Health Access WeBlog: February 2008

The San Diego Union Tribune, today, has a story about an entrepreneur who is providing limited-benefit health plans, useable in both US and Mexico, and marketed toward low-wage workers.

Details on exactly how this works are thin, so I'm a little shaky on the economic benefits of this, but from what I was able to glean from the story, I'm not clear that consumers are getting THAT MUCH of a benefit.

So the premise is this: lots of low-wage Latino workers, who consider both countries home, don't buy health coverage because it's too expensive and it's not useful in both countries. So this company, Sekure, sells insurance policies at a cost of between $100 and $300 that can be used in both the US and Mexico.

Benefits are a $300 annual maximum on doctors visits, $3,000 maximum on hospital and discounts for doctors visits, prescription drugs, etc. from participating providers.

So essentially -- you get approximately $3,300 in actual dollar benefits (excluding discounts) for shelling out $3,600 in premiums. (The individual may not be responsible for *all* these premiums, the idea is employers would buy this kind of plan, rather than a comprehensive plan -- or no plan at all.)

The entrepreneur says he doesn't think this kind of plan is for everyone, and I'm sure he genuinely believes that. That's what they all say. But the reality is, given this option - versus a more expensive comprehensive option that actually provides coverage - some employers who consider their workforces "disposeable" will opt for this cheaper, bare bones plan.

I don't see this type of bare bones plan an "innovation.'' It's more of a distraction to what we really need to do, which is to somehow extend affordable coverage -- that is useful practically and culturally -- for all Californians. Lowering the bar for coverage hurts everyone.

Labels: InTheNews, Underinsurance

posted by Hanh Kim Quach | Permalink | 1:56 PM

By the way, Secretary Dale Bonner was confirmed today by the Senate Rules Committee.

But not before several Senators asked a series of tough questions about his oversight over the Department of Managed Health Care. This was part of a wide-ranging hearing that reflected the broad scope of the department, from housing to transportation issues as well.

Senator Padilla asked about the level of fines levied at Blue Cross and other insurers over rescissions, and said he's "not convinced [they] get to the level of deterrence needed" and that he's thinks that "all of the players have not gotten the message." After being asked about how the Department is made aware of consumer complaints, Bonner stated "I don't think [the Department] is sufficiently pro-active."

Senator Padilla also asked about the letter by Senate Health Committee Chair Kuehl expressing concern that the timely access regulations adopted are not reflecting the will of the legislature. He ask about the Department's adoption of new regulation that allow the health plans to set their own standards: "that sounds a little permissive to me." He made the argument for such clear, enforceable standards. "We know that justice delayed is justice denied. Well, health care delayed is health care denied," and he pointed out the additional costs and burdens that such delays place on emergency rooms. Padilla also asked about the implementation of language access regulations. Bonner stated that he thought the implementation of language access is "all over the map," and that "I don't believe we have enough coherency" with regard to the goal of language access.

Senator Ashburn asked about the appropriateness of Blue Cross' letter to get doctors to reveal information to the insurer that would get patients retroactively denied. Bonner stated that he didn't read the infamous letter himself, but that he recognized "the discomfort in anything that interferes in the doctor-patient relationship," and he thought Blue Cross' restraction of the letter "confirms that there was a serious problem." asked more specifically about the actions that Bonner took with regard to the issue, including any conversations with DMHC Director Cindy Ehnes. He said he hadn't spoken with her directly, but did through staff, and was satisfied that there was a investigation underway. Later, Senator Perata followed up Ashburn's scolding, saying "you should have seen the letter, and you should have been all over it."

Senator Perata also agreed about the need for more responsive DMHC. "This isn't an academic exercise, for those who are in trouble with their HMO, someone who is being horsed around." Senator Perata also urged higher fines: "you have to put a sharper point on it," he said, and later, "fines are a real attention getter." Senator Perata even asked if the DMHC should be in his far-flung Business, Transportation, and Housing Agency. Bonner indicated that it should, given the kind of expertise it regarding business oversight and solvency issues.

Consumers groups like Health Access California and Western Center on Law and Poverty were there, not to oppose Bonner's confirmation, but to make clear our concerns about how the Department is abdicating their responsibilities to the industry they are supposed to be overseeing.

Senator Cedillo followed up on the language access issue and making sure people have notice of their rights under the law, saying "this is an absurdity. You don't know you have a right unless someone communiciates it to you. If you don't know it, it doesn't exist.... It's the law. The Escutia law is the law." Senator Perata suggested that Bonner didn't want former Senator Escutia coming back to ask questions.

Secretary Bonner was confirmed, but promised to reach out to stakeholders, including consumer groups, to deal with these issues and the other issues presented.

Labels: DMHC, Perata, TimelyAccess

posted by Anthony Wright | Permalink | 8:44 PM

While we glow about how the Department of Managed Health Care's regulations on timely access to care were returned to them yesterday -- without approval -- by the Office of Administrative Law, we also want to take the opportunity to talk about the obscure process in state government called rulemaking.

I'll strongly note here that the OAL's refusal to finalize DMHC's proposed Timely Access regulations had nothing to do with how miserable the regulations actually were. Office of Administration Law merely dinged DMHC because they did not follow the proper waiting periods and rules -- (hey, we'll take our wins where we can get them). This is an importnat point as we embark on another year of rulemaking for Timely Access to Health Care standards.

First, I want to point everyone to the Office of Administrative Law's handy dandy lay person's guide on How to Participate in the rulemaking process.

Secondly, some context. Here's how the Timely Access regulations came to be:

January 1, 2003: AB2179 (Cohn) takes effect, having passed in 2002, requiring the state to adopt regulations to ensure that enrollees have "timely access to needed health care services.'' (Timely access means reasonable waiting times for appointments with physicians, quick and timely care when a patient is sick or needs services, etc. )
January 1, 2004: The date by which DMHC was supposed to have adopted regulations.

July 9, 2004: DMHC begins writing regulations, but withdraws them in April 2005 because of feared "unintended consequences" and restarts discussions with various parties, including insurers, providers and consumers on how to craft the rules.

January 11, 2007: DMHC reopens the rulemaking process with Office of Administrative Law on this date; the department has 365 days from this date to complete the regultions.
March 5, 2007: DMHC holds its first public hearing on its first set of proposed regulations. The 14-page regulations (among many other things) spells out exactly how quickly patients should be able to get in to see a doctor in certain situations. (I.E. Urgent primary care needs: 24 hours; Routine primary care needs: 10 days; Urgent spcialty care: 72 hours; Routine specialty care: 14 days).
July 15, 2007: DMHC releases second version of regulations. As in the March version, this draft also contains time-elapsed standards.
September 18, 2007: DMHC holds second public hearing on a revision of the proposed regulations and accepts comments.
December 10, 2007: DMHC's third version of these rules completely strips out all specificity. Gone are state standards requiring that a patient who needs urgent care be able to see a primary care physician within 24 hours. Instead, the new rules allows health plans to define, for themselves, what constitutes "timely access.'' This stripped-down draft shrinks from 28 pages to 7 pages. The Department gives interested parties 15 days to submit comments -- from Dec. 10 - 26. (Note: It's this final 15 days where DMHC gets into trouble).
January 11, 2008: DMHC submits final regulations for approval with Office of Administrative Law. (The Office of Administrative Law has 30 days to approve the regulations -- which it refused to do yesterday.)

Health Access, the sponsors of of AB2179, and consumer advocates have many substantive reasons to scream and howl about the latest draft of the regulations. We believe the state flouted the law, intended to get consumers proper health care when they need it (not weeks and months later). In doing so, we believe they lacked the "statutory authority'' to do what they did. We also believe that the Department was deliberately vague and unclear, allowing insurers to willy nilly make up their own rules.

But what hung the DMHC was its "belief" that the differences between the second and third versions were not substantial (though, anyone who is not color blind looking at all the red in the "track changes'' function could see otherwise.) The Department gave the public only 15 days to comment on the rules -- clearly not enough time for "major changes,'' which require 45 days. But the full 45 days would have meant that the Department blow its January 11 deadline.

What OAL inadvertently did this week was provide consumer advocates time to make the regulations right. That means we'll have another year to fight at the Department level (again) to ensure patients get care when they need it. In the meantime, Health Access will continue to keep advocates abreast of movements on Timely Access and post relevant documents. (We'll post letters, correspondence from the past year soon).

Labels: DMHC, TimelyAccess

posted by Hanh Kim Quach | Permalink | 6:12 PM

Jacob Hacker--soon to be at if UC-Berkeley--may have been someone who helped advise the Democratic candidates on their health care plans, but they didn't listen to his LA Times op-ed yesterday asking for a truce on the question of an "individual mandate."

They spent 16 minutes of their Ohio debate last night on the differences of their health care plans, mostly on the individual mandate. As Hacker says, it's not the central benefit of either of their health plans. Rather, it's the ability to make coverage more available, affordable, and automatic through group coverage.

In their debate, they are arguing over details that neither of their plans currently spell out.

Obama is right to take umbrage at Clinton's suggestion that his plan isn't as universal. It would certainly get to 95%+ coverage, the standard of most industrialized nations with "universal" health care. The Obama and Clinton plans are remarkably similar in how it expands coverage, especially with regard to new subsidized public program expansions, new opportunities and automatic enrollment in coverage at work, and a new public coverage option.

Obama is also right to say that the real problem is not that people don't want coverage--it's that it is not available or affordable, and the so-called "free rider" problem largely resolves itself. Only 2% of Californians are uninsured yet over the 400% of the federal poverty level, and half of them are under $60K for an individual, or $125K for a family of four.

Clinton is right to be upset at the Obama's mailers than are suspiciously similar to "Harry and Louise" ads of 15 years ago, and specifically the contention that she would require people to buy coverage, even if it wasn't "affordable." Her plan specifically would cap the amount that people would be required to pay at a percentage of their income. It doesn't say the specific percentage, so perhaps they might disagree on the definition of "affordable," but right now there's no way to know.

As a critique, Obama also mentions the Massachusetts plan, which had enforcement where people were required to pay a fine is they were uninsured, but still wouldn't get coverage. But the Clinton plan doesn't specify that type of enforcement: In California's AB x1 1, the proposal was not to have fines, but merely to automatically enroll people in coverage--and then consumers would have to pay the premium, like any other bill, but they would also have the benefit of coverage.

So how about a truce? The individual mandate proponents have a point that everybody needs to contribute to the health care system in order for it to work best. The opponents are correct that any contribution needs to be affordable, and as such scaled to income. While it would be preferable to collect these contributions through a progressive tax based on income, it could possibly be done privately through a requirement to get coverage, but then additional protections are needed: some assurances of the benefits and cost-sharing, the value of group coverage, and yes, an overall structure that provided assurances that coverage is available, adequate, affordable, and administratively simple. If the proponents say that part of the benefit of an individual mandate is to make the government more responsive and accountable to ensure that people can access coverage, then such responsiveness should be built into the proposal at the beginning.

Obama says he's willing to do a requirement for children because that infrastructure of Medi-Cal and Healthy Families/SCHIP is largely already there. Clinton promises to have that infrastructure in place before her mandate kicks in for adults. Obama said he would consider a mandate for adults.

What are they arguing about?

Labels: IndividualMandate

posted by Anthony Wright | Permalink | 1:29 AM

Two interesting pieces in today's news on mandates.

First, California Insurance Commissioner Steve Poizner is dropping his ballot effort, which would have punished drivers without car insurance by allowing police to seize the license plates (and possibly impound) these drivers' vehicles.

Instead, he says, "One of the key problems with why people don't buy auto insurance is a lot of people who come from low-income families believe they can't afford it.'' So, he's going to focus on expanding the state's Low Cost Auto Insurance program.

BINGO.

In spite of California's mandate to obtain car insurance, approximately 14% of drivers remain uninsured, and rates continue to rise. The comments posted about this story about auto insurance refer to high costs -- not whether drivers feel like they're being put upon for being forced to buy insurance. They just want it to be affordable -- just like in health care.

This brings me to the second piece, which is "The Great Risk Shift'' author Jacob Hacker's piece in the LA Times about Obama and Clinton's bickering over to have -- or to not have -- mandates in health plans.

In fixating on mandates, they ignore the really key elements of their plan -- expanding group insurance through expanding public programs, employer-sponsored coverage, and a public insurance pool, which can negotiate for lower (read: affordable -- what Americans want) insurance premiums on the public's behalf.

Even more problematic, it is takes up energy and diverts attention away from combatting the seriously bad "YOYO" (You're On You're Own) ideas, which propose to do the opposite -- having everyone pay for their own health coverage in little silos, rather than pooling risk.

Hacker includes an individual mandate in his plan, but makes the calculation that Poizner does: the issue isn't the mandate (or some other required contribution), it's what you do to make it affordable. That's the debate for the general election.

Update: Here is Ezra Klein's take on Hacker's piece.

Labels: IndividualMandate, InTheNews, YearOfReform

posted by Hanh Kim Quach | Permalink | 12:02 PM

Why do we think quarterly status reports (QSRs) are such a problem?

Look, people recognize that paperwork and bureaucracy are endemic to any large enterprise. To run a large health care coverage program of 6.8 million people, we are going to need to get information from the people getting coverage--they are going to need to fill out a form or two.

When you need to go to the much-maligned Department of Motor Vehicles, there's a form... and sometimes there's a line. But we can be pleased when the DMV makes the renewal of driver's license automatic so we don't have to show up in person every time. We can be annoyed when staffing cutbacks means the line to get service is longer than it needs to be.

We may think these bureacratic barriers are avoidable or annoying. But we don't expect that they are placed there on purpose.

A long time ago, I was an intern for Vice President Al Gore, assigned to his "reinventing government" project. The whole philosophy was how to make government work better for citizens and consumers, to streamline processes so that people could get what they needed and were entitled to from the government in the most hassle-free way possible.

QSR's are are the inverse of "reinventing government." It's government in the service of the budget, of the bureaucracy, rather than the people and the patient.

It may be better than a direct cut in eligibility. But that's doesn't mean it's good, and it probably has a more insidious impact on how people view government (and their relationship to it) in the long run.

Labels: Budget

posted by Anthony Wright | Permalink | 10:29 PM

Big front-page story in the San Francisco Chronicle by Tom Chorneau today on one of the proposed budget cuts in health care.

It's not every day there's a front-page story on "quarterly status reports," but the article does a good job of explaining the real impact of the cut, and has engendered many interesting reader comments. (My wife, a frequent sfgate.com reader, noted that the posts are more supportive of our consumer advocacy position against the cut than the normal commentary.)

Instead of making a direct cut to eligibility, the Schwarzenegger Administration proposes to impose more paperwork on both children and adults with Medi-Cal coverage, by having them have to verify their address and income every three months.

You might wonder: how does more paperwork save money? It doesn't. It costs money. But what it does do it mean that a percentage of those with Medi-Cal will fall off coverage as a result. Having over 100,000 Californians lose coverage yields the sought-after budget savings, of over $92 million.

The Administration will admit that many of the people that fall off coverage will still be eligible. But if the paperwork falls through the cracks, if they get confused, if they don't fill out the paperwork and mail it back in 30 days, they lose Medi-Cal coverage.

It's insidious. So much of our efforts in the past few years (and in various health reforms, both those passed and proposed) was to make health coverage more automatic, more streamlined, and less bureacratic. This goes in exactly the wrong direction.

Labels: Budget

posted by Anthony Wright | Permalink | 9:06 PM

The NY Times had a really interesting article this weekend about Americans who are reluctant (fearful) to have DNA tests screen them for inherited genetic illnesses. Those who want a DNA test pay out of pocket so that no one else -- including their own doctor -- sees the results.

The reason for the reluctance and secrecy? They're afraid insurance companies will deny them coverage or charge them higher rates.

The effect of this fear of discrimination by insurance companies is:

Patients withholding information about their conditions from their doctors, which means their physician is unable to treat them effectively;
Patients refusing to take necessary tests, leaving both themselves and their doctors ignorant of their conditions and lead them to get sicker
Fewer volunteers willing to participate in disease research, which is bad news for everyone.

All this seems dire. But for some strange reason, the story made me feel hopeful. In reading the article, everyone must recognize how truly perverse and untenable the current system is. Your genetics -- which you cannot control -- should not dictate whether or not you can get insurance coverage at a reasonable cost. Your genetics, and what it reveals, should be helpful to you, not harmful. And it's this general knowledge of how blatantly unfair this system is that will compel Americans to demand change.....

Hopefully.

Labels: Insurers, InTheNews, YearOfReform

posted by Hanh Kim Quach | Permalink | 11:30 AM

For all the handwringing on whether health reform would violates ERISA federal law, there's another positive signal today in this AP article:

The U.S. Supreme Court says a San Francisco program that provides health care to the uninsured can continue while a lawsuit challenging the initiative is pending.
Without comment, Justice Anthony Kennedy on Thursday refused a request by the Golden Gate Restaurant Association to halt the program while the 9th U.S. Circuit Court of Appeals considers its legality.
The appeals court earlier ruled that city officials could implement the program, dubbed Healthy San Francisco.
The first-in-the-nation initiative requires companies with at least 20 workers to provide health coverage or pay the city a fee to help offset the program's estimated $200 million price tag.

Let's remember, the lower court struck down the minimum employer contribution part of the Healthy San Francisco plan, due to concerns about ERISA.

But then the city not only appealed, but also sued to stay the decision--and the Ninth Circuit agreed, saying that the appeal had a strong likelihood to succeed.

For the Supreme Court to implicitly agree-is a positive sign. For this silent agreement to come from Justice Kennedy--the main swing vote on the Supreme Court--it is even a better sign.

There's no slam dunk on any of this, but for those who are *so* sure that ERISA prohibits any health reform at the state or local level, we have one really important Supreme Court Justice thinking it's not unreasonable for San Francisco to go ahead with their reforms...

Labels: SanFrancisco, YearOfReform

posted by Anthony Wright | Permalink | 3:06 PM

HEALTH ACCESS UPDATE
Friday, February 15th, 2008

ASSEMBLY BUDGET COMMITTEE FOLLOWS SENATE
IN REDUCING MEDI-CAL RATES
* Other 10% Providers Rate Cuts to CCS, GHPP
* Lawmakers State Intent to Revisit This Cut in Budget Year Discussions
* Assembly Casts Bipartisan Vote for Mid-Year Budget Cuts Package
* Floor Votes Scheduled TODAY in both Senate and Assembly

Click Here for the Health Access WeBlog: More Reporting on the Assembly Budget Committee; More on the Blue Cross Letters Scandal on Doctors Being Dragged into Retroactively Denying Patients.

A day after their Senate counterparts passed emergency spending cuts aimed and whittling down the state’s $14.9 billion deficit, the state Assembly passed their own version which largely mirrored the Senate’s cuts.

The Assembly Budget Committee passed $1.4 billion in “solutions,’’ which shrinks the overall shortfall to $7.4 billion.

Unlike the Senate, though, Assembly Republicans also voted in favor of the measures.

In past deficit years, lawmakers have dawdled on taking budget action until the May Revision, when policymakers have a truer idea what the fiscal year budget outlook will be. But this year, the state is expected to begin running out of money in spring, and could begin defaulting on loans and payments by July 1.

THE HEALTH CUTS: The Assembly Budget committee cuts to health services were similar to what was passed in Senate Committee the evening before. Providers who serve Medi-Cal recipients, and Medi-Cal managed care plans would see their rates reduced by 10 percent for a total savings of $544 million to the general fund in the 2008-09 budget year. The rate reductions would not take place until July 1, the start of the fiscal year.

But Assembly Budget Chairman John Laird offered some hope. “Our hope is that through the budget process, we will restore this cut,’’ but he added it would mean "balancing this thing globally."

Added Assemblyman Roger Niello, the ranking Republican on the committee, “nobody is pleased with what we have to do.’’

This will directly impact the over six million low-income children, parents, seniors, and people with disabilities with Medi-Cal coverage, who will find a harder time getting access to a doctor or specialist.

It also has impact on the health system all Californians rely on--since every dollar cut means the state loses a dollar of federal Medi-Cal matching fund, this $544 million cut is actually a loss of over a billion dollars from the state's health system.

Assemblyman Hector De La Torre said he and fellow Democrats would “fight to figure out how we can avoid this drastic step’’ describing the eventual longer lines at emergency rooms when fewer Californians can get access to a primary care physician.

Niello signaled a direction he and his party would go. “This compromises our ability to provide essential services to the most needy. We need to take a look at benefit levels and eligibility as we move forward.’’ Niello may have been making a reference to cuts that were not taken this time around:
* the reinstatement of quarterly status reports
* the elimination of “optional benefits’’ such as adult dental and podiatry.

For a full list of the Governor's proposed health care cuts, visit the Health Access website:
http://www.health-access.org/preserving/Docs/Budget%20Fact%20Sheet%20013008.pdf

More commentary from the Assembly Budget Committee is available at the Health Access WeBlog, at:
http://www.health-access.org/blogger.html

The full Senate and Assembly are expected to vote on the packages today on their respective floors.

For more information, contact the author of this report, Hanh Kim Quach, policy coordinator for Health Access California, at hquach@health-access.org.

Labels: Budget, Updates

posted by Anthony Wright | Permalink | 9:31 AM

Earlier today, the Assembly Budget Committee, chaired by Assemblyman John Laird, also passed their major budget cuts on a bipartisan vote.

On the health care cuts, they made the same significant cuts in health care as did the Senate yesterday, including the $544 million cut in Medi-Cal provider rates, and other 10% cuts to California Children's Services and the Genetically Handicapped Persons Program. (Like the Senate, they postponed action on the Medi-Cal benefits like dental coverage, and the quaterly status reports.)

The health provider cuts were cited as some of the toughest things in the budget cuts package, and in fact multiple Assemblymembers made a point to suggest that they would fight to prevent the budget year cut in the first place.

Assemblymembers Laird, Niello, De La Torre, Swanson, Feuer, Wolk, and Bell all made comments on the health portion of the bill.

"This is the most difficult bill," said Laird about AB 5xxx, the bill with the health cuts. However, not acting now "would erode 1/3 of the savings" in the budget year. And given that "the budget problem could get worse by the May revision," Laird felt compelled to schedule the cut. However, he said that "my hope is to restore this cut," but that would take "global settlements on a number of issues.... The major discussion on these cuts will be this spring."

Assemblyman Niello, Vice-Chair of the Budget Committee and lead Republican on these issues, echoed that "no one is pleased with what we have to do," even if he was plased that we were getting spending "into line." Later, he did suggest to his colleagues that "California offers every single optional benefit available for federal participation.... We finance that by under-reimbursing providers. This compromises our ablity to provide essential services to the most needy."

Assemblyman De La Torre made the point the the Assembly Budget Subcommittee on Health "flagged certain issues that we had troubles with... and this is absolutely one of them." He cited that some Medi-Cal rates are "sub 50% of Medicare" and the problem of taking "another whack at 10%" is something that would not "help people get the care they need." De La Torre said that by this action regarding this cut, they are "queuing it up for July 1," but they will "continue to fight, and find how we can avoid this drastic step."

Assemblyman Swanson reiterated his concerns about the cuts, but said that in light of the deficit, "we have an obligation to move the state forward," and to make the cut in order to "save this money in the long run." But he also said that the next few months will be an opportunity where "we are going to have to set our prioirities."

Assemblyman Feuer noted he doesn't make comments much, but he wanted to join in the commentary, to say, "we want a send a very strong message to the provider community. There is a collective will that this cut does not stand." He decried the cut, and said "the euphemisms here matter... cuts in Medi-Cal rates really mean cuts in access to beneficiares." Feuer also pointed out that "This is a major cut in what we receive from the federal government." Ultimately, he said, "This is an excruciating thing to do."

"This is a difficult cut for many of us." repeated Assemblywoman Wolk, who raised her own question about the bill.

Assemblymember Bell ended with some personal comments, as "a step parent of someone who is developmentally disabled." he took issue with the cuts to California Children's Services and the Genetically Handicapped Persons Program. "It doesn’t make sense to cut the budget for sick children and those with genetic handicaps."

With those exxpressions of intent to revist the issues, the committee voted unanimously to move forward with the health care cuts.

Labels: Budget

posted by Anthony Wright | Permalink | 2:28 PM

HEALTH ACCESS UPDATE
Wednesday, February 13th, 2008

SENATE BUDGET COMMITTEE APPROVES MAJOR PROVIDER RATE CUTS
* Cuts to doctors, hospitals, other providers, managed care plans to begin July 1
* Committee postpones QSRs and cuts to dental and other benefits, for now
* Other cuts may need to be revisited for 2008-09

Click Here for What's New on the Health Access WeBlog: Blue Cross' Letter to Get Doctors to Help Cancel Their Patients' Policies; More on the Issues in the Individual Insurance Market; Timely Access to Care Regulations; Comparing Canada; An Autopsy on AB x1 1; Valentine's Day Budget Actions; More on Upcoming Budget Battles

The Senate Budget Committee on Wednesday evening passed a series of bills that would eliminate the $3 billion shortfall in this year’s budget and leave it with a cushion of $1 billion. Additionally, it shrinks the 2008-09 deficit from $11 billion to $7 billion.

Lawmakers and the governor are acting hastily on the budget this year because the state is expected to beginning running out of cash this spring and could begin defaulting on its loans and payments by the beginning of the fiscal year.

To ease the impact of cuts for 2008-09 and to begin making progress toward reducing the deficit, it was seen as important for lawmakers and the Governor to agree to cut some programs mid-year. Gov. Arnold Schwarzenegger, when he unveiled his budget last month, had proposed 10% across the board cuts to all departments. For a quick one-page fact sheet on the health cuts proposed by Governor Schwarzenegger, visit the Health Access website at:
http://www.health-access.org/preserving/Docs/Budget%20Fact%20Sheet%20013008.pdf

Senators approved SB 1x, the budget line items with budget reductions, and SB 3x, the health services "tralier bill" portion of the budget cuts, on a party line vote, with Democrats voting in favor, and Republicans abstaining. Other bills contained cuts on education, human services, transportation, and other areas of the budget.

THE HEALTH CUTS: The biggest blow would be borne by providers who serve Medi-Cal recipients, and Medi-Cal managed care plans. Rates would be reduced by 10 percent for a total savings of $544 million. The rate reductions would not take place until July 1, the start of the fiscal year.

This will directly impact the over six million low-income children, parents, seniors, and people with disabilities with Medi-Cal coverage, who will find a harder time getting access to a doctor or specialist. It also has impact on the health system all Californians rely on--since every dollar cut means the state loses a dollar of federal Medi-Cal matching fund, this $544 million cut is actually a loss of over a billion dollars from the state's health system.

“The 10% cut on Medi-Cal is the hardest thing on many of us,’’ said Sen. Denise Ducheny, chair of the Senate Budget Committee. “I don’t think any of us particularly thinks this is the best for our health infrastructure. But, it is $500 million, and there are few places where you can find that level of proposed savings.’’

Ducheny also noted that while no cut was being made in the current year, the reason they were moving forward now with the provider rate cut in order for the State to make the necessary changes so it can go into effect immediately on July 1, and the state could get the largest possible savings in the budget year.

The rate cut includes a 10% rate reduction for most Medi-Cal providers as proposed by the Governor for both fee for service and managed care plans (this by itself is a $544 million for the 2008-09 budget year.) There are also reduced Medi-Cal reimbursement by 10% for certain long term care providers, and reduced payments for "non-contract" hospitals.

Programs for children with chronic illnesses and handicapped Californians would also suffer a 10% cut. This cut is to California Children's Services providers ($10 million for the 2008-09 budget year) and to Genetically Handicapped Persons Program (GHPP) providers ($3.8 million for 2008-09 budget year). Other health cuts included a plan to delay payments to institutional providers, Medi-Cal managed care plans and Delta Dental Plans, and to permanently defer Medi-Cal Checkwrite.

“Given all the debates we’ve had on health care, this is counter to what we’d want to be doing,’’ said Sen. Darrell Steinberg. He was referring to the now-stalled AB x1 1, which would raised new dollars to raise Medi-Cal rates by over 20%--as opposed to the pending proposal, which is to cut by 10%.

In earlier hearings, the Department of Health Services testified that California ranks 41st in the nation in paying providers who care for the poorest Californians. The low rate at which providers are paid acts as a disincentive for providers to accept Medi-Cal patients, which in turn, makes it more difficult for the state's 6 million Californians on Medi-Cal to seek treatment. These cuts will only exacerbate that situation.

SOME CUTS NOT MADE, STILL PENDING: Health cuts proposed by the Governor that were not made, however, were:
* Elimination of optional benefits, which provide California residents with glasses, incontinence creams and washes, dental care, hearing aids, access to podiatrists and other medical lifelines.
* Reinstatement of quarterly status reports, which would have forced Medi-Cal recipients to verify their income every three months, as opposed to annually, or semi-annually.
* Reductions in payments to hospitals that care for large numbers of uninsured patients – mainly public hospitals.
* Premium payments to Medicare Part B for seniors who qualify for Medi-Cal share-of-cost.

While many of the health services cuts escaped the knife this round, Ducheny did say that they may need to be reopened when discussions about the larger budget are discussed.

The full Senate is expected to vote on the midyear budget cuts package on Friday. In the meantime, the Assembly Budget Committee is expected to meet Thursday to vote on its midyear budget cuts package.

Labels: Budget

posted by Anthony Wright | Permalink | 10:38 PM

The reversal of Blue Cross' efforts to drag doctors in as collaborators into their efforts to deny patients coverage is a welcome step. But it's only a step, treating the symptom, not the underlying disease.

First of all, congratulations to Lisa Girion at the Los Angeles Times for her ongoing coverage of her story, and its broad reach and impact. If anything, it shows how the harsh spotlight of national media (including the network news broadcasts and significant print and electronic coverage) can make a difference. While the outrage was consistent from all sides, I was pleasantly surprised that the media prioritized this story accordingly.

Why does this story have such a powerful impact? After all, relatively few people--5% of all Californians--are subject to these shenanigans. That's the number of people--about 2 million--who have coverage by purchasing it as an individual.

By contrast, 19 million have group coverage through their employer. Another 10 million have coverage through a public program like Medi-Cal or Medicare. (The rest--6-7 million--are uninsured.) Through group coverage, the insurers are not allowed to select who they want to cover, and who they don't. The deal with the insurer is that they have to cover the entire group (all the workers at the employer), the healthy and the sick.

In the individual market, the individual has no market power. They are subject to be denied and discriminated by the insurer. So an individual tries to buy coverage, they are subjected to a mulitple-page questionnaire asking you to detail your health history--and any answer can be grounds for denying you coverage, for so-called "pre-existing conditions." People fill out that questionnaire under penalty of perjury.

But what this recission scandal has revealed is that mistaken answers on that questionnaire can be used against patients--even those who have been paying premiums for months--in revoking their coverage. And Blue Cross is attempting to use their financial power over their network doctors to get them involved in this game of gothcha.

Why has this struck a chord, even though it's a small population?

* Because everybody can imagine being in this situation. Even those with good employer-based coverage know that one day, they'll be: between jobs, working at an employer that doesn't provide coverage, an early retiree, a divorcee, a freelancer, self-employed, starting a new business, or otherwise not have group coverage available to them.

Given the kinds of reasons that people have been denied coverage, it seems that merely living is a "pre-existing condition." And for most people, the idea that they won't have access to coverage--even if they are willing to pay for it--is terrifying.

* This is a core values issue: it strikes right at the heart of the doctor-patient relationship. A doctor should be able to ask about the most sensitive questions--about medical problems, sexual history, drug use--and have the trust to get the most honest answers, in order to be able to provide the most appropriate care.

This places that trust in jeopardy, by having the patient wonder if an ailment he just remembered but forgot on the insurance company application should be withheld from his doctor. It provides a doctor a undeniable conflict of interest, between the patient's best interest to get treated and be covered, and the rules of the insurer who provides the doctor's income stream.

It goes to one of the greatest fears that patients have: that the care provided by doctors is being impacted by profit, rather than medical, considerations.

There will be legislation to address this issue. Some of it will be focused on the issue of recissions.

But the real question is how we can minimize or eliminate underwriting altogether, so that people are not denied for so-called "pre-existing conditions."

* The first is to expand subsidized group coverage as much as possible--through employers, public programs, or ultimately a universal, single-payer health care system, so that insurers are not allowed to pick and choose which individuals they want to cover. They have to cover the *entire* group.
* If there has to be an individual market, it needs to be radically reformed with "guaranteed issue" and other, much stronger oversight over insurers. Clearly there need to be protections against "adverse selection," whether through an individual mandate or other mechanisms, but without guaranteed issue as a starting point, then the individual market is just hopelessly broken.

The health reform that stalled in the California Senate, AB x1 1, would have *both* expanded group coverage, shrunk the individual market, and put those new "guaranteed issue" rules in place. So would the outlines of the Clinton and Obama health reform plans. SB840, pending in the California Assembly but the financing blocked by legislative Republicans, would create one big statewide group insurance pool, and would also address this issue.

As for Senator McCain, his health plan actually wants more consumers to rely on the individual market, and to do away with state consumer protections by allowing insurers to sell across state lines.

This issue of Blue Cross' letters--it's a small story that went big, because it goes to the very heart of the health care debate in this country. Blue Cross' reversal doesn't end the debate... at the national level, it may have helped jump-start it.

Labels: BlueCross, YearOfReform

posted by Anthony Wright | Permalink | 12:21 PM

Daniel Weintraub has his own post-mortem of health care reform in the Sacramento Bee. This should not be the last word on the subject.

First, there's some straight-out inaccuracies: For example, he states that the Legislature's original proposal, AB8, "would cover only employees," when in fact it had public program expansions based on income, not employment, for both children and adults. He also stated that the final negotiated plan, AB x1 1, did not cover part-time workers (when, in fact, part-timers were covered, largely under the public program expansions--the question was whether employers would have to pay a contribution on them as a specific population).

There's glaring omissions: the fact that consumer groups don't get any mention at all is telling in Weintraub's worldview. Or that the Governor only released legislative language for his proposal, not to mention make any movement on policy--a month *after* the legislative session had ended, in October. The timing mattered, since it was a crucial reason why the effort ultimately ran out of time a few short months later.

But the biggest problem is Weintraub's thesis statement, as proposed in the final sentences of the first paragraph:

The bill died in a partisan crossfire, opposed from the beginning by conservative Republicans and ultimately killed by liberal Democrats. It was a centrist approach in a Capitol where centrism has become a dirty word.

AB8 was also opposed by Sen. Kuehl and those organizations who oppose major health reforms that are not single-payer. (This is a distinct group from many organizations who support single-payer as well as other health reforms, including Health Access.) Such attacks didn't help AB x1 1 and are certainly part of the mix... but there are other key reasons that AB8 passed and was placed on the Governor's desk, and AB x1 1 wasn't. The notion that AB x1 1 died at the hands of liberal purity doesn't make sense when AB8 passed the Senate floor a few short months earlier.

Senator Kuehl made her opposition clear early, but it would have passed without her vote. The question of whether the bill would pass out of Senate Health Committee rested on so-called "centrist" members, especially when one of them, Senator Yee, made a public pronouncement about his "no" vote.

There's real questions about timing, the process, the salience of the proposed policy, the politics betweeen the two legislative houses, the political will in the Senate, and yes, about the influence of insurers that didn't want to cover the sick, employers who didn't want to cover their workers, and tobacco companies that didn't want their product taxed.

Weintraub is right that the two-thirds vote requirement and the solid blockade of opposition from Republicans on any major health reform made it so that the Republicans marginalized themselves, but created significant procedural and political barriers for those pursuing health reform.

But the rest of the negotiations on policy and politics between the Governor, the Assembly and the Senate can't be explained using a left-center-right axis. That's the kind of analysis that obscures, rather than illuminates, the discussion.

Labels: YearOfReform

posted by Anthony Wright | Permalink | 4:55 PM

California state legislators will be receiving special Valentine greetings. Next week, all over the state, California will ask their state legislators to “Have a Heart” and how the cruel cuts can hurt California families.

Local families will bring valentines, flowers, and chocolates to several district offices around the state across the week. The actions are the work of a broad coalition of over 50 California organizations that support a balanced approach to the current budget crisis (see a partial list of organizations below.) Governor Schwarzenegger’s $17.3 billion in solutions include deep cuts to schools, health care, and human services with $1.1 billion in cuts to Medi-Cal spending, $4.8 billion in cuts to K-12 education, and the closure of 48 state parks.

The week of Valentine's Day is a big moment in the buget battle: both budget committees of the Assembly and the Senate will hold hearings on Wednesday, February 13th to agree on a final package of mid-year cuts.
* Assembly Budget Committee, chaired by Assemblyman John Laird (D-Santa Cruz), will meet Wednesday, February 13 at 1:30pm, at Room 4202.
* Senate Budget Committee, chaired by Senators Denise Ducheny (D-San Diego), will meet Wednesdat, February 13 around 1:30pm, at Room 4203

We expect that legislators will take action on some mid-year cuts, but leave most of the Governor's proposed reductions for the discussion of the main 2008-09 budget, with hearings starting in March, and negotiations beginning in earnest after the Governor's May Revise of the budget.

Before then, the deadline for the Legislature to act on a mid-year cuts package is February 23rd. After Proposition 58, the State Constitution requires that the Legislature send a bill (or bills) to the Governor 45 days after the Governor declares a "fiscal emergency", which he did on January 10. If the Legislature fails to do so, the Legislature cannot adjourn the special session (except for the day or short periods) or take up other business.

Labels: Budget

posted by Anthony Wright | Permalink | 11:03 PM

HEALTH ACCESS ALERT
Thursday, February 7th, 2008

STATE FAILS TO SET STRONG STANDARDS ON TIMELY ACCESS TO CARE
* Recent LA Times Article Spotlights Issue; Ability to Get Timely Care at Risk
* In Implementation of AB 2179, DMHC Would Let Plans Set the Rules
* New Regs Have No Specific Standards for Consumers to Keep HMOs Accountable

* ACTION ALERT: Call or fax state officials to urge them to withdraw proposed regs, and to set strong and specific standards for timely access to care.

Click here for the Health Access WeBlog: The Next Legislative Leadership; What's Next?; From the Ashes; ITUP Conference; New Paper on Hospital Charging; More on Timely Access

Six years after California passed a law that would guarantee patients an appointment with doctors and specialists in a reasonable timeframe, the state has pulled back on regulations that would have set explicit standards, and are on the verge instead of letting each health plan make their own rules on this important issue.

Consumer advocates, including Health Access California, were dismayed by recent regulations on timely access to care that were proposed by the Department of Managed Health Care (DMHC), the state regulatory agency that oversees health plans in California.

Airlines are not allowed to regularly overbook flights so that passengers are routinely bumped to planes in future months; But HMOs will overbook their provider networks, and without strong oversight, patients are often asked to wait weeks for urgent care, or months to see a specialist.

Care delayed is often care denied. Some patients end up with worse health conditions, while others decide they can't wait any longer and go to the emergency room for more expensive, less efficient care.

ACTION ALERT: Call or fax state officials to urge them to withdraw the proposed regulations on "timely access," and to put forward new rules with strong and specific standards. These regulations will affect every Californian’s ability to obtain a medical appointment, or receive a timely referral to a specialist. Contact:

* Governor Arnold Schwarzenegger, at (916) 445-2841 or fax (916) 445-4633, and
* Secretary Dale Bonner, Secretary of Business, Transportation and Housing the responsible cabinet secretary over DMHC at (916) 323-5400 or fax (916) 323-5440, and
* Director Cindy Ehnes, Director of the Department of Managed Health Care, at (888) HMO-2219 or fax (916) 255-5241.

BACKGROUND: These long-delayed regulations are supposed to implement a law passed in the California legislature in 2002 that guarantees consumers the right to see a doctor within specific times for emergencies, for routine care, or for referrals to specialists. The Office of Administrative Law is now reviewing the current proposed regulations to implement 2002's AB2179 by Assemblywoman Rebecca Cohn, sponsored by Health Access California.

The Department has also limited the scope of these regulations by refusing to apply these rules beyond full-service health plans to specialty plans, such as dental and vision plans.

Rather than following the law that requires the Department to set specific time limits that plans must adhere to, the DMHC is proposing to allow each plan to set and enforce their own, presumably more lenient, requirements that the Department would review.

The Department has also given plans the option to set up more lax alternative timely access standards in geographic areas where plans say it is hard to recruit doctors, especially specialists, such as rural, low-income, or inner-city areas. This regulation would also permit plans to make health care professionals available to give telephone advice to consumers, but only during weekday work hours. If a consumer had what they thought was an emergency after working hours, their only option would be to leave a voicemail message with the health plan for a call back during the next working day or the following week.

Even though the goal of timely access to care has been in the Knox/Keene law regulating health plans since the 1970s, the lack of timely access to health care remains a common complaint by Californians, representing roughly 10% of the complaints that are received by some consumer health advocacy organizations who advise consumers on health care issues. Even though this law was passed six years ago, plan and providers continue to vocally object to the imposition of any measurable time-elapsed standards that the Department could enforce.

These problems were featured in a Los Angeles Times article Tuesday, which spotlights the unfulfilled promise of the legislation from 2002 that has still not been implemented.

Consumer advocates from Health Access California, Western Center on Law and Poverty, and other organizations, have pressed Cindy Ehnes, the Director of the Department of Managed Health Care, to withdraw this version of the regulations on timely access to care. Advocates pledged to participate in an expedited negotiation with the Department and the industry to come up with meaningful and enforceable timely standards that would actually ensure consumers would get timely access to their health care providers.

If you have questions or need more information, please contact the author of this alert, Elizabeth Abbott, Project Director at Health Access at eabbott@health-access.org, or (916) 497-0923, ext. 201.

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 2:25 AM

Several hundred folks in the health care world gathered today for the annual Insure the Uninsured Project (ITUP) conference. HHS Secretary mentioned the "awkward" timing of the event, so closely following the setback for health reform in Senate Health Committee.

Many of the panels were about describing various parts of the reform proposal, so the entire conversation was funereal, where we all talked about how great the deceased was, and even those discussions about the tough compromises and imperfections were bittersweet.

I had a chance to be the last speaker of the day to the final five folks still assembled, and tried to be upbeat about the big question, "what's next?"

Let's be clear: there's no silver lining in our setback last week. A defeat is a defeat. And we lost perhaps the best chance in a generation to have health reform on a high-turnout ballot with a pro-reform constituency. It's sad.

But it doesn't mean we are done. We've come close before, and we didn't go away, whether to expand worker coverage in 2003 (SB2) and 2004 (Prop 72), to expand kid coverage in 2005 (AB772) and 2006 (Prop 86), to pass a single-payer plan in 2006 (SB840), or to pass a "shared responsibility" reform in 2007 (AB8) or 2008 (AB x1 1).

None of these ideas are off the table: expanded public programs for children and adults, minimum employer contribution to health care, or even a single-payer system. The Governor added individual insurance market reforms to the mix, and now that's on the table, in a way that's never been before.

And the climate continues to be right. This isn't 1994: the public still very much wants health reform; its a top presidential domestic issue.

Like each of the previous several years, we dust ourselves off, and keep working, and get closer. We can't wait until the next potential ballot measure in 2010 to get started. We need to see what we can do this year in the Legislature in 2008, next year in 2009, as stages to getting to universal coverage by 2010. We know the direction we need to go, and we can get started now. Let's go.

Labels: YearOfReform

posted by Anthony Wright | Permalink | 8:53 PM

Really important lead story by Jordan Rau in the California section of the Los Angeles Times today.

We've written before about pending rules at the Department of Managed Health Care on timely access to care, and how important they are for patients trying to get the care they need. They are based on a law, AB 2179 (Cohn) in 2002, that Health Access sponsored.

Well, right before the holidays, the DMHC drafted a new set of regulations that were significantly weaker, and they have already been submitted to the Office of Administrative Law for final review. The regulations are weak enough that we have asked the Governor and the DMHC to withdraw the regulations. Here's the article:

HMO rules stuck in limbo
Three years past the deadline, the health plans are now writing their own standards for timely appointments for patients.
by Jordan Rau
SACRAMENTO -- In 2002, California's HMO czar, Daniel Zingale, declared, "The days are over when they could make patients wait and wait for healthcare."

Zingale was heralding a new law that required his department to ensure that HMO patients received timely appointments with doctors. The law was spawned by the case of a 74-year-old woman who died from an aneurysm in a Kaiser Permanente waiting room while pleading to see her physician.

The Schwarzenegger administration's enactment of the new rules, which the law required by January 2004, has not been prompt. The Department of Managed Health Care did not release its proposed rules until 2007. When HMOs and doctors groups objected to them, the department scrapped the rules in favor of ones that let health plans come up with their own methods of complying with the law. The plans have to submit their guidelines in October, and the department will review them.

Consumer advocates charge that the way the department is putting the law into action controverts the promise six years ago from Zingale, who is now a senior advisor to Gov. Arnold Schwarzenegger and chief of staff for Schwarzenegger's wife, Maria Shriver.

"The pending rules are a betrayal of consumers and of the clear intent of the law," said Anthony Wright, executive director of Health Access California, a consumer advocate group that sponsored and helped write the original legislation. "The department is letting the insurance companies set their own standards."

The industry says they can't meet timely access standards, or the sky will fall. But if that's the case, they have been admitting that they haven't been in compliance with the basic principle of timely access, which has been in the Knox/Keene law since the 1970s.

Imagine if we let the airline industry overbook their flights (or have too few planes) so people are routinely bumped for weeks or months onto other flights. Yet without strong standards, we are letting the HMOs do the same thing with our medical care!

For a good example of why this matters, here's an example from the article:

Bobby Perry, a pharmacy clerk whose employer insures itself and uses Blue Shield of California's provider network, said that for five weeks, Blue Shield could not provide a psychiatrist who would treat her 15-year-old son. He has psychosis that sometimes makes him violent.

Perry, who lives in a Sacramento suburb, said that because she couldn't get an appointment for her son to obtain appropriate medication, she ended up having to call the police to have him institutionalized during an episode.

"Most of the doctors wouldn't take adolescents," she said, while the others "didn't have appointments until one month later.""I asked them what happens in the meantime, and they said, 'Just send him to the emergency room,' " she said....

But "why am I paying insurance," Perry said, "if they're not going to give me services?"

Labels: DMHC, TimelyAccess

posted by Anthony Wright | Permalink | 10:15 AM

HEALTH ACCESS UPDATE
Tuesday, February 5, 2008

SENATE PANEL WEIGHS PROPOSED BUDGET CUTS
• More than $1.6 billion in general fund cuts to the neediest families
• Senate Budget Committee reviews provider rate cuts, QSRs, cuts of "optional" benefits
• Absent health reform, senators reflect on sinking status quo
• ALSO: President Bush unveils federal budget; Reminder: VOTE TODAY

More on the Health Access WeBlog: More on the State Budget Cuts and Committee Hearing; Analysis on President Bush's Budget and Proposed Cuts to Medicare, Medi-Cal and SCHIP; The Presidential Candidates and their Experience with Health Issues; Dusting Off After California's AB x1 1 Stalls; Post-Mortems Galore for Health Reform;

The Senate Budget Committee met Monday to comb through $1.6 billion in proposed health budget cuts, which would force the state’s poorest residents to overcome bureaucratic burdens to keep their coverage, and leave many residents without access to eyeglasses, hearing aids, teeth cleaning or incontinence creams and ointments. And that's not including the biggest cuts aimed at the health providers on which all Californians rely.

Some cuts, Chairwoman Denise Ducheny classified as “knee-jerk” policies, and lamented that “some of these savings are so small, we’re spending more time talking about them than what they’re worth,’’ specifically in that instance referring to the $251,000 to be saved (out of a $141 billion budget) by eliminating adult psychology services.

CALIFORNIA’S BUDGET BLUES

Lawmakers need to make big decisions about these and other programs by March in order to avoid a statewide financial catastrophe, such as defaulting on loans, on July 1. The state is short about $14.5 billion.

California’s perennial budget problem is particularly acute this year because the state has papered over its budget deficits for most of the past decade – borrowing internally from funds it shouldn’t have, deferring payments – several times – that were later ruled illegal, selling bonds to pay off its debt, and reversing the Vehicle License Fee. The latter two make up $9 billion of the $14.5 billion deficit.

Gov. Arnold Schwarzenegger proposed a budget that cuts spending by 10% across the board. See Health Access’ Fact Sheet on the proposed budget cuts at our website, or view the Senate Budget Committee’s analysis of budget impact here:
http://www.senate.ca.gov/ftp/SEN/COMMITTEE/STANDING/BFR/_home/20408SbfrAgenda.pdf

Medi-Cal, whose recipients earn less than approximately $17,600 annually for a family of three, would weather the bulk of health reductions -- $1.1 billion -- for the current and 2008-09 fiscal year. The biggest ticket cuts in health services are:

* Rate reductions for providers who care for Medi-Cal recipients; California already ranks 41st out of 50 states in reimbursement rates.
* Elimination of certain benefits for roughly 3 million adults with Medi-Cal coverage, such as eyeglasses, incontinence creams and dental coverage;
* Reinstatement of quarterly status reports for Medi-Cal, forcing children and adults to renew their coverage and justify their income and eligibility every three months.

Healthy Families enrollees would also face higher co-pays and restrictions on their dental benefits.

WHAT KIND OF STATE DO WE WANT?

Budget Committee Chairwoman Denise Ducheny and other lawmakers shook their heads, muttered under their breaths and interrupted the Administration’s staff with questions and assertions, during the afternoon hearing that stretched late into the evening.

Some cuts seemed antithetical -- such as eliminating optometry services (but not more expensive opthamology services), and eliminating eyeglass and contact lens benefits for those who obtain the more-expensive eye-prescriptions from opthamologists.

According to some Senators, some cuts just seemed wrong. At one point, a dejected Sen. Joe Simitian after hearing about rashes, lesions and other discomfort resulting from not having incontinence creams, said, “Every now and again, we have to stop ourselves and say, ‘What have we come to?' We’re talking about people in need. This is just to save $4.7 million. At some point, you just need to stop yourself and to say, ‘What the hell have we come to? Is this really what we aspire to be as a state?’’’

The state that California would become, if the budget cuts are enacted, is the kind that would kick 160,000 children off Medi-Cal because their parents did not, for some reason, submit the proper paperwork every three months.

During one exchange about quarterly status reports, lawmakers hammered staff about the true intent of such a policy.

“Do you have evidence that things like that change on a quarterly basis?’’ Ducheny asked.“We do have evidence that it changes the enrollment,’’ responded administration staff impassively.

“That’s not the question,’’ quipped Ducheny. “The question is, ‘How likely is it that people’s status is actually changing versus ‘Sure, it changes the enrollment because someone didn’t turn in a piece of paper.’’’

Sen. Darrell Steinberg summarized: “We need to be clear about what is happening. [Quarterly status reports] are a pretext for hoping that adults, who may be confused, disabled, or unable to figure it out will not fill out the paperwork and that thei children will suffer.’’

“On it’s face, [filling out the paperwork] is not an unreasonable thing. But when you know that it will lead to children being thrown of the rolls, that’s not the right policy.’’

SPECTER OF HEALTH REFORM RESURFACES

Monday’s health budget hearing came one week after Senate Health Committee members – of which two budget committee members also participate – failed to pass comprehensive health reform, which would have injected the state with approximately $14 billion in new money, allowed the state to avoid cuts to health programs, and expanded health coverage to nearly three-quarters of the uninsured.

ABx1 1 garnered one “aye’’ vote, while three Democrats voted ‘no’ and three abstained. All Republicans rejected the measure. Lawmakers cited budget and economic concerns as the reason they could not push the proposal forward.

Sen. Alex Padilla, after nearly two hours of testimony, urged his colleagues to view health reform and its connection to the budget. “The critique of the financing of that bill didn’t make a whole lot of sense when put up against the proposed cuts in the budget,’’ he said. “By the same token, the proposed cuts don’t make sense, if indeed, we’re going to pursue and achieve an improvement in the healthcare system. As much as people would like to suggest they’re not linked, in fact, they are.’’

LEGIONS OPPOSE CUTS

Several dozen recipients and beneficiaries of the state’s programs, as well as advocates and various consumer and professional organizations, stepped forward to oppose the cuts.

Patients spoke of the need for podiatrists to monitor diabetes patients, adults to continue to receive preventive dental cleaning and procedures, and dually eligible Medi-Cal/Medicare recipients to have their $96-a-month Medicare premiums paid for through Medi-Cal.

Lawmakers on the panel were particularly impressed with one witness, who communicated by typing words into a computer, and allowing the computer to “read’’ what he had “said.’’ Such speech therapy equipment would be unavailable under the proposed cuts.

“These ‘optional’ benefits aren’t really ‘optional’ for everybody,’’ Ducheny acknowledged.

The committee on Monday heard testimony about the cuts, but will not make a decision until later this spring.

Health Access will continue to provide updates on budget negotiations throughout the year.

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

Labels: Budget, Sacramento, Updates

posted by Anthony Wright | Permalink | 11:58 PM

What comes between Super Sunday and Super Tuesday?

Subtraction Monday.

The California Senate Budget Committee held a umpteen-hour hearing on the health care budget cuts, the last hearing on specific cuts before putting together a mid-year cuts package. Hanh will have a full report later today.

President Bush put out his new budget today, and it's also not pretty.

For starters, he proposes $560 billion in cuts from Medicare over the next decade. Here's Families USA:

Following up on his indefensible veto of the kids' health bill, President Bush proposed inadequate funding for the State Children's Health Insurance Program (SCHIP). Under the President's proposal, the program could not even continue to serve the children currently eligible for the program. The President also proposes drastic cuts to Medicare and Medicaid. These public programs offer health security for many families and are more important than ever when we face hard economic times.

The President's solutions for the rising cost of health insurance and the growing numbers of uninsured follow three simplistic principles:
* Ask people to pay more out of their own pockets for health care;
* Create tax breaks that provide little or no help to low-income families;
* Provide no government oversight of the behavior of insurance companies.

This budget, like many over the last seven years, offers clear insight into the Bush Administration's priorities for our health care system — priorities that place working Americans at risk.

Here's the Center for Budget and Policy Priorities, from their budget brief, well worth reading in full:

The President's budget would provide more tax cuts heavily skewed to the most well-off while cutting vital services for low- and moderate-income Americans, generating large deficits, and increasing the strain on states already confronting budget problems as a result of the economic downturn. The budget reflects misguided priorities that would leave the American people more vulnerable in a number of ways....
MEDICAID: In addition, the budget would cut federal Medicaid expenditures by $18.2 billion over five years (with $17.4 billion in reductions from legislative changes and another $800 million from regulatory changes). These “savings”
would primarily be achieved not by lowering health care costs, but rather by shifting costs to the states.

MEDICARE: In addition to the Medicaid cuts, the budget includes $556 billion in Medicare reductions over ten years. Many of the proposed cuts go well beyond the reductions that MedPAC, Congress’ expert advisory commission on Medicare payments, recommended and considers safe. These reductions could drive some health care providers to limit the number of Medicare patients they see or drop out of the program entirely. That, in turn, would jeopardize health care for significant numbers of people who are elderly or have serious disabilities... At the same time, the Administration rejected MedPAC’s call to curb the tens of billions of dollars of overpayments being made to private insurance companies that serve some Medicare beneficiaries through the Medicare Advantage program.

SCHIP: The budget includes what it describes as a $19.7 billion increase in funding for the State Children’s Health Insurance Program (SCHIP). This would not, however, allow states to cover more uninsured children, millions of whom are eligible for SCHIP and Medicaid but unenrolled. States need an increase of approximately $21.5 billion over the next five years simply to maintain their current programs. This is because the budget “baseline” for SCHIP includes no adjustment for health care inflation in coming years; the baseline actually assumes a reduction in SCHIP funding for 2009. Under the Administration’s funding level, therefore, states would be required to scale back their SCHIP programs modestly unless they were able to increase their own funding.

We have a lot of work to do in the new year, at both the state and federal levels...

Labels: Budget, Bush, Sacramento

posted by Anthony Wright | Permalink | 9:24 PM

So the big news is the election tomorrow.

While we don't endorse candidates, we've commented extensively on the presidential candidates and their various health care policy platforms.

What I am impressed by is how much experience the candidates have with health policy and health reform.

Senator Clinton clearly knows the issue inside and out, from the experience in 1993-4. While there is a debate whether the mistakes of the 1993 Clinton effort were hers or her husband's, it's clear she knows the policy, the politics, and has learned lessons from her previous effort. She kept her interest in health policy issues in the U.S. Senate, and the fact that she has made it a priority despite her previous failed attempt suggests a perseverance that is welcome for such an important fight.

Senator Obama was one of the "go-to" legislators on health policy for my consumer advocate colleagues in the Illinois legislature. He was a leader on issues around the expansions of the Illinois version of SCHIP. When the majority changed to his party, he became the chair of the Health and Human Services Committee, and from there he pushed through the Health Care Justice Act, which started the process to get universal coverage in Illinois--a process that is roughly in the same place as California's effort (regrouping but continuing). He knows the policy and politics of these issues as well. Having been on the front lines of state health policy, he is likely to be very sympathetic to the specific health needs of a large, diverse state like California.

While they have done less to prioritize health issues, even the Republican candidates have some experience on the issue.

Let me be clear: they have pur forward several proposals that consumer advocates oppose--one trope that most of them endorse is to eviscerate state consumer protections, by allowing insurers to sell plans across state lines. (How would you like to complain to the Nebraska Department of Insurance if you were denied care?) While the Democrats want to regulate insurers so they can't deny coverage to those with "pre-existing conditions," the Republicans explicitly reject such oversight.

But the Republican presidential candidates have shown flashes of moderation in support of health reforms, even in areas that have been opposed by President Bush, or the Republican legislative caucuses in Sacramento. Senator McCain supported the long-stalled HMO Patients' Bill of Rights. Governor Romney signed the Massachusetts health reform, including the major public program expansions that now is covering half the uninsured. (He vetoed elements, that by agreement with the Legislature, were overridden.) Governor Huckabee was involved in Arkansas' early expansion of child health care, before SCHIP was created.

So whatever the outcome, it's clear is that the next President of the United States will have more direct experience with health care policy issues than the current occupant. We'll find out more next week...

posted by Anthony Wright | Permalink | 11:55 AM

It's Groundhog Day, as I re-emerge...

As readers of the blog may have noticed, I've stayed away from posting for a few days, except for an initial reaction, a first crack reflecting on future health reform chances in other states and here in California, and links to what others are saying.

My lack of posts is more than abiding by the saying "if you can't say anything nice....", or even spending some time with my little boy (who is lucky to be insured, unlike over 800,000 California children who could have been helped... whoops, there's the bitterness again). It's actually surprising that you can be as busy in defeat as in victory, from trying to understand the outcome, recalibrate plans and begin to regroup, and catch up on all the work that was neglected during the final push for reform.

We'll have more to post about next steps in health reform--beyond the immediate debates like who's to blame, whether the Senate hearing was "fair" or "hostile," or what could have been done differently, by proponents or opponents of AB x1 1.

There's a lot of work that needs to be done, and Californians--insured and uninsured--need help, desperately and immediately. There will be the annual "Insure the Uninsured Project" conference on Wednesday, and I'm on a panel that was going to be talking about the ballot campaign, and that now is charged with the question "What's next?" We're in the process of developing the answer.

The most immediate issue now is the pending budget cuts. Monday afternoon will bring a full Senate Budget Committee hearing on the health cuts, and the next two weeks will be a mad dash to pass a mid-year cuts package. And that's only the opening act, to the main fight in the next several months over the much bigger cuts proposed for the 2008-09 budget.

So the groundhog says at least six months of budget battles.

Labels: Budget, HealthAccessCommunity, YearOfReform

posted by Anthony Wright | Permalink | 3:38 PM

Health Access Blog

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