that make America's health care system the greatest. But it's a total waste to have an amazing arsenal of doctors if the people who need to see them can't.

A new article in Health Affairs this month says the US is dead last among industrialized nations in preventing deaths from amenable diseases (those illnesses that can resolved with good healthcare, such as whooping cough, tuberculosis, treatable cancers, diabetes, bacterial infections, etc.)

For a full list of what's considered an "amenable illness," click here. My personal favorite is euphemistic "misadventures to patients during surgical and medical care."

Some interesting stats:

  • In 1997, the US ranked 15th among OECD countries in amenable mortality, with a rate of 114.7 deaths out of 100,000
  • In 1997, the US fared better than Finland, Portugal, UK and Ireland.
  • In 2002-03, the US ranked last (19TH) among OECD countries in amenable mortality, though our rate improved to 109.7 deaths per 100,000
  • Other countries improved their rates by up to 20%, while US improved by only 4%

There are many reasons people die from diseases and illnesses that are treatable, but one of those reasons is lack of insurance -- people deferring or skipping care until it's too late and the cancer as spread, etc.

Perhaps most interesting is the number of preventable deaths annually. IF the US achieved the same mortality rate as other industrialized nations, between 75,000 and 101,000 Americans would survive annually. That's at least four times higher than the figure we often cite from the Institute of Medicine, which describes how 18,000 people die annually due to uninsurance.

Ironically, we also learned this week that the amount the US spends per capita has increased to $7,026 -- a collective $2 trillion plus annually -- more than any other industrialized nation.

So WHAT exactly are we getting with our money?

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posted by Hanh Kim Quach | Permalink | 5:00 PM


 
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SF wins stay, employer contribution in effect, for now...

 

The Ninth Circuit Court of Appeals has ruled in favor of San Francisco, to grant a stay of the lower court decision to strike down the employer contribution of their Healthy San Francisco plan.

This means that San Francisco can begin implementing its Healthy San Francisco plan, including the employer contributions, while the case is fully heard and deliberated at the Ninth Court of Appeals. There's no guarantee that SF will win the final appeal (or appeals to the Supreme Court), but it send s a powerful signal. From the decisions:



In this case, we hold both that there is a “probability” — indeed, a “strong likelihood” — of success on the merits, and that “the balance of hardships tips sharply in . . . favor” of the City and the Intervenors. We further hold that the public interest supports granting a stay.


We're not done with this. The legal challenges for the San Francisco plan, and for state-based health reforms in general, are still ongoing. But this suggests there is a "strong likelihood" of defending local health reforms against these challenges.

Most of all, this is good news for the San Franciscans who can now get better access to care as a result.

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posted by Anthony Wright | Permalink | 1:39 PM


 
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State of the Budget...

 
So Governor Schwarzenegger is not just proposing mid-year cuts, but also a "budget reform" that includes giving himself more unilateral power to make cuts. Here's the details, from his materials.
Today, Governor Schwarzenegger proposes the Budget Stabilization Act, a Constitutional amendment to fundamentally reform the state budget process. This reform requires a vote of the people. The Budget Stabilization Act:
* Establishes a Revenue Stabilization Fund (RSF), which is simply a savings account for excess revenues taken in by California during a prosperous year. This will allow the state to transfer the difference from the RSF into the General Fund in years when tax revenues are below average and California cannot meet its spending obligations.
* Allows California to reduce spending when necessary. Right now, California doesn't have this flexibility. Once the Governor signs the budget, spending is locked in unless he declares a fiscal state of emergency and calls a special session. Under this act, state agencies must reduce their spending if a year-end deficit is projected by the Department of Finance.
* Requires the legislature to enact a statute specifying how the state will reduce spending to meet Budget Stabilization Act requirements as soon as a deficit is projected. If the legislature does not specify the reductions-or if their reductions are insufficient-the amendment allows the Governor to waive state law and regulations in order to achieve the savings needed to bring California's budget into balance.
* If the Budget Stabilization Act had been in effect since 1998, the state would not have developed a structural budget deficit. In years where a deficit emerged, the Budget Stabilization Act would have triggered moderate cuts automatically to avoid draconian cuts later.

There's clearly a separation-of-powers, checks-and-balances issue with giving the Governor so much additional authority to make cuts and "waive state law and regulations."

Both the Democratic legislative leaders gave very good responses to the State of the State, making the case about why a cuts-only strategy to the budget crisis--or a regime of automatic cuts for the future--does not work.

Nunez made the case of all the painful cuts you could make and still not make up the shortfall. Perata made a case about the future, asking if California really wanted to handcuff its ability to improve education, transportation, social services, now and into the future.

Important points to remember in the months ahead.

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posted by Anthony Wright | Permalink | 12:11 AM


 
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State of the Reform...

 
Speaker Nunez mentioned health care in his response to the State of the State. Senate President Pro Tem Perata did not. Here's Nunez:

And no conversation about where the state should be headed can be complete without acknowledging the overwhelming need to fix the state’s broken health care system.

California families face a fiscal emergency every time they struggle to pay for health care. And our overburdened emergency rooms face a fiscal crisis every day. The health care reform we negotiated with the governor takes a giant step toward the universal coverage that Californians want.

And we wrote the plan specifically so it wouldn’t impact the state budget or add to any deficit. Seizing this historic opportunity can provide one of the bright spots on a tough road ahead.

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posted by Anthony Wright | Permalink | 12:04 AM


 
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Forget Johnson, Brown, Warren. FDR!

Tuesday, January 08, 2008
 
Governor Schwarzenegger has been accused of trying to channel previous California Governors before. He's now set his sights higher, now invoking FDR as an icon. The Governor even invokes the WPA (while suggesting budget cuts on the other hand. Hmmm.) Here's the section of the State of the State on health care:


This last year, we took on other tough issues - the very contentious issue of prison reform and rehabilitation, the world's first low carbon fuel standard and the most comprehensive health care reform in the nation.

Let me explain why health care reform is so important.

Here in California, the health care system is collapsing under its weight, its costs, its gaping holes, its injustices. Millions of people can't afford - or can't get - health care.

* Our emergency rooms are crowded or closed. 60 closed in the last ten years.
* Medi-Cal patients are being turned away at hospitals.
* Businesses and families are experiencing double-digit increases in health care costs.
* Medical bills are the number one reason people file for personal bankruptcy.
* All this is weakening our economy and contributing to our budget deficit.


But let me make this more personal and real - through a true story about a 51-year-old, self-employed San Diego man named Todd.

Todd had been on his wife's insurance plan, but after a divorce, he found a policy with a well-known company. Five months later, he started feeling tired, and soon learned he had lymphoma.

The insurance company then went back through all his records looking for a reason to cut him off. They pointed to a minor knee problem unrelated to the cancer. They noted that he now weighed less than he did when he applied for the insurance.

Well, of course, he did. He was now sick with cancer. But they cut him off. One month after he got sick, the company cancelled his insurance. Todd died eight months later.

We are taking action so that what happened to Todd will not happen to any other Californian.

Now, I understand the concern that we have a deficit, and that our plan is too daring, too bold, too expensive. But sometimes you have to be daring, because the need is so great.

You want daring?

FDR didn't ignore the problems of the Depression because times were tough. He addressed those problems in big, visionary ways because times were tough. He saw the problems and he acted on behalf of the people and the nation.

For example, to give America jobs, he created the WPA, which built 650,000 miles of roads, 78,000 bridges and 125,000 buildings. All these things we are still enjoying today.

We, too, must act boldly on behalf of the people and the state. And I want to thank the Assembly for its action on health care. When the Senate finishes its deliberations, I am confident the people of California in November will approve the most comprehensive health care reform in the nation.

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posted by Anthony Wright | Permalink | 4:17 PM


 
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The word of the year, the work of the next several years

 
It's an evocative term. In fact, "subprime" is the "Word of the Year," according to the American Dialect Association. (It beat out other noteworthy words, including Googleganger, vegansexual, and waterboarding.)

Typically use in reference to mortgages, it's clear that such a designation is needed in the world of health insurance. There's lots of "junk" health insurance out there, where people pay a premium and may not realize how little it covers--until it is too late. This includes disease- or treatment-specific coverage, "bare-bones" or "skeleton" plans, coverage that is capped, etc. It includes products sold by companies like Mega with daily caps and other signficant cost-sharing, and simply some of the high-deductible policies, like Tonik, sold by Blue Cross.

Some represent a trade-off that some wealthier people can afford to make, to have greater cost-sharing in order to get cheaper premiums. But other plans are, frankly, close to consumer fraud, and should not be certified to be sold in the market. In the interest of disclosure, some of these plans should, at the very least, be clearly marked as "subprime," so people know what they are buying the first place. Right now, there's no minimum standard for health insurance--It's just "let the buyer beware."

With support from the national group Community Catalyst, Health Access is working with Western Center on Law and Poverty and several other consumer and community groups over the next several years to work on issues of "underinsurance." This Health Initiative on Overcharging and Underinsurance ("Health IOU" for short) will work to prevent medical debt that too many insured people face.

We will work to better implement AB774, the law against hospital overcharging we passed in 2006. But we also want to do a better job providing oversight of these "subprime" insurance plans as well.

The proposed health reform does set a minimum standard for coverage, that is inclusive of "physician, hospital, and preventative services," as well as "existing coverage requirements under law." It doesn't do all we wanted, but it does much more than what exists in the status quo, including creating a process to set more specific standards, including on cost-sharing. It establishes a framework to work from, including organizing the insurance market in tiers, so people have a much better sense of what kind of coverage they are buying in the first place.

In other words, if health reform passes, there's still will be work to do. If health reform does not pass, there will be a helluva lot of work to do, to protect consumers from the perils of subprime insurance.

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posted by Anthony Wright | Permalink | 1:31 AM


 
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The GOP Group of Candidates on Group Coverage...

Sunday, January 06, 2008
 
In the Republican presidential debate tonight, Dr. Tim Johnson of ABCNews won the section on healthcare, of which none of the candidates had an adequate response.

Dr. Johnson's set-up piece made the point that the Republican plans more perhaps more radical than the Democratic plans, in that they attempted to shift people away from group coverage--largely through the employer-based coverage that people have now--into the individual market, via Health Savings Accounts, etc.

Dr. Johnson further gave facts about how individual coverage is more expensive and less efficient--partially because of administrative costs, the inefficiency of having to sell the products one at a time, the lack of any economies of scale, and the inability of the purchasers to leverage their market power to get better cost and quality. He didn't land the most obvious punch--that many of the Republican candidates, as cancer survivors, would be unable to buy coverage in most states, including New Hampshire (and California), because of their "pre-existing conditions."

It's probably the most important distinction between how the two parties view health care. One direction is to expand subsidized group coverage, through employers, public programs, or even a single-payer system. The other is to shift more people in the individual market, leaving consumers at the mercy of the insurers. Guiliani wanted to shift around 17 million to about 50 million buying coverage as individuals-- I am not sure those 30+ million would prefer that approach.

Romney came the closest to responding, by saying that the Connector in Massachusetts does provide an opportunity for individuals to take advantage of those efficiencies of group coverage. He's right. But then he went on to completely misrepresent his own plan in Masssachusetts. He took credit for the fact that over 300,000 people in his home state now have coverage, but then he made a big point of saying it was "private coverage," which is just untrue. All but a handful of those 300,000 got coverage through the public program expansion for those under 300% of the poverty level.

He mentioned Governor Schwarzenegger's efforts at health reform in California, not as endorsement, but as a way to say that states should take the lead in designing different plans, and suggested that those that do should get federal funding assistance. That's helpful to know. But given how all-over-the-place he has been on his own plan in Massachusetts, I am not sure I would take anything to the bank.

posted by Anthony Wright | Permalink | 12:35 AM


 
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The budget and health care are always intertwined...

Saturday, January 05, 2008
 
One more thing... Governor Wilson said in his radio statement that when "our economy does slow down, state law must require that state government slows down its spending, too."

But it already does. The requirement to have a balanced budget in effect provides for this: when less revenue comes in (as it is doing now), it puts forward the challenge to elected policymakers to make the tough choices--including making the cuts that do the least harm, and to raise revenues if need be.

Here's the problem in health care, and other social services: it is exactly during bad economic times, when policymakers are seeking to cut the state budget, that health care services are needed the most.

It's countercyclical: when economic times are good, people are more likely to be able to get and afford private coverage. The need for public health programs grows at exactly the times that state revenues start to dry up, and this, in fact, exacerbates the budget crisis.

That's why passing new revenues on the ballot as part of health reform would help the overall budget crisis. It would reduce the fluctuations in enrollment in public coverage programs between good and bad times, lessening the budget roller coaster that California has been on.

The proposed budget cuts that we will see will likely attempt to lessen the number of people enrolled in public programs, either through direct eligibility cuts, or indirectly, by placing administrative burdens in place, like imposing quarterly status reports, or eliminating outreach efforts.

Such efforts may reduce the pressure on the budget, but they only exacerbate the actual problem--that those people still need care and coverage. Raising the revenues for health reform would actually help resolve the problem, which in turn would reduce the pressure on the general fund.

A reporter asked if we could both deal with the budget crisis and health reform in the same year. I said it was possible to walk and chew gum at the same time. But a moment, I take that back... It's part of the same problem, and they need to both be addressed... it's not just possible, it's necessary.

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posted by Anthony Wright | Permalink | 4:52 PM


 
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The Return of Robo-Cuts?

 
Governor Pete Wilson gave the Governor's radio address today, and hinted at what the Governor Schwarzenegger might be thinking, as we head into the week where the budget will be announced.

Josiah Greene at the California Majority Report is right to sound the alarm. Wilson invokes his attempt at Proposition 165, to give him as Governor more budget-cutting authority. It also raises the specter of Schwarzenegger coming back with something similar to Prop 76, which would have allowed the Governor to make unilateral budget cuts in certain emergencies. Both measures failed at the ballot box, and for good reason.

Whether the cuts are "unilateral" or "automatic" doesn't make them better, it makes them worse.
* It means that cuts are made without proper consideration of what is penny-wise and pound-foolish;
* It means that cuts are prioritized over other budget solutions, including raising revenues, and yes, taxes.
* It means that legislators escape accountability to make the tough choices, whether cuts or revenues.

I hope we don't have to go through this fight again.

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posted by Anthony Wright | Permalink | 4:29 PM


 
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A potential San Francisco treat?

Friday, January 04, 2008
 
Promising news from the ERISA lawsuit on the Healthy San Francisco plan at the Ninth Circuit Court of Appeals. Yesterday, a three-judge panel ini Pasadena heard arguments about whether it should stay the ruling and let San Francisco proceed with the employer contribution of its new health plan.

So while no rulings were made, on the stay or the substance of the ERISA challenge, it seemed the judges poked holes in the logic of the opponents of San Francisco's health reform. Bob Egelko at the San Francisco Chronicle has the intriguing write-up.


Court gives San Francisco health plan a boost
Bob Egelko, Chronicle Staff
Writer

Friday, January 4, 2008

PASADENA--A federal appeals court boosted San Francisco's hopes Thursday of reviving its plan to extend health coverage to all uninsured residents and make employers share the cost.

Members of a three-judge panel of the Ninth U.S. Circuit Court of Appeals made it clear they thought U.S. District Judge Jeffrey White was on shaky ground last week when he struck down a key funding provision of the health program, which would require medium and large companies to offer insurance to their workers or pay a fee to the city.

Ruling in a lawsuit filed by the Golden Gate Restaurant Association, White said San Francisco was trying to require employers to provide a specific level of health benefits. That violates a 1974 law prohibiting state and local governments from regulating employee benefit plans, White said.

But San Francisco's lawyers argued - and the appeals court judges appeared to agree - that White had misread the law. The city says the law provides only that employers must spend a certain amount on health care, either in coverage for their workers or in payments to the city.

That's a crucial distinction under past U.S. Supreme Court rulings that have given states and cities some leeway to pass laws protecting their inhabitants' health and welfare, said Judge William Fletcher. If the city's interpretation of its law is correct, he said, "that takes away virtually all of Judge White's reasoning."

When Richard Rybicki, lawyer for the Golden Gate Restaurant Association, conceded that the city was reading its ordinance accurately, Fletcher said, "It seems to me your argument just disappears on you."

Rybicki argued that the San Francisco ordinance still intruded too deeply into employers' health care decision-making and would contradict Congress' goal of national uniformity in health plans. But Fletcher and the other two panel members, Judges Stephen Reinhardt and Alfred Goodwin, seemed skeptical.

The court gave mixed signals on whether it would grant the city's request for an emergency order suspending White's ruling and allowing the ordinance, including the employer fees, to be fully implemented during the appeal process.

But the judges' questions and comments during the one-hour hearing in Pasadena suggested that the court was prepared to interpret the 1974 federal law in a way that leaves room for universal, shared-cost health coverage at the state and local levels, in the absence of a national health care law....


For those who are supposedly so confident that any attempt at health reform will run afoul of ERISA (I'm looking at you, Chris Reed), this hearing should give pause that some judges who matter might not be so sure

There's no ruling to celebrate, and just like we said with Judge White's lower court decision, there's still a long way to go in the legal review of the San Francisco case, as well as statewide health reforms. But it's clear there's an opening, and the question is how big that opening is, and what is the right policy that is able to make it through.

The San Francisco Chronicle editorial board makes it clear why this legal inquiry is so important, well beyond the city's borders.

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posted by Anthony Wright | Permalink | 8:34 AM


 
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Happy New Year..

Thursday, January 03, 2008
 
HEALTH ACCESS UPDATE
Friday, January 4th, 2008


A NEW YEAR BRINGS NEW EFFORTS AROUND HEALTH REFORM

  • Governor, Speaker file initiative language to accompany reform package
  • Lower court rules against employer contribution for Healthy San Francisco, although Appeals court sends promising signals
  • Senate Health Committee to hear AB x1 1 (Nunez) on January 16th

In a typical year, Sacramento stands still the week between Christmas and New Year. Not so, in 2007, especially regarding health care.

The last Health Access Update reported from the Capitol (December 17th to be exact), when Gov. Arnold Schwarzenegger, Assembly Speaker Fabian Nunez, and a broad and diverse number of supporters were at a celebratory press conference right after the passage of ABx1 1 (Nunez/Perata) out of the Assembly. (Senate Leader Don Perata chose not to immediately hear ABx1 1, waiting until after the break as analysts looked at fiscal forecasts for the measure.)

If ABx1 1 (Nunez) is passed along with its accompanying ballot measure – which was filed last week – it would represent the largest public program increase in more than 40 years and would require all California businesses to contribute toward their workers’ health care. (Read a more detailed analysis of ABx1 1 here, and about its passage here. Ongoing updates will be posted on the Health Access blog.)

THE INITIATIVE

Last Friday, the Governor and Speaker filed with the Attorney General the initiative that accompanies ABx1 1. As previously agreed upon, the initiative contains some of the financing of ABx1 1. The initiative includes four financing components:

  • $1.75 per pack tobacco tax;
  • Minimum employer contribution of 6.5% of payroll (if payroll exceeds $15 million); 6% (if payroll is between $1 million and $15 million); 4% (for payrolls between $250,000 and $1 million); and 1% (for payrolls below $250,000);
  • $1 billion from counties in return for the state assuming care of medically indigent patients;
  • Hospital provider fee of 4%, which would be used to bring down federal funds to help increase Medi-Cal rates and partially fund coverage expansion.

The money that the initiative raises largely goes to expand public programs for lower income Californians -- both children and adults -- to provide subsidies for moderate income families, and to raise Medi-Cal rates and to fund some public health and prevention efforts. It also sets a standard for employer contributions to health care for their workers.

The measure also includes a $25 million loan to finance children’s coverage from January 2009 through June 2009, allowing children to continue to be enrolled in county programs until statewide coverage takes effect. Without this provision, the counties would run out of money and would likely disenroll children from coverage.

The initiative also contains various door-stop/triggers to prevent the program from creating a fiscal threat to the general fund. First, the Director of Finance, twice a year, would look into the state’s special health account to determine if there is enough money to run the program. If not, then he tells the Governor and Legislature, giving lawmakers a chance to do something about it. If the Governor and Legislature fail to act, then the law is inoperative and the reforms revert to the current status quo, in an attempt to calm the fears of those who have questioned whether the program might create too much of a strain on an already strapped state budget.

The initiative will likely emerge from the Attorney General’s office with a Title and Summary and fiscal analysis in the next month. The measure then heads to the Secretary of State’s office, who will certify the initiative and start the (less than) 150-day clock for signature gathering efforts to place the initiative on the November ballot.

LITIGATION ON HEALTHY SAN FRANCISCO

Other news broke over the holidays with potential but uncertain impact on health reform. A Bush-appointed San Francisco Superior Court judge, Judge Jeffrey White, struck down a key provision in San Francisco ’s near universal health care plan, which required employers to either provide coverage to workers or pay a fee that would enable the city to provide medical services to employees.

The decision says the San Francisco law would violate the federal ERISA (Employee Retirement Income Security Act). The federal law, passed in 1974, was meant to assure that mulit-state businesses did not have to contend with a hodgepodge of rules about benefits for each city, county, state they operated in. The city of San Francisco has appealed the decision to the Ninth Circuit Court of Appeals, which heard initial arguments yesterday.

The ruling creates a problem for the implementation of the Healthy San Francisco program, which moved ahead with the rest of the proposal with a rollout on Tuesday, January 1. The court decision, if left to stand, would force San Francisco to limit enrollment, which means that 26,000 middle-income San Franciscans (out of the 82,000 uninsured residents) will not be able to benefit from health care. While a financial hit, the employer assessment was not the dominant part of the funding: Employers contributions were expected to pay for approximately 19% of the city’s program.

PROMISING HEARING YESTERDAY: A three-judge panel yesterday heard arguments about whether the employer contribution piece of the Healthy San Francisco Plan should continue while the lower court decision is appealed. As reported in the SF Chronicle today, the comments by all three judges suggest that the lower court ruling may be overturned, and that the federal ERISA law does allow room for states and localities to construct health reform for their citizens.

Meeting the requirements of both health reform and ERISA has been an issue for health reformers around the country. Since the beginning of this year’s health debate, advocates and the authors have consulted with experts – including lawyers who helped write ERISA –to help prepare for such a court case against the proposal.

UNKNOWN RULING IMPACT ON ABX1 1

There are some similarlies between the statewide reform proposal, and city's effort. But the San Francisco health plan and ABx1 1 are not mirror images, therefore, any ruling on the San Francisco proposal won't necessarily have an impact on ABx1 1.

But perhaps most importantly, is a suggestion which the lower court judge gave into how an ERISA-compliant reform could be structured.

From Judge White’s conclusion:


The Court is not convinced that other alternatives for creating a program for
providing public health private employers into account in the form of tax
credits. are 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 the legislative dominion, the
Court can envision such a tax program that takes existing health care
expenditures by private employers into account in the form of tax credits.

White’s suggestion parallels language in the initiative that was filed by Gov.
Schwarzenegger and Speaker Nunez:


19003 (a): On and after January 1, 2010, each employer shall pay a health care contribution equal to a percentage of wages paid to its employees during the calendar year. Each employer shall be eligible for a credit to offset the contribution by the amount that the employer expends for health expenditures for employees and their dependents during that same period.


It remains to be seen whether the SF health plan will advance or be impacted by the courts, but in absence of a definitive court ruling, many health advocates continue to seek to advance reform at the state and local level.

ABX1 1 IN SENATE JANUARY 16

As attorneys toil away in separate corners, the state Senate Health Committee is scheduled to hear AB x1 1 (Nunez) on January 16.

Senate Leader Don Perata, who has been supportive of health reform in the last year, has asked the Legislative Analysts' Office to perform an independent review of ABx1 1's impact on the state's general fund in light of the $14 billion budget deficit in the fiscal year.

The state Department of Finance has testified in hearings that the plan would have no impact on the state budget because it uses its own sources of revenue -- from employers, workers, the federal government, savings, providers and the tobacco tax -- to pay for itself and would shut itself off if it were found to have insufficient funds.

The Legislative Analyst is expected to have an analysis in the coming weeks.

CALL TO ACTION: Submit letters about ABx1 1 (Nunez) to the Senate Health Committee by January 10th to be reflected in the committee analysis. Health Access will post our Support (if Amended) letter shortly.

Sen. Sheila Kuehl, Chair
Senate Health Committee
State Capitol
Sacramento, CA 95814
FAX: 916.324.0384

Health Access will continue to provide updates on ABx1 1, the initiative and other health reform efforts, including late-breaking developments that will be posted on our blog, at:
http://www,health-access.org/blogger.html

To view other resources from the Year of Health Reform, visit our website, at:
http://www.health-access.org/advocating/2007_healthdebate.html.


You may also contact the author of this report, Hanh Kim Quach, at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 11:55 PM


 
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Caucus night!

 
So Obama and Huckabee had a good day in Iowa. What's the news for health care?

Well, as those of us in California face a budget crisis with major health cuts looming, it's interesting to note that the winner of the Republican caucus was a Governor who saw fit to raise taxes when necessary to invest in his state, and support some coverage expansions for children and parents in Arkansas. He has quite a conservative record--and much I would disagree with--but this particular point is something that legislative Republicans in California might want to take a look at.

On the Democratic side, it was clear that the health care was one of the top three issues, with Iraq and the economy. Edwards spent a significant chunk of his speech tonight talking about the uninsured and those denied care by insurers, and deserves credit for coming out first with a broad and comprehensive health reform plan, and setting a benchmark for the field. In his memorable speech, Obama started his issue list with a commitment to health care, and his history in Illinois. And Clinton's commitment is well known. In the end, the candidates had very similar proposals, so there's a little for voters to distinguish on specific plans. And they roughly split the voting public on the question of who would do the best in terms of health care.

But they did have a difference in what they emphasized. I think Obama had a slight edge (34%) to Clinton (30%) not because of the substance of the proposal (which are very similar), but what they emphasized. Clinton attacked Obama on not having an individual mandate and not being "universal" enough, Obama responded not by saying he's against a mandate, but by emphasizing the aspects of his plan that will help people get coverage, especially with regard to affordability.

It goes to my earlier point about the national health reform debate: while health reformers should be upfront about what is need to achieve health reform, we need to focus on the actual help that any reform will provide voters. Rather than get lost in philosophical debates, we need to emphasize what any plan will actually do to make coverage more available, affordable, and administratively simple.

posted by Anthony Wright | Permalink | 9:00 PM


 
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Lots of areas to debate...

Wednesday, January 02, 2008
 
My dad was impressed with the New York Times chart this weekend comparing the positions of the various candidates, on a variety of issues.

I thought it was useful, mostly to demonstrate the similarities within the parties, and the large gulf between them. In a chart that small, it doesn't go too much into detail, so the nuances aren't really specified. So on taxes, the Democrats are all for repealing the Bush tax cuts for the wealthy; the Republicans largely want to make them permanent.

On health care, I think the descriptions are less than helpful. They lead the description of the Democratic proposals by emphasizing the mandate on individual to get coverage (and of the Republican proposals their opposition to any mandate).

This is a difference between the Ds and Rs, but its not the fundamental one. The vast majority of voters want coverage, so the issue isn't the requirement to have it: it's what the plan does to break down barriers to get coverage.

The real dividing line is that the Ds want to expand subsidized group coverage, through employers or public programs, and by creating/opening up purchasing pools. They would place greater regulation over insurers, especially with their ability to deny people for "pre-existing conditions."

The Rs say they are "for free-market, consumer-based system," and the Times merely repeats their rhetoric without describing what that means. The Rs largely do not support setting a standard for employer health coverage, or expanding public programs--or the revenues that make the coverage expansions possible. The help their proposals offer, if any, is some tax credits to buy coverage in the individual market--where people can be denied for "pre-existing conditions." Rather than further regulating insurers, they argue that less regulation would allow insurers to offer cheaper plans with scaled-back benefits.

The chart does not really help illuminate these important distinctions--ones that will have a direct impact on people's lives.

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posted by Anthony Wright | Permalink | 8:18 PM


 
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Taking suggestions...

 
While Chris Reed of the San Diego Union-Tribune is so sure that the state health reform plan is going to be struck down because of ERISA, given the recent decision in San Francisco, the judge who made that decision isn't so sure. In fact, he proposes a structure similar to what the initiative filed last week proposes.

From Judge White’s conclusion in his opinion:

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 the legislative dominion, the Court can envision such a tax program that takes existing health care expenditures by private employers into account in the form of tax credits.

From the initiative filed by Governor Schwarzenegger and Speaker Nunez:

19003 (a): On and after January 1, 2010, each employer shall pay a health care
contribution equal to a percentage of wages paid to its employees during the
calendar year. Each employer shall be eligible for a credit to offset the
contribution by the amount that the employer expends for health expenditures for
employees and their dependents during that same period.

There's no guarantees, but it seems that the initiative takes the judge advice--and let's remember this is one judge who takes a broad view of ERISA pre-emption.

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posted by Anthony Wright | Permalink | 4:55 PM


 
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Knowing where your food comes from....

 
In light of last week's San Francisco Superior Court ruling on the Healthy San Francisco plan, I think we should take take Michael Pollan's nonfiction hit The Omnivore's Dilemma a step further.

The Golden Gate Restaurant Association contested the portion of the Healthy San Francisco Plan which requires the city's employers with more than 50 workers to provide health coverage or pay an assessment to the city, which would then give employees access to the city's network of medical services. Healthy San Francisco aims to provide health coverage to the city's 82,000 uninsured residents. The GGRA won the first round, meaning that approximately 26,000 middle-income workers will remain uninsured -- and presumably many of those are also toiling over the range, serving up food, greeting guests and washing dishes.

The association's website claims it has more than 800 members. Clicking through, I'd say it included about 600 restaurants, including uniquely San Francisco gems like The Slanted Door, Green's and Citizen Cake and chain restaurants such as Hooters, Pasta Pomodoro and Il Fornaio.

The trend among the health conscious is knowing the origins of food: where it comes from, what impact its production had on the environment, whether it had to travel far to arrive at your table.

Let's make part of that "knowing,'' discovering whether the food is served by someone who has access to a doctor when they need it (and can afford it). And if it isn't? We have the ability to walk away.

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posted by Hanh Kim Quach | Permalink | 12:45 PM


 
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Anthony Wright is the executive director,
with a background as a consumer advocate and community organizer on many issues, including health issues for the last ten years in California and New Jersey.