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The stars aligning again...

Wednesday, April 30, 2008
All week, we've seen signs that while health reform stalled, the need and the urgency--and the opportunity--has not.

* We have had a Field Poll showing broad support for the proposed California legislation that did stall, and even the broad provisions that any major reform is going to need to do.

* A Kaiser Family Foundation poll showed health as a major election issue this year, outpacing many other pocketbook issues--and the startling factoid, picked up by Ricardo Alonso-Zaldivar of the LA Times, that 7% of Americans said they made a decision about marriage based on the need for health coverage.

* A Robert Wood Johnson study, as reported by Lisa Girion in the Los Angeles Times, that laid out the bare facts about the rise in health care costs and the decrease in the number of jobs that now come with health benefits. Yes, the worry that the polls found is based on real trends-- people are appropriately more concerned about the status quo than the needed reforms.

* The playing field is set, the public is there, and so are many of the politicians. Governor Schwarzenegger made a strong commitment to revisit health care reform in the remaining years in his term.

The editorial board of the San Jose Mercury News may have cracked even the cynics, with their opinion piece today:

By all appearances, Gov. Arnold Schwarzenegger's plan for health care reform died an ugly death on the floor of the Legislature in January.

But as Billy Crystal's Miracle Max cracked in "The Princess Bride": "There's a big difference between mostly dead and all dead. Mostly dead is slightly alive."
Besides a great movie reference, the Mercury News also provided another key element to a new possibility: the need to get legislation passsed this year, to set the stage for 2009. We appreciate their spotlight on the Health Access California-sponsored SB1522 (Steinberg), and there are other key bills that can provide real help for people and patients as soon as possible, and lay the foundation for further reform.

It's not too late to resurrect the governor's plan. And even though it might take a miracle to reform health care in California, it's worth a shot in 2009.

That doesn't mean the subject can be ignored this year. The Legislature has work to do now to set the stage.

Next year Karen Bass will be Assembly speaker, Darrell Steinberg will lead the Senate and someone other than George Bush will be in the White House. If public support for reform remains strong, the stars will be aligned for the governor to make another run at passing his comprehensive package.

According to a Field Poll released Monday, a whopping 72 percent of voters said they generally favor Schwarzenegger's plan. And the need for reform continues to grow. Some 6.6 million Californians, 19 percent, are uninsured, and that number is certain to increase as the economy worsens. A Kaiser Family Foundation poll released Monday showed that every 1 percent jump in U.S. unemployment would cause the number of uninsured to rise by 1.1 million nationwide.

Two bills before the Legislature may give an early indication of the prospects for reform in 2009.

The first, Steinberg's SB 1522, would set up what consumer advocates call an apples-to-apples comparison for individuals seeking private insurance coverage. It's sure to draw intense interest from insurance companies, and it will test the governor's willingness to collaborate across party lines.

The second, Sen. Sheila Kuehl's SB 1440, would require insurance companies to spend a minimum of 85 percent of premium dollars on health care expenses. That's a concept from the earlier reform package that insurance companies hoped was more than "mostly dead."

Calling Miracle Max.

With all this momentum, I don't think we need a miracle to get comprehensive health reform in 2009-10, just our work and commitment. It would help to have some movement, as the editorial points out, by putting some of the legislative building blocks in place.

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posted by Anthony Wright | Permalink | 9:44 PM


High-risk health reform...

Tuesday, April 29, 2008
John McCain is getting beaten by a woman, and it's not Hillary Clinton. It's Elizabeth Edwards.

In unveiling his health care plan, McCain seems super-focused on the fact that many more people could be denied coverage because of "pre-existing conditions," as he seeks to shift people from employer-based coverage to the individual insurance market, with some assistance from a tax credit.

Elizabeth Edwards pointedly has challenged McCain, saying that an American with her or his health history would be denied under McCain's plan in the individual insurance market. (To be fair, the Los Angeles Times made this point earlier.) She's absolutely right.

And because of this, McCain has a liability. He even has a "myth and facts" section of his website designed to counter exactly one, and only one, myth:

"MYTH: Some Claim That Under John McCain's Plan, Those With Pre-Existing Conditions Would Be Denied Insurance.

FACT: John McCain Supported The Health Insurance Portability And Accountability Act In 1996 That Took The Important Step Of Providing Some Protection Against Exclusion Of Pre-Existing Conditions.

FACT: Nothing In John McCain's Plan Changes The Fact That If You Are Employed And Insured You Will Build Protection Against The Cost Of Any Pre-Existing Condition.

FACT: As President, John McCain Would Work With Governors To Find The Solutions Necessary To Ensure Those With Pre-Existing Conditions Are Able To Easily Access Care."

The multiple "facts" don't really the answer the charge. The "myth" is a factual statement. Where do those those with "pre-existing conditions" go under the McCain plan? Some will get left behind. In the new twist to the slim pickings already on his website, McCain would now have states figure out how to solve the issue of the "uninsurables." .The New York Times coverage by Michael Cooper and Kevin Sack focus on this aspect. Bob Laszewski from Health Care Policy and Marketplace Review thinks McCain has opened a major liability for himself.

I think the Democratic rivals made good responses but didn't quite capture the central critique of this plan in their responses.

* Some of what they say is a criticism of what is *not* in McCain's plan, which indicates it lacks a certain ambition, but doesn't really say why the proposal is still not an improvement from the status quo. (Frankly, it doesn't take much.)

* Clinton appropriately criticizes state high-risk pools (and her statement--"virtually all high-risk pools today have waiting lists, high premiums, and scaled-back benefits"--is a dead-on description for California's MRMIP, Managed Risk Medical Insurance Program, which now has a waiting list, is underfunded, has high premiums and a $75,000 benefit cap.)

* But in our current system, the state high-risk pools are an essential lifeline to coverage for many. The problem is not the high-risk pool itself, but the major people who are denied in the individual market, that the high-risk pool provides some comfort.

* The real issue is not the high-risk pools in the state as a solution, but that his plan seeeks to make the problem much bigger. The more he accomplishes his goal of moving people from group coverage (like that of their employer) to individual coverage, the more he creates the problem that he seeks to solve.

Here in California, Health Access California supports AB2 (Dymally) and other efforts to improve and better fund our high-risk pool, so more people, denied for pre-existing conditions, can at least get some coverage.

We were more pleased to support AB x1 1, the negotiated reform between the Governor and the Speaker, that included not only guaranteed issue--so no insurers could deny for health status--but it would expanded group coverage enough that there was a net decrease in the number of people having to get individual coverage.

This was important, because the individual market is fundamentally a place where the individual has little market power against the big insurers, as opposed to when they at least have the purchasing power of a group. McCain would place more people in the individual market.

So the criticism isn't that McCain relies on state-based high-risk pools, it's that he would increase the need for them in the first place.

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posted by Anthony Wright | Permalink | 11:42 PM


Tobacco's doubly dirty deeds...

Niko Karvounis at the Health Beat Blog has a full article on Big Tobacco being the leading cause of death for... state health reform.

The excellent piece appropriately spotlights Big Tobacco's $65 million opposition to Proposition 86--which would have funded emergency rooms and children's coveage, and their instrumental role in opposing health reform in 2007-8. It's worth quoting the California section:

Consider California. The Times notes that the state’s recent bipartisan plan for instituting universal health care, endorsed by Republican Gov. Arnold Schwarzenegger and Democratic Assembly Speaker Fabian Núñez, “died in the State Senate in January partly because of opposition to the $1.50-a-pack increase it included.”

This wasn’t the first time cigarette taxes have been an issue in California. In 2006, California voters turned back a ballot initiative, Proposition 86, that proposed to increase the cost of a cigarette pack by $2.60. Supporters of the proposition estimated proceeds from the tax at $2 billion—which would have been used to help fund health care reforms—and forecasted a $16.5 billion long-term decline in health care costs thanks to reductions in smoking. Good stuff.

But the proposition failed by a narrow margin: 48 percent of voters approved the measure while 52 percent said no. Observers are quick to note that this close call came about despite the fact that Big Tobacco spent a whopping $65 million to fight Proposition 86, pouring that money into lobbying and advertising.

These efforts often get ugly. The industry's anti-tax campaign listed non-existent groups like the “Chamber of Commerce of Los Angeles County” as being opposed to the proposition. It also sent out mailers that attributed anti-86 stances to politicians—wrongly—without their approval, and issued statements suggesting that terrorists would somehow benefit from a higher tobacco tax.

In retrospect, it’s unsurprising that tobacco companies got down and dirty—after all, the tobacco industry has a lot invested in California. A 2006 Business Week article breaks down the numbers: “California is home to 9 percent of all U.S. smokers, and a successful Prop 86 would certainly dent tobacco companies' bottom lines. An analysis by the Tobacco Control Section of the California Health Services Dept. expects that it could cut cigarette sales by 312 million packs a year. Let's estimate, conservatively, that Philip Morris makes a profit of 20 cents per pack. Given its 51 percent market share, that's a $32 million hit. Plus, the Tobacco Control Section predicts the smoking rate among high school students will drop from 13.2 percent in 2004 to 7.6 percent [after the passage of Proposition 86].”

Clearly, tobacco companies had a lot to lose. $65 million and lots of lies later, however, it seemed they were safe. That is, until Governor Schwarzenegger’s 2007-2008 health care plan began to garner public support. In a February analysis, Daniel Weintraub of The Sacramento Bee noted that “the basic outline of the governor's plan – a requirement that every Californian have insurance, with the costs shared by employers, health care providers and individuals themselves – attracted the support of 60 percent to 70 percent of those surveyed by the Public Policy Institute of California in several polls taken during 2007.” Here, it seemed, was a plan that could pass.

Of course, health care reform is never cheap because if you are going to mandate that everyone have insurance, you must provide subsidies for the many families who cannot afford to pay for it on their own. California’s plan was estimated to cost $14 billion, to be funded partly by an increase in cigarette taxes.

Enter Big Tobacco. The industry had been digging its heels into the Golden State’s political scene for years. According to an October report from the Center for Tobacco Control Research and Education at the University of California San Francisco School of Medicine, the tobacco industry had already made major inroads into the CA State legislature by the time Schwarzenegger’s proposal surfaced.

The report notes that “the [tobacco] industry steadily increased monies spent on state level political activities in the period 2003-2007, from $4,086,553 in 2003-2004 ($1,083,448 to candidates) to $4,359,205 in 2005-2006 ($1,895,584 to candidates).” In the 2005-2006 election cycle, almost one quarter of the state legislators on committees relevant to health care—the Health, Budget, and Appropriation committees in the State Assembly and the Health, Human Services and Budget and Fiscal committees in the State Senate—received contributions from the tobacco industry.

It’s thus unsurprising that the tobacco tax became a sticking point for California’s health care plan, and that the proposal sunk. But it’s not just California that’s in Big Tobacco’s crosshairs—the shoot-out between health care reformers and Big Tobacco extends across the nation.

Tobacco has a major negative impact, and not just on the health of our youth...


posted by Anthony Wright | Permalink | 11:26 PM


Gov: Another round?

Governor Schwarzenegger is committed to trying health reform again, according to a 30-minute interview with Juliet Williams at the AP:

"Now we'll try again. We will continue on, keeping the stakeholders together, fine-tuning it and seeing if we can improve on it since we have the time now, then be back again. We feel very confident."

We have an interest in making as much progress as possible under Governor Schwarzenegger in 2009. We don't know who the next Governor will be, and what their interest in health reform will be. And if they do prioritize health reform, they will be able to do more if there was some momentum from their predecessor. The poll shows strong support and the opening of a new window of opportunity, but these windows are short-lived, and you never know when the next time will come.

There is time now to look at the proposals, fix things that weren't right, resolve issues that were pushed to the future, and even take another look in areas where there might be better alternatives. The key thing, as well, is to lay a foundation for reform, which includes a budget that doesn't take us backwards in terms of Medi-Cal cuts, and is sustainably funded.

Not small tasks for the rest of the year.

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posted by Anthony Wright | Permalink | 11:04 PM


The new McCain plan, and his opponent(s)

Ben Smith at Politico usefully put forward a link to the revised McCain health care plan that was spotlighted in a speech by the Arizona Senator today. He also quoted the responses by the two Democratic presidential campaigns:

Sen. Clinton:

John McCain is proposing a radical plan that would mean millions of Americans would lose their job-based coverage: The McCain plan eliminates the policies that hold the employer-based health insurance system together, so while people might have a ‘choice’ of getting such coverage , employers would have no incentive to provide it. This means 158 million Americans with job-based coverage today could be at risk of losing the insurance they have come to depend upon.

While Senator McCain touts the choices his plan offers, people who are older or sicker would actually have no choice under his new proposals. Older Americans or those with pre-existing conditions would be allowed to get only one type of coverage in a high risk GAP pool. That kind of arrangement does more to help insurers than individuals. In addition, high-risk pools fall far short of helping people in need. Virtually all high-risk pools today have waiting lists, high premiums, and scaled-back benefits. The millions of vulnerable Americans who lose employer-based coverage could have to wait months, maybe years, to access the GAP high-risk pools, if they are like the pools that exist today.

To top it off, Senator McCain has offered no straight talk on how he would pay for these initiatives.

Sen. Obama (via spokesman Hari Sevugan):
At a time when 47 million Americans don't have health care, and millions more are being driven to financial ruin trying to pay their medical bills, John McCain is recycling the same failed policies that didn't work when George Bush first proposed them and won't work now. Instead of taking on the big health insurance companies and requiring them to cover Americans with preexisting conditions, Senator McCain wants to make it easier for them to reject your coverage, drop it, or jack up the price you pay. But the only choice he's offering the American people is a tax break that won't guarantee coverage and doesn’t ensure that health care is affordable for the working families who need it most. Barack Obama has a universal health care plan that will cover every American and cut the cost of a typical family's premiums by up to $2500 a year.

posted by Anthony Wright | Permalink | 3:02 PM


A bad budget year, indeed...

Tuesday, April 29th, 2008

* Assembly and Senate Budget Subcommittees review cuts to health programs
* Proposals include eliminating various Medi-Cal benefits, like dental
* Also: Cuts to safety-net hospitals, community clinics, and children's enrollment
* Votes will take place after Governor’s May revision
* May budget numbers look grim, Schwarzenegger warns

Click Here for What's New on the Health Access WeBlog: New Field Poll Shows Strong Support for Stalled Health Reform Measure, and Continued Momentum for Reform; A New Window of Opportunity in 2009-10?; The False Choice Between State and Federal Action; Musical Chairs Among the Governor's Health Team; Bush's Medicaid Changes: How They Would Impact California, and How the California Delegation Voted; The World Health Care Congress and the Presidential Plans; Budget Blues Becoming Bigger; The Student Insurance Scam; New Report on QSRs; and more...

Yesterday, both the Senate and Assembly budget subcommittees that oversee the public programs for health coverage reviewed cuts proposed by the Governor. The committees held off on big ticket items pending the May Revision of the budget – which will be released in a couple of weeks.


Sen. Elaine Alquist presaged the Senate budget subcommittee hearing by saying that “all cuts were on the table,’’ even if members of the committee did not like them.

ACTIONS: The Senate subcommittee took actions on three small items, one to increase staffing for HIPPA compliance, and another to cut staffing for the Primary Care and Rural Health Branch.

WORKING DISABLED: Another vote eliminated the sunset on the CA Working Disabled Program, which provides Medi-Cal coverage to people with disabilities who work, as long as their income is below 250% of poverty ($26,000 for an individual). (A related bill is Assemblywoman Julia Brownley’s AB 851.) That action makes this program permanent.

PRESCRIPTION DRUG DISCOUNTS: Another item that had been slated for approval – further delaying the implementation of the CA Discount Prescription Drug Program – was taken off the agenda for day, but may be considered in the future. This program is the result of 2006’s AB 2911, which would allow the state to use its leveraging power to negotiate lower prescription drug prices for millions of California’s uninsured, who currently pay full price for drugs. The program has already been delayed once. The Governor's budget does include its implementation this year.

CHILD ENROLLMENT SELF-CERTIFICATION:The Administration is pushing for the implementation of SB 437 (Escutia) which would allow Santa Clara and Orange Counties to start up a “self-certification’’ pilot program, which would streamline enrollment processes for children enrolling in Healthy Families or Medi-Cal by allowing families could self-certify their income and assets for enrollment in these programs. Like AB 2911, the implementation of this legislation has also been delayed once before. The Administration is asking for $30.9 million to start up this program ($14.4 million from the general fund). The Legislative Analyst's Office has recommended the delay, but health and child advocates, including the 100% Campaign and Health Access California, testified against the cut. Action was "help open."

GOVERNOR'S CUTS STILL PENDING: The following cuts were proposed by the Governor and heard by the Senate Health Committee, but action was "held open," with decisions likely to be made after the Governor's announces the May Revise.

• CLINICS: In the Governor's budget proposal, 400 clinics in the state, providing care to both urban and rural populations, as well as special programs for migrant workers and Native Americans would be reduced by $3.5 million. All told, the funding cut would mean about 120,000 fewer visits to clinics for primary medical care, dental care, tobacco cessation and other health education information.

• CHILD HEALTH & DISABILITY PREVENTION PROGRAM (CHDP): The governor proposes to cut local administrative funding for this program by $1.1 million, though the Department of Health Care Services said it will be up to counties to decide whether this particular program would be cut, or whether they could absorb the cuts elsewhere. Either way, cutting administrative costs for CHDP would make it harder for children – from birth to 21 – to get access to health care through this program.

• CALIFORNIA CHILDREN’S SERVICES: This program would be hit three times, losing a total of $115 million ($51.4 million general fund), in provider reimbursements, case management and administrative costs. Many provider and patient groups testified that CCS saves the state money because it provides case management, care, treatment and therapy for children with medical conditions such as birth defects, chronic illnesses or genetic diseases, such as hemophilia and cystic fibrosis. These children would undoubtedly become more severely ill without these services and wind up needing far more expensive care.


As in the Senate, the Assembly budget subcommittee did not take votes on any items but did discuss the following proposals:

MEDI-CAL BENEFITS: The Administration has proposed a $19 million cut to services that are not federally mandated by Medicaid--so called "optional" benefits. That includes access to optometrists, podiatrists, therapists, opticians and prescribed creams and washes. In total, these cuts would affect nearly 1 million Medi-Cal recipients who need eyeglasses, mental health therapy, speech therapy after a stroke, creams to avoid bedsores and regular checkups for their chronic diseases.

DENTAL BENEFITS: The biggest chunk of savings from cutting optional benefits comes from the elimination of the adult dental benefit – which would reduce state spending by $115 million, but also cause the state to lose an equivalent amount in federal matching funds. The California Dental Association presented an alternative to a full elimination of the program, which would eliminate specific procedures while retaining the program. The program is already threadbare, with 4,000 dentists serving 6.5 million patients. If it adult dental benefits were eliminated, it could take up to 10 years to rebuild provider networks and infrastructure once money was made available again, the association said.

PUBLIC HOSPITAL FUNDING: The Administration proposes to shift more money from public hospitals, to pay for other health services. All told, the state would siphon $78.8 million from public hospitals in 2008-09. The state would need federal approval to do this, to amend a "hospital financing waiver" agreed to three years ago. Assemblyman Jim Beall suggested the state wait until after the presidential election to see if “we could do better if we had a more cooperative administration’’ to get more federal fund in the first place.

PRIVATE "SAFETY-NET" HOSPITALS: Under this proposal to the "Disproportionate Share Hospitals (DSH)" payments, funding would be reduced by 10%, resulting in a $24 million state savings, but a loss in equivalent federal funds. These funds are used to help private hospitals that see a large number of uninsured and Medi-Cal recipients.

A number of advocates testified against the cuts, including: California Association of Public Hospitals, individual public hospital systems, Western Center on Law and Poverty, Health Access California, Californians for Disability Rights, children’s hospitals and others.


The May Revision is expected to be released in the next two weeks. Gov. Arnold Schwarzenegger has projected an even bigger gap than the current $16 billion shortfall.

Health Access will keep advocates up to date on budget issues through these E-mail updates and on our blog. For more information, contact Health Access Policy Coordinator Hanh Kim Quach at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 10:08 AM


Budget hearings and benefits...

Monday, April 28, 2008
Lots of budget hearings for health advocates today.

The Senate Budget Subcommittee on Health, chaired by Senator Alquist, met this morning. It heard several proposed cuts. It did *not* take action on a proposal to delay the state's prescription drug discount program, and similarly held open other proposals to cut community clinics, and various other efforts to get care for children and vulnerable patients.

The Assembly Budget Subcommittee on Health, chaired by Assemblywoman Berg, is meeting this afternoon. The big topic is the elimination of Medi-Cal "optional" benefits, especially dental coverage.

My colleague Hanh will have a full report later.

Also: Stan Rosenstein was also finally confirmed by the Senate today for his position today at the Department of Health Care Services.

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posted by Anthony Wright | Permalink | 4:04 PM


Continued urgency... and a new window...

The new Field Poll out today shows continued urgency for health reform, including increased worries about the current health system, and increased support for the expansion of group coverage, including both the proposal negotiated by Gov. Schwarzenegger and Speaker Nunez, and even a single-payer model.

There's coverage by Bill Ainsworth in the San Diego Union-Tribune where I give my take, as well as by Matthew Yi in the San Francisco Chronicle and Joe Rodriguez in the San Jose Mercury News.

The actual text of the Field Poll is here. There's a lot to chew on.

What's clear: Even though health reform stalled earlier this year, the need and urgency and momentum for reform has not. Californians continue to strongly support broad health reform, especially to expand group coverage, whether through public programs, purchasing pools, or employer-based benefits.

* 72% supported the package negotiated by Governor Schwarzenegger and Speaker Nunez (AB x1 1)--and there is even greater support for specific elements of the proposal, including a minimum employer contribution (73%, 77%), public program expansions (77%), and guaranteed issue requirements on insurers (84%).
* On a broader sense, Californians believe they are better off in group coverage, either through an employer (38%), or government (31%), than a model where they have "personal responsibility for getting your own coverage" (20%)--the focus of moving people to the individual market, which is what President Bush has proposed.

This isn't 1994, when the failure of the Clinton reform effort was caused after the public was scared away from changes in the health system, and soured on reform in general. In fact, the poll suggests that people are understandably concerned and angry about the status quo in health care.

This strong public support creates a new window of opportunity in the 2009-10 legislative session at both the state and federal levels. We have the opportunity this year to pass some key reforms and shore up our budget, so that we are ready to roll starting next year, with a new President on down.

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posted by Anthony Wright | Permalink | 10:19 AM


Working on both fronts...

Friday, April 25, 2008
Lots of hub-bub in health circles about an article in the Capitol weekly publication The Hill, suggesting health reform isn't a certainty in 2009 at the federal level. There's lots of pushback and clarification as a result.

Either way, it suggests that reformers and advocates, while continuing to push for national health reform, should *not* sit on their hands at the state level. We have a window of opportunity in 2009-10 at *both* the federal and state levels, with a new President and Congress, and here in California with new legislative leaders and a Governor interested in prioritizing health care. We need to work on both, in simultaneous and complementary ways.

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posted by Anthony Wright | Permalink | 5:50 PM


Adding fuel to the fire...

Earlier today, Families USA released a short report about the proposed Medicaid rule changes put in place by the Bush Administration. They are projected to cost California more than $10.8 billion in federal funds over the next five years.

The report suggests that the cut in federal funding will, in fact, act like a giant anti-stimulus package. Those lost Medicaid funds will eliminate an estimated 46,700 jobs and an accompanying $1.9 billion in wages, and, even worse, cost the state an estimated $5.4 billion in lost business activity.

Virtually all that economic pain comes in the first year of implementation, when California would fail to receive approximately $2.2 billion in Medicaid payments. Titled “Bad Medicine,” the report analyzed the economic impact of seven new Medicaid regulations that were issued in 2007.

“The devastation caused by the Administration’s cuts will affect millions of people who rely on Medicaid for their health lifeline. This will be tragic for their families,” Ron Pollack, Executive Director of Families USA, said today.

“Additionally, these cuts will harm state budgets at the worst possible time. These cuts in federal Medicaid payments will have a ripple effect through state economies that are already struggling during this economic downturn. This economic harm will increase the number of people who may need Medicaid, as tens of thousands of Californians see their paychecks being cut or their jobs being eliminated.

“This lost business activity in California will hurt business and industry, and it will force governors and state legislators to make increasingly difficult choices about providing state services,” Pollack said. “This Bush Administration’s decision is ill-timed and ill-considered, and it should be reversed by Congress.”
There was also comments from our state's Medicaid director.
“The proposed changes to the Medicaid program would result in a significant and potentially devastating shift of costs to California taxpayers,” Stan Rosenstein, chief deputy director, California Department of Health Care Services, said today. “Our state would be saddled with an estimated $12 billion financial burden resulting from such a drastic change in how the federal government supports the Medicaid program. The Governor strongly believes that such changes should undergo further evaluation and a full congressional review before being implemented."

The seven regulation changes issued by the Bush Administration in 2007 – and imposed on states without congressional review or debate – restrict funding for a variety of Medicaid services, including rehabilitation services, school-based transportation, as well as Medicaid administrative services, such as outreach, enrollment, and case management. The seven rule changes are now either under a congressional moratorium or awaiting implementation.

Just a comment: On top of proposed cuts at the state level, these federal cuts by the Bush Administration would be a 1-2 punch for California patients, our health system, and our economy. These cuts would add fuel to the fire of our deteriorating economy, and our deteriorating health system, one that we all rely on.

We are happy that most (but not all) of our California Congressional delegation voted to delay these regulations, as Hanh reported below. These is the exact wrong direction for California and for health care.

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posted by Anthony Wright | Permalink | 5:06 PM


Now that's straight talk, to the President...

Merrill Goozner has an amusing anecdote about a medical legend who got to give advice on health policy to President Bush, directly and publicly.


posted by Anthony Wright | Permalink | 2:51 AM


Health Care Musical Chairs in the Administration

Thursday, April 24, 2008
Big changes on health care in the Governor’s office: Ana Matasantos, legislative deputy extraordinaire and health reform maven, has moved on up – to be deputy director of Department of Finance. A big job given our BIG deficit, and we’re lucky to have someone who comes from and understands the health and public program world occupying that spot.

Filling the legislative position in the Governor's office will be Jennifer Kent, formerly of Department of Health Care Services, and most recently at Health and Human Services Agency. Jennifer was instrumental in drafting and negotiating the transparency/price and quality disclosure language in ABx1 1 (Nunez), which has since been dropped into AB 2967 (Lieber). Jennifer can be reached at Jennifer.Kent@gov.ca.gov.

The legislative position in the Governor’s office was formerly held by Richard “Fig” Figueroa, in a prior Administration, who is now staffing the Governor’s cabinet on health and human services.

Congrats to all.

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posted by Hanh Kim Quach | Permalink | 2:34 PM


Congressional Republicans join in to stop Bush Administration cuts

Wednesday, April 23, 2008
The House voted 349-62 today to extend the existing moratoria on Bush's Medicaid regulations that would have hurt low-income children and people with disabilities the hardest. (read more about the bad regs here and here.)

Besides the huge human impact state's would have lost LOTS of money -- like $50 billion in federal matching funds. California's share was $2.2 billion in the first year of implementation.

Given that we're facing our own budget crisis, let's thank California's members of Congress who continue to block these regulations. Here is the full roll call from today's vote.

VOTING YES: All the Democrats, and Republicans Brian Billbray, Mary Bono, Ken Calvert, David Dreier, Elton Gallegly, Duncan Hunter, Jerry Lewis, Dan Lungren, Kevin McCarthy, Gary Miller, Devin Nunes, George Radanovich, and Dana Rohrabacher.

VOTING NO: Out of 19 Republicans in California's Congressional delegation, only four voted no, which would allowed the Bush Administration cuts to go forward. Republican No votes were: Wally Herger, Darrell Issa, John Doolittle and Buck McKeon.

NOT VOTING: Republicans John Campbell and Ed Royce. Maxine Waters, a Democrat also did not vote.

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posted by Hanh Kim Quach | Permalink | 3:42 PM


From the World Health Care Congress...

Just wanted to spotlight some of the blog posts and reports from the World Health Care Congress, now at the World Health Care Blog.

Joe Paduda of Managed Care Matters has an excellent report, especially his commentary on the presentations by the presidential campaigns, as well as other panels. ChangeNow4Health also has notes from that panel. Notes are also taken by jenmccabegorman and ajfortin on Twitter.

With the Pennsylvania primary just past us, Richard Eskow at the Sentinel Effect has more opinion about the presidential plans.

Here's my basic gist: the Clinton and Obama plans are very similar, and very good. There's an important difference about the individual mandate, but it's one of emphasis, rather than actual implementation. But both plans are far from what McCain has put on the table, which simply isn't serious, and would actually do harm.

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posted by Anthony Wright | Permalink | 12:50 AM


Bigger budget blues...

Monday, April 21, 2008
This isn't like every other year.

That's the budget message: it's worse than normal, and basic state services like health, education, and public safety are at major risk without significant action.

The deficit projections have grown significantly in just the last couple of months, reports Matthew Yi of the San Francisco Chronicle. The article goes on to quote several legislative leaders, that suggest that it's nearly impossible to fix the problem with a "cuts only" budget--and such an approach would be devastating if tried.

Ed Mendel of the San Diego Union Tribune blog also quotes Senator Denise Ducheny, chair of the Senate Budget Committee, about how bad it is. She thinks that cuts are going to happen--and that new revenues are need just to prevent the most severe.

Clearly, the optimism is at a low point as we approach May Revise, when the Governor puts out the new version of the budget...

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posted by Anthony Wright | Permalink | 10:45 PM


On top of student loans...

Sunday, April 20, 2008
We are coming close to high school and college graduations, so it's a good time to spotlight this post by Henry Stern on InsureBlog on student insurance.

The young are the most likely to be uninsured, and what is offered to them isn't a very good value. The post spotlights a very typical student policy that will leave some students will have significant medical debt even before graduation.

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posted by Anthony Wright | Permalink | 2:38 PM


Quite Shocking, Really..

Friday, April 18, 2008
It was a bit of good news earlier in the week when the Assembly Budget Subcommittee on Health and Human Services took a stand, and rejected the proposal for quarterly status reports in Medi-Cal for children and adults. With all the other items--even though it was clear the legislators were personally opposed, concerned, and questioning of some very tought cuts, say, of Medicare Part B premiums for vulnerable "dual-eligible" seniors and people with disabilities--the committee largely left the items open.

It's standard for committee to leave the potential cuts on the table before May Revise, to keep options open until we know how much money comes in from the April 15 deadline. (Watch the money come in at Controller's John Chiang's website here.)

But they made a point by rejecting them outright, to indicate the severity of having hundreds of thousands of children and adults fall off the program. Now it's our turn to convince people to reject a cuts only budget that includes QSRs, Medi-Cal rate increases, etc.

On this subject, The California Endowment recently put out a new report, "Stability and Churning in Medi-Cal and Healthy Families," that indicates the insanity of QSRs. In looking at enrollment and retention patterns, the report finds:
    • Overall, approximately 50% of newly-enrolled children “survive” after 21
      months of enrollment in both Medi-Cal and Healthy Families;
    • The sharpest drop in enrollment is seen at the 12-month renewal point, especially for children in Healthy Families and those in the 1931(B) and children’s percent programs in Medi-Cal;
    • For children in other Medi-Cal – especially those who are also receiving food stamps or cash assistance -- the drop is more gradual over time. These families need to renew more frequently to maintain the other social supports and thus, stay in closer touch with county assistance agencies.
    • More frequent renewals will hit hardest children in the 1931(b) and percent programs of Medi-Cal. It is likely that half the children in these programs will be dropped at every renewal period.
    • These families are teetering on the brink of poverty, are likely to be affected by an economic downturn, and may need the support health coverage offers for their children.
    • Costs of medical care are substantially higher immediately after a gap. The longer the gap, the higher the cost afterwards.
    • In Medi-Cal, it is likely that costs saved in the short-term by reducing enrollment using Quarterly Status Reports will be offset by pent up needs later on (or transferred to the safety net in the shorter term).


posted by Anthony Wright | Permalink | 11:18 PM


If you like reading this blog...

Friday, April 18, 2008

* Project Manager, Organizers Wanted
* Also: Los Angeles Shared Office Space Available

Click Here for What's New on the Health Access WeBlog: Rescinding Rescissions: Patient Reinstatements Ordered by DMHC & Governor Outlines Potential Legislative Solution; New Big Five with Bass and Cogdill; Bush vs. Healthy San Francisco; Prescription Drug Costs

Health Access, California's statewide health care consumer advocacy coalition, is hiring. Please circulate these job opportunities to work for quality, affordable health care for all. Health Access has a 20-year history of successful advocacy in fighting health care budget cuts, winning consumer protections (against insurers who deny care, drug companies that price-gouge, or hospitals that overcharge), and advancing comprehensive health reform.

Please circulate this announcement and let us know who may be interested in joining this diverse, committed, and effective team.

Community Organizer:
Health Access seeks two experienced community and/or political organizers: a Northern California Regional Organizer based in our Oakland office, and a Southern California Regional Organizer based in our Los Angeles, office. Each organizer would manage Health Access activities such as coordinating regional coalitions, campaigns, actions, and events in support of our goal to defend and expand access to health care.

Project Coordinator:
Health Access seeks an experienced community and/or political organizer to serve as Project Coordinator responsible for coordinating the campaign activities of a statewide coalition of organizations working to acheive comprehensive health reform to expand access to quality, affordable health care for all Californians. This position may be based in either our Oakland or Los Angeles office.

For detailed job descriptions, visit our website at http://www.health-access.org/about/jobopps.htm

Health Access is a nonprofit organization dedicated to achieving quality, affordable health care for all Californians. We offer competitive salaries with excellent benefits including health, life, and disability insurance, 401k savings plan, and a fast-paced but casual work environment.

Promoting diversity is integral to the mission of Health Access. Health Access seeks applicants for all positions without regard to race, color, religion, national origin, ancestry, sex, age, sexual orientation, gender identity, marital status, veteran status, or physical or mental disability. Health Access embraces equality of opportunity and treatment for all employees in all employment matters.

Interested candidates should send a cover letter and resume with salary requirements referencing JOB TITLE position in the subject line to: jobs@health-access.org or 1127 11th Street, Suite 234, Sacramento, CA 95814

Shared office space available $425 - $725

Health Access is currently looking for another organization or individual to sublet a portion of our downtown Los Angeles office suite located at 1930 Wilshire Blvd.

The available space includes one private office (approx. 175 sq. ft.) and/or an additional office that can easily accommodate two individuals (approx. 300 sq. ft.), plus shared use of the reception/meeting area. The building has a secured parking lot with spaces available for an additional $60 per month.

Contact Rick Pavich at Health Access at 916-497-0923 ext 203 or by email at rpavich@health-access.org


posted by Anthony Wright | Permalink | 3:00 PM


More on rescissions

I wanted to follow up on Anthony's post with some more details about what Gov. Schwarzenegger's administration has laid out as his goals, this year, to tackle the rescission problem.

A quick recap: The state ordered the immediate reinstatement of health coverage for 26 enrollees who had their health policies retroactively cancelled in the past four years by Kaiser, Blue Cross or Blue Shield. Thousands more policies of consumers insured by the three named insurers, Health Net and Pacificare, could also be reinstated after review by an independent arbiter. These retroactive cancellations typically occured after a consumer started using lots of expensive health services -- triggering a second and very, very close look at their application by insurers.

As the system is now, said Daniel Zingale, one of the governor's health policy advisors, "If you use it, you lose it,'' of health coverage. To change this, the governor is supporting the following guidelines and principles to protect consumers:

1) A clear application process, which could help prevent mistakes and omissions
2) If there is no evidence of "willful misrepresentation,'' a policy cannot be rescinded
3) Plans must give adequate notice to consumers about the fact that they are investigating their applications. There would also be an established appeals process for consumers.
4) A prohibition on bonuses, quotas and other incentives for insurance company employees to rescind.

Of course, Zingale pointed out -- and we wholeheartedly agree -- this would all be moot had we passed ABx1 1. With health reform, we would have:
  • Guaranteed issue: everyone receives coverage, regardless of pre-existing conditions,
  • Guaranteed that everyone was paying into the system so insurers didn't go nuts about NOT being able exclude the really sick and expensive people,
  • And guaranteed affordable health coverage and/or subsidies to purchase health coverage for 4 million Californians.

In the absence of that, though, this is a great place to focus reforms that would begin to help consumers feel more secure about the coverage they have.

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posted by Hanh Kim Quach | Permalink | 1:18 PM


The Big Five on the Budget changes...

Assemblywoman Karen Bass will take the reins of the Assembly and assume the Speakership in mid-May, right at the time the budget negotiations get going with the unveiling of the Governor's May Revise. Those Big Five meetings will also include Sen. Dave Cogdill, representing the Senate Republicans, who takes over this week. Marty Omoto at the California Disability Community Action Network has the update at the California Progress Report.

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posted by Anthony Wright | Permalink | 10:25 AM


Rescinding rescissions...

Thursday, April 17, 2008
Earlier today, the Administration announced plans to allow for the reinstatement of all Californians who were rescinded for coverage in the past four years. This includes some immediate reinstatements, and an automatic process for those who can be identified to have their cases get a third party review, and have their care retroactively covered.

I was pleased to be at a press conference with Cindy Ehnes, Director of the Department of Managed Health Care, and Daniel Zingale, Senior Advisor to the Governor. There's more to be vigilant about, to make sure that these patients get the care as quickly as possible, and their financial issues settled expeditiously, but this is positive movement forward.

More details are coming, including in articles by Lisa Girion and Marc Lifsher in the Los Angeles Times, and Dorsey Griffith in the Sacramento Bee. The other part of the story, that seems to be getting less play but is crucially important, is that the Governor has put forward principles for a legislative solution moving forward, so that no innocent person is ever rescinded again. As supporters of bills in the legislature, like AB1945(De La Torre), that help do that by requiring independent third-party review for every rescission case, that's welcome as well.

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posted by Anthony Wright | Permalink | 5:14 PM


Bush vs. San Francisco...

As if San Francisco didn't need more bad press this week, the Bush Administration is weighing in against Healthy San Francisco in court today, reports Bob Egelko of the San Francisco Chronicle.

Here's some previous posts on the background of the Healthy San Francisco effort, including the legal ERISA challenge to the San Francisco program, to strike down the policy of getting employers to contribute to the health care of their workers.

There's a hearing today at the Ninth Circuit Court of Appeals. Given that effort around Healthy San Francisco came about in part because of federal inaction on health reform, it's disappointing that the White House couldn't stay out of it, and allow state and local groups to proceed with their own reforms.

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posted by Anthony Wright | Permalink | 8:03 AM


Drug cost-sharing and other wonkery...

Maggie Mahar and Niko Karvounis at Health Beat host this week's Health Wonk Review. In addition to a better-than-the-original summary of our post on ER overcrowding, the blog hightlights lots of good issues and posts.

There's lots of commentary (some compiled by Brass and Ivory) on the recent New York Times article by Gina Kolata (reprinted in the Sacramento Bee and elsewhere) about the astonishing co-payments and cost-sharing for a new "tier 4" class of prescription drugs.

Here's the Wonk summary and links on this issue:

"...many insurers are now insisting that patients suffering from diseases such as MS, Hepatitis C and some cancers pay a percentage of the cost of super-expensive drugs.

Normally patients are asked to pay a flat fee of $10, $20, or $30, depending on whether an insurer classifies a drug as tier 1, tier 2 or tier 3. But now patients are forced to pay 20 percent to over 30 percent of the cost of “tier 4” drugs that can cost $100,000 a year—or more. Emrich presents the full range of responses coming from MS Bloggers, Health Policy Wonks, and Medical Professionals.

While some think that “Patients have been shielded from costs far too long, subsequently leading to an entitlement mentality,” others sympathize with MS bloggers like Jeri who writes: “I am terrified about what will happen when this Fingolimod trial ends and I no longer get my medication for free. I strongly believe that the medicine is the reason for this long period of remission that I am enjoying, and the health care system is putting a price on that for me. I know it will be out of my reach once it has gone to market and I am forced to pay for it."

Meanwhile, at the Sentinel Effect, Richard Eskow quotes a surprising industry response from Robert Zirkelbach of America’s Health Insurance Plans: "When plan designs are no longer made to change behavior, but simply to transfer high-cost items back to the insured party, that’s risk transfer and not benefit design. As a result, the insurance concept is being subtly modified - and arguably undermined." [Note: this, from an interview by American Prospects’s Ezra Klein.]

Lisa ends by tipping her hat to Merrill Goozner of GoozNews, re-printing Goozner’s post on tier 4 in its entirety.

At Colorado Health Insurance Insider, blogger Louise offers her own very sharp take on tier 4 drugs, and offers her solution for keeping costs down without imposing an unfair burden on a smallgroup of very sick patients. Her concluding paragraph deserves to be reprinted in full: “Charging insured [patients] slightly higher prices for common drugs - the ones that are prescribed to millions of Americans - and not having to charge dramatically higher prices for the rarely prescribed, expensive drugs would be a better way of spreading the rising cost of prescriptions out over the whole population, instead of dumping it at the feet of those who are already battling against some of the nastiest illnesses around.” Amen to that.

Finally, for Health Beat's take on Tier 4, check out Maggie's last post, where she asks “Who Sets the Price at $100,000” and, does anyone happen to know, “Are These Drugs Effective?”

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posted by Anthony Wright | Permalink | 3:01 AM


Bills, bills, bills...

Wednesday, April 16th, 2008

* Bill fails that would license and regulate "discount" health cards
* Panel passes bill to allow local county-run health plans to expand, compete
* Roundup of bills: children's coverage, mandatory Medi-Cal managed care, benefits

Click Here for What's New on the Health Access WeBlog: Health Wonk Review: Drug Co-Payments and Tier 4; Are the Uninsured the Cause of Overcrowded ERs?

The Senate Health Committee heard nearly two dozen bills on Wednesday in the final hearing before Friday’s policy committee deadline to get bills to a fiscal committee. Following is a roundup of the fate of some of the bills of interest to health and consumer advocates:


SB 1603 (Calderon) would have directed the state Department of Managed Health Care to license and regulate so-called discount health cards, which promise consumers deep (though often unverified) discounts on medical services from a network of providers (also often unverified). Consumers purchase a list of discount providers at a cost of up to $120/month. The state is in the process of promulgating regulations to address these plans, but current state law bans them, even though some currently operate in California.

With bipartisan opposition from committee members, the bill failed in committee. Consumer advocates have long argued that discount medical cards claim "discounts" off a non-public price, rendering the only true value of the card unknown and/or meaningless. Additionally, surveys have shown that medical providers contacted are not even aware that they are included on many discount cards' list. Additionally, the plans often use misleading language to confuse consumers, and rely on the expectation that the consumer will not understand the difference between a discount health card and actual insurance coverage. Consumer advocates would need to see these issues resolved in order to support a regulation that would license these cards and give them the state's seal of approval.


SB 1622 (Simitian) would facilitate a statewide public insurer, connecting existing county-based health care plans to be able to offer a broader regional network of providers. This would provide a more options for existing enrollees, especially those who live in one county and work in another, and also allow these local initiatives to better compete with private health care plans. Using economies of scale, this publicly owned health plan would compete with private health plans and provide an affordable alternative for uninsured and small businesses that feel squeezed by insurance costs. This concept was part of ABx1 1 (Nunez), the omnibus health reform legislation that failed in this committee earlier this year. The bill passed.


SB 1593 (Alquist) passed, which stipulates that children currently covered by county health initiatives would be the first in line to receive Medi-Cal and Healthy Families coverage once those programs are expanded to cover children up to 300% of poverty ($52,800 for a family of three). Currently, only citizen children up to 250% of poverty are covered by the state. Many counties now pick up the population between 250% and 300% of poverty. This measure complements two bills sponsored by the 100% Campaign – SB 32 (Steinberg) and AB 1 (Laird/Dymally) -- that would expand state children's coverage.

SB 1459 (Yee) passed, but with conditions for significant amendments, given the grilling by committee members, and their statements of concern and opposition about elements of the bill. The bill would consolidate both the Healthy Families and Medi-Cal programs under one name “Cal-Health’’ and sought to expand insurance for some children and some adults. Some advocates supported the stated intent to streamline enrollment and extend coverage, but many also raised concerns and/or opposition, with regard to the structure and specific provisions. These included issues about whether it included coverage all or just some children, the proposal's relationship with current child expansion strategies, the interaction with already-passed streamlining efforts, and whether, as written, the proposal would privatize county eligibility workers, divert funding from public providers to private plans, and be a threat to public hospitals.

MANAGED CARE: Another bill that got significant discussion was SB 1332 (Negrete-McLeod), which sets up a a pilot that would mandate that seniors, and people with disabilities in San Bernardino and Riverside counties be required to enroll in Medi-Cal managed care plans. While it passed despite opposition from consumer, low-income, and labor advocates, the chair, Senator Kuehl, admonished the author to address their concerns, about the potential impact of the mandatory enrollment on these vulnerable populations, and the overall safety-net.

BENEFITS: A number of bills dealt with mandated benefits for consumers in insurance plans. Two bills that would guarantee additional benefits passed. One bill that took away benefits failed.

* SB 1198 (Kuehl) would require health plans to offer coverage for durable medical equipment, such as wheelchairs, bath seats and crutches, at the same levels applied to other benefits. Passed on a bipartisan vote.

* SB 1634 (Steinberg) would require the coverage orthodontic services for cleft palate. Passed on a bipartisan vote.

* SB 1669 (McClintock) would have allowed insurance companies to exclude coverage of conditions for which an individual policyholder has received medical advice, a diagnosis, treatment, of prescription drugs at any point in the previous 10 years. Failed with Republicans voting in support and Democrats voting in opposition.

OVERSIGHT: SB 1525 (Kuehl) would require the state to review how health plans decide what services are “medically necessary’’ and should be paid for, and which are not. Passed on a bipartisan vote.

Bills, votes, and analyses are available at the website of the California legislature, at:

A broader list of pending bills of interest to health and consumer advocates is updated and available at the Health Access website, at:

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

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posted by Anthony Wright | Permalink | 2:54 AM


Find the solutions, not blaming the victim...

Tuesday, April 15, 2008
"Don't Blame Crowded ERs on the Uninsured" is the pitch-perfect headline of an article by Suzanne Bohan in the San Mateo County Times and other papers.

The articles reports on a UC-San Francisco study that reports that asks "Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?" and answers "no." In fact, the "proportion of adult ED visits by persons without insurance was stable across the decade," roughly in the 14-15% range.

Despite the belief that the uninsured are the majority of those crowded in our emergency rooms, I note that this figure is a bit lower than the overall percentage of uninsured people in the country, which is around 16%.

This is consistent with other findings, such as a 2004 Urban Institute report by researchers Zuckerman and Shen on ocassional and frequent ER users. That paper concludes, in part, "The uninsured and the privately insured adults have the same risk of being frequent users... It seems hard to blame the overcrowding of EDs on the uninsured."

MISSING THE MESSAGE: Some conservative commentators will use this research to attack the notion that of a "hidden tax" that we all pay in our premiums for having such a large uninsured population, and to attack the notion of health reforms and coverage expansion generally. I get a very different lesson from the study.

I too have been a skeptic of the Governor Schwarzenegger's "hidden tax" rhetoric, because it led people to blame the uninsured for high health costs, rather than the reverse.

If the uninsured go to the emergency room, they have only a right to be stabilized. But even then, they get a bill--typically the biggest bill they will see in their lives, and often one that is inflated well above what an insurer would pay for the same service. No wonder they may actually go to the ER less.

LOTS OF FACTORS: That said, there's nothing inconsistent with saying that the uninsured, when they finally do go to get care, are in a worse condition since they let their conditions linger and mestatisize, costing the health system more money in the long run. Or that the uninsured get the bill, but some face bankruptcy not being able to pay, and as a result leave the hospital unpaid.

In other words, I think the real world in health care is more complicated than one cause. Some uninsured get the care they need. Others go without and simply die. And in between, some uninsured wait until the problem gets worse. And some of these factors end up costing the health system. So reforming health and increasing coverage is needed and urgent, even for the regular, insured California.

SOLUTIONS: So how much is the "hidden tax?" I don't know, but it's real. But I think the focus should be on fixing the system, not the victims of that system:

* We all pay when McDonald's, Wal-Mart, or Applebee's don't, when some employers don't pay their fair share. Those who are uninsured are those who fall through our health system that relies on voluntary employer contributions.

* We should ensure that those who are uninsured are not overcharged and thus discouraged from getting needed care. California passed a fair hospital pricing law in 2006, and other protections would be helpful.

* We who are *insured* would not go to the emergency room as much if we had the ability to get timely access to care to primary care and specialists. There's pending regulations for insurers and providers at the California Department of Managed Health Care.

Our health care system doesn't have just one problem, and doesn't have just one solution. The new research helps us understand that.

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posted by Anthony Wright | Permalink | 10:45 PM


Assembling a benefit package...

Tuesday, April 15th, 2008

* Bills fill out benefits on some bare bones plans
* Legislation passes to improve safety, protect consumers

Click Here for What's New on the Health Access WeBlog: Are the Uninsured the Cause of Overcrowded ERs?; Discount Health Plans; Etc.

With deadlines fast approaching, the Assembly Health Committee on Tuesday tore through and passed nearly three dozen bills, including many that would improve the benefits provided in bare bones, high deductible health plans.

A broad and constantly-updated list of bills of interest to health advocates is available at the Health Access website, at:

The bills considered Tuesday with the broadest reach were:
* AB 1887 (Beall), which would provide coverage for all mental illness – not just the most serious.
* AB 1962 (De La Torre), which would require all plans cover maternity services.

For these and other bills that would require certain benefits as part of coverage, the biggest impact would be felt in the individual market, where premiums are expensive, but benefits are skimpy. The trend is especially acute for maternity coverage, where the California Health Benefits Review Board reports that the number of Californians without maternity benefits has tripled from 192,000 in 2004 to 600,800 today.

For Assemblyman Hector De La Torre, the issue was fairness, and of "spreading the risk." He countered the opposition of some of the health plans, who stated that the bill would eliminate lower priced premium products from the market. “It’s a false choice’’ that is being given to consumers, he said. “It’s not really a choice when all of the options are equally bad. Women are forced to choose between a product they can afford, without the coverage they need. Or a product they can’t afford, with maternity coverage.’’

Other bills of interest to consumers that passed committee Tuesday included:

* AB 3027 (De Leon) requiring health plans to translate materials into threshold languages.
* AB 2400 (Price) requiring public notice before closing a hospital.
* AB 2146 (Feuer) which bans billing when a hospital or physician has made a preventable, “never mistake,’’ such as operating on the wrong arm, or wrong person.
* AB 2220 (Jones) would require providers and health plans to go to binding "baseball" arbitration when they can’t agree on payment for services provided to a consumer, rather than having providers bill consumers directly.

The Senate Health Committee meets Wednesday to consider another passel of bills. Health Access will keep advocates abreast of committee actions.

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

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posted by Anthony Wright | Permalink | 8:00 PM


An Action Against Administrative Hassle...

Monday, April 14th, 2008

* Assembly Subcommittee on Health reviews DMHC, CMAC, Healthy Families, QSRs
* Quarterly Status Reports could result in over 400,000 kicked off Medi-Cal
* Administrative costs and "churning" negates proposed savings
* Other budget items left open: increased premiums and costs, etc.

Click Here for What's New on the Health Access WeBlog: Junk Insurance; Strange Alliances on Transparency; Consumer Reporting; Committee Humor; What Happens in Health Care; More on QSRs; Fake "Discount Cards"

The Assembly Budget Subcommittee on Health and Human Services, chaired by Assemblywoman Patty Berg, rejected Gov. Arnold Schwarzenegger’s proposal to require Medi-Cal recipients to submit paperwork every three months in order to keep their coverage.

This year, California is grappling with a $14.5 billion budget deficit. Schwarzenegger has ordered a 10 percent across-the-board cut. Altogether, Medi-Cal would have been reduced by $1.1 billion through 2008-09. Due to a decline in enrollment caused by the paperwork burden, these Quarterly Status Reports are estimated to potentially save the state $92.2 million, but also would cause the state to lose an equivalent amount in federal matching dollars.

While the subcommittee left many items open, the subcommittee's rejection of QSRs was a important signal as negotiations start on budget issues. However, the cut is still officially pending in the Senate. Also, no action, either a cut or the resinstatement of a cut, is final until a full budget is passed and signed into law.


Health experts and advocates argue that Quarterly Status Reports are a way for the state to reduce the number of people enrolled in Medi-Cal, without having to throw them off directly.

If recipients fail to turn in a form that reports changes to their income, health coverage, living situation, property, disability or pregnancy status, then they would be disqualified from coverage. Currently, children need to update this information annually, while adults update the information every six months. The state expects, in the first year, that about 150,000 children will lose coverage at some point, and 14,000 adults. Eventually, 472,000 children are estimated to eventually lose coverage.

The committee voted 4-2 on a party line, with the Democratic majority voting to reject the cut.

“It’s not something we’d like to do…’’ said Toby Douglas of the state Department of Health Care Services, given the Administration's other proposals for continuous eligibility. But he argued that quarterly status reports – compared with reduced benefits or payments -- are a preferable, “simple approach’’ to helping balance the budget. The state reported that constant reporting uncovers some people who are receiving benefits, who are no longer eligible.

Assemblyman Ed Hernandez countered: “What about the individuals who are eligible? I have a concern that there are more individuals who should be getting Medi-Cal, but aren’t getting it.’’ Douglas responded that the state does send a reminder and does not disenroll recipients until 30 days after they do not return the form. Additionally, “If they have a serious problem, they go to the Emergency Room, where they are re-enrolled,’’ Douglas said. Reponded Hernandez: “That’s not very efficient.”

Assemblymember Beall also took a similar line of questions, asking whether QSRs would have a positive or negative impact on children's health.

QSRs SAVINGS CHALLENGED: Any savings from reduced Medi-Cal enrollees would be easily negated by the extra time, effort and dollars required to not just impose the paperwork, but to re-enroll these same recipients who have to come back on to get services, advocates argued. The County Welfare Directors’ Association shared a study that shows that more than 65% of those disenrolled were back on Medi-Cal within three months at a cost of about $200 per head to process paper.

That cost does not include higher health care costs accrued because the patients were “uninsured’’ when they sought medical attention, or delayed seeking care and exacerbating their health problems because they did not have insurance. “I see this as a reduction to counties because the state is not going to add additional dollars to handle this,’’ said subcommittee chair Patty Berg.


The subcommittee also:
* Approved two limited-term positions at the Department of Managed Health Care to review health plan filings
* Cut $244,000 from the California Medical Assistance Commission. Staffing would remain the same.


Centralized Eligibility Determinations: As a potential alternative cut, the Legislative Analysts’ Office suggested that some Medi-Cal determinations should be done at the state – rather than county – level, use a “single point of entry’’ process parallel to what is used for Healthy Families, saving $75 million. CWDA, however, explained how Medi-Cal with 125 aid codes is far more complicated than Healthy Families. Additionally, this would make it more difficult for recipients to contact workers helping them with applications at the local level, and take the process out of county hands and hand it to a private vendor.

Medicare Part B Premiums: Under the Governor’s proposal, low-income seniors (above 129% of poverty -- $13,416 annually) who qualify for both Medicare and Medi-Cal would have to pay their own Medicare Part B premium if they do not meet the monthly share of cost – approximately $500. That means nearly 48,000 seniors, living on about $1,100 a month would now have to dedicate about $100 toward premiums for Medicare physician coverage, a cost now covered by the state of California.

Healthy Families: The Legislative Analysts’ Office suggested the state delay the implementation of SB437 (passed in 2006), which would streamline eligibility and enrollment of children in the program. The state said the program had already been delayed and wanted to begin implementation.

Health Plans in Healthy Families: Health plans opposed a five percent reduction in plan rates. The administration, which has been negotiating rates, has been told the plans have threatened to change or restrict provider networks, or reduce dental care as a result of the rate cuts. Assemblyman Jim Beall prodded and revealed that plans received a 4 percent rate increase in the last fiscal year.

As with many budget items to be heard in the coming weeks, many issues remain unresolved until the governor unveils his May Revision, which will contain a truer picture of the state’s fiscal situation.

Health Access will continue to keep advocates abreast of budget actions. For more information, contact the author of this report, Hanh Kim Quach, policy coordinator at Health Access, at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 2:17 AM


Fake Plans

Monday, April 14, 2008
One of the bills Health Access is watching that's up in Senate Health Committee this week is SB1603 (Calderon), which would authorize the state to license and regulate so-called discount health cards.

We question the very existence of these things. Not only do they annoyingly clog up the fax machine (you've seen those strange health "insurance'' offers), but they rely on consumer naivete to make money.

Their sin is that they're incredibly deceptive and provide questionable -- if any -- value to consumers. Discount health plans entice consumers with words like "no pre-authorization,'' "no pre-existing condition denial,'' and "no waiting period." They exaggerate their value, promising low prices -- discounts of as much as 80% -- at a vast "network'' of providers.

But often, neither is true. Consumers have no idea what the price for which the "discount'' is based on, rendering the discounts essentially meaningless -- and often, they could have received the discount anyway if they told the provider they were uninsured.

Mila Kofman, health policy expert formerly of Georgetown University, also tested out some cards and found that nearly three-quarters of providers contacted did not even realize they were part of the "provider'' network. Complaints filed against these cards in California show a similar patern.

Kofman's research also finds that the monthly cost for the identical card can range from $54.95 to $120 because of the pyramid-esque marketing for these products. Cancelling the cards can also be tricky, as many continue to charge a former subscriber's credit card even after they consumer quit the service.

Sadly, SB1603 would create a way to allow these fake plans to operate legally and continue to bilk consumers.


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posted by Hanh Kim Quach | Permalink | 10:27 AM


Even worse?

Sunday, April 13, 2008
The Assembly Budget Subcommittee on Health and Human Services will be hearing some Medi-Cal issues on Monday at 4:00pm.

On the agenda are the proposals for quarterly status reports and other changes that would make it harder for children and adults to get on and stay on Medi-Cal coverage. As experts delve into the proposals, they are revealed to be more and more pernicious.

The official estimates of the decrease in child enrollment in Medi-Cal was under 150,000, but the cumulative impact is now understood to be much greater. Hopefully the Subcommittee will go into this at greater length.


posted by Anthony Wright | Permalink | 2:42 PM


Only in LA?

Friday, April 11, 2008
For those who were not able to witness Senate Health Committee in person, this week, it's not always as boring as you might think.

Committee Chair Sheila Kuehl and Sen. Dave Cox had an interesting exchange during testimony of our bill SB1522, which would help organize the individual insurance market and place caps on out-of-pocket costs. Most importantly, it would help weed out junk coverage and require at least mimimum coverage of doctor's office visits and preventive care.

Kuehl shared a story of a caller on a radio show who had ambulance workers lay a bill on her chest as she was being wheeled into the hospital emergency room.

"Surely,'' snorted Sen. Dave Cox, R-Fair Oaks, "they would do no such thing.''

Responded Kuehl: "Yes, Sen. Cox. And a hospital in LA would surely not dump patients on Skid row in the middle of the night.''

"Well...'' grunted Cox. "Maybe in Los Angeles.''

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posted by Hanh Kim Quach | Permalink | 2:12 PM


Consumer reporting on health care...

Thursday, April 10, 2008
Another moment during the debate on the transparency bill, AB2967(Lieber) was when Assemblymember Ted Gaines questioned a key supporter of the bill, Laurie Sobel from Consumers Union, and asked "isn't this something that you should be doing?"

It's not a uncommon question for those who work at Consumers Union, publisher of Consumer Reports magazine--one of the one of the most read magazines in the country, and one of the most trusted. I've been proud to work alongside them in different roles in my decade-and-a-half of consumer advocacy.

Laurie had an answer: she thanked the Assemblymember for the confidence, but that as much as Consumer Reports would be happy to provide the same kind of evaluation of doctors and hospitals as they do for cars and ceiling fans, with the trademark circles, there's a limit to what they can do without this bill in place.

Most tellingly, no independent group can mandate reporting of doctors and hospitals, and it's hard to provide a meaningful and complete report with the largely voluntary reporting systems we have now. This is a governmental function. There might be a role for CU or other advocates in analyzing the data, but we need the government to collect it and appropriately categorize it.

There's often been several times in just the last few years when policymakers who oppose legislation to set consumer standards or provide more consumer information will say on the floor of the Assembly that this should be the role of Consumer Reports, not government. Yet these same policymakers never seem to follow the position of the actual publisher of Consumer Reports.

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posted by Anthony Wright | Permalink | 11:05 PM


Transparent motives...

One of the surreal moments of the week was when lobbyist Beth Capell, in testifying in support of a bill, representing her clients Health Access California and SEIU, ceded half her time to... the NFIB.

The NFIB made it's name opposing the Clinton health plan in the early 1990s. Perhaps it's a sign of the times. The bill was AB2967 (Lieber), to allow for better transparency of cost and quality from health care providers. It's disappointing, although perhaps not surprising, that doctor and hospital associations opposed more reporting on themselves.

What was new and interesting was the unique coalition in support. That included consumer groups, like Consumers Union, AARP, Health Access, and CALPIRG; many labor unions including the California Labor Federation, SEIU, AFSCME, CTA, and yes, key employer groups, with Pacific Business Group on Health, Small Business Majority, and the NFIB.

It's makes sense that purchasers of health care--whether individuals, employers, or union trusts--would want better information on what they are buying. But these alliances are less frequent than that common interest would suggest.

It's a sign that the unique alliances around health reform last year were not a fluke, and not dependent on the Governor's urging. So let's see if this goodwill continues.

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posted by Anthony Wright | Permalink | 10:18 PM


Making Insurance Matter More...

Wednesday, April 09, 2008
Thursday, April 10th, 2008

* SB1522 (Steinberg) would set standards for coverage, weed out "junk" insurance
* SB1440 (Kuehl) would require a minimum percentage of premium dollars for patient care
* Health reforms geared to improve the value of coverage, while not costing state money

Click Here for What's New on the Health Access WeBlog: More Quotes and Comments from the Health Policy Committee Hearings; More Coming on the Budget Battles Ahead...

Two bills that would begin to tame the state’s "wild, wild west" health insurance market passed the first policy committee on Wednesday, maintaining the forward momentum of health reform discussions.

SB1522 (Steinberg) would organize the individual insurance market to enable apples-to-apples comparison shopping for consumers, and also weed out junk coverage by requiring that plans met minimum standards to cover doctors visits, hospital and preventive services. The bill would also ask state regulators to set overall limits on out-of-pocket costs.

SB1440 (Kuehl) would require plans to spend at least 85 percent of premium dollars on health expenses – rather than administration and profit.

Other bills of note coming up in the next few weeks are described at the Health Access California website, at:


SB1522(Steinberg), sponsored by Health Access California, would categorize all plans offered in the individual market. It would create five tiers of coverage with different standards that would need to be met in each tier. That way, consumers would have a better sense of which plan are more comprehensive, and which are less so.

Currently, consumers searching for a health plan on their own must sort through a confusing array of at least 100 plans on the market with different premium prices, deductibles, covered services, and copays--and since none of these plans are exactly the same, it is now hard to make these comparisons. And by requiring the plans to offer "benchmark" plans, the bill would allow for apples-to-apples comparisons between plans, and thus encourage direct competition based on price and quality.

Finally, the bill would set a minimum standard for coverage, so people have a better sense of security that when they have coverage. The bill states that the the lowest tier plans would cover physician visits, hospitalization, and preventive care.

All these concepts was part of AB x1 1 (Nunez), the comprehensive health reform bill supported by Gov. Arnold Schwarzenegger. The bill got votes from the Democrats on the committee, and was opposed by the Republican members. The bill also sets a foundation for further efforts. “I am carrying this bill as an important component of what will hopefully be comprehensive health reform at some point,’’ Steinberg said.

One testifier, Susan Braig, a self-employed Blue Cross policy holder in Altadena, told committee members how she bought her Basic PPO 1000 plan seven years ago, knowing that it was “catastrophic’’ hospital-only coverage that carried a $1,000 deductible, $3,500 maximum out of pocket. She knew it would not cover her doctor’s visits, nor would it cover prescription drugs, but she bargained that she would be able to afford the “small stuff’’ and that her plan would cover any “catastrophic’’ illnesses.

Shortly afterward, she was diagnosed with breast cancer. None of her doctors visits, labs, MRIs, prescription drugs were covered. Neither was chemotherapy, which was not covered as it was considered a “doctor’s visit’’ unless she went an hour away to a hospital to receive the treatment. While Blue Cross did pay a portion of a lumpectomy and radiation, Braig is still more than $40,000 in debt due to her illiness and medical expenses and will continue to rack up debt for years to come as she continues to pay out-of-pocket for cancer follow-up treatments. She is stuck with her Blue Cross plan because no other insurance company will take her now due to her cancer as a pre-existing conditions. She pays premiums, and over $6,000 a year in out-of-pocket costs a year, yet her insurance isn't covering any of it. “I’m paying insurance premiums for what?’’ she asked.

OPPOSITION: Health plans opposed the legislation, saying that any requirements to cover health care would cost money and increase premiums. They also opposed SB1522 on grounds that it would take “lower costs options off the market’’ and reduce “product flexibility.’’

SUPPORT: Beth Capell for Health Access conceded there is “price sensitivity, but there is a balance to both price and benefits." Additionally, hospital-only coverage functionally leaves a consumer paying to be uninsured, as most services – as in Braig’s case – are left uncovered. For example, about 70 percent of surgical procedures are outpatient. “We run into these cases and people obligated for hundreds of thousands of dollars when they believe they have purchased insurance.’’

Other organizations testifying in support included Western Center on Law and Poverty, CalPIRG, AARP, Jericho for Justice, MALDEF, California Medical Association, ACORN, CARA, Congress of California Seniors, and AFSCME.


SB1440 (Kuehl) is also a bill that places oversight on insurers, that would assure that consumers received more value for their premium dollar requiring health insurers to devote at least 85% of what consumers pay to patient care, rather than administration, marketing, and profit. While HMOs are already required to approximate this standard, PPOs are not. Some spend as little as 51 cents of every dollar on patient care, spending nearly half on overhead and profit. The bill to set a "medical loss ratio" passed with Democrat votes.

Some of the overhead dollars are used to keep consumers from benefiting from coverage they buy. A February 2007 article in the Wall Street Journal described how insurers and health providers combined spent approximately $20 billion annually in administrative costs fighting each other on claims expenses. Administrative overhead also includes the employees hired to scrutinize applications for justification to cancel coverage, or deny other consumers a policy altogether.

OPPOSITION: Insurers opposed Kuehl’s bill, saying it would eliminate low-cost products (which ironically have higher “overhead’’ costs), and complained that they were being picked on compared with other health industries that also had high overhead costs. Insurers also argued that SB1440 would discourage competition to keep premiums low.

Kuehl responded, “Then I guess we don’t have (a competitive market) now,’’ reminding the audience of double digit increases over many of the past 15 years. “We must be thinking of emulating the oil companies, because we’re competing to see how fast we can raise prices.’’

SUPPORT: Supporters included the California Medical Association, Congress of California Seniors, Jericho for Justice, AARP, CARA, California Academy of Family Physicians, California Labor Federation, and Health Access California.

The deadline for legislation to pass out of policy committees is April 18th. A number of bills of interest to health consumers will be coming up the next two weeks.

Health Access will update advocates at each turn. For more information on any of these bills, contact the author of this report, Hanh Kim Quach, policy coordinator, at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 11:42 PM


Chaps my hide

It's really really annoying to me when people who talk about the "affordabilty'' of insurance only fixate on the premium prices.

And it's especially offensive when we have a person travel from Los Angeles to Sacramento to testify about junk insurance plans -- after having incurred $40,000 costs -- be told that "at least you had insurance.''

As part of an illustration for why we need SB1522 (Steinberg) to organize the individual health insurance market and weed out junk insurance plans, we brought up someone who actually had one of these hospital-only junk insurance plans -- Susan Braig, a former art teacher.

Susan was a conscientious consumer with a modest income. Approaching age 50, she decided she needed to get health insurance after having dropped it briefly in the late-90s during the huge run-up in premium prices. After carefully researching the balance of premium and benefits, she selected the coverage she could afford -- hospital-only, catastrophic coverage through Blue Cross -- the Basic PPO 1000. This has a $1,000 deductible with a $3,500 maximum out-of-pocket, and did not cover doctors visits. After the deductible, 80% of big-ticket services (like surgeries, hospitalizations, etc.) would be covered.

But, Susan rationalized, as many in her predicament might, that she's healthy, never used her insurance before, and could afford the doctor's visits here and there, but that $3,500 was a modest amount to pay if a catastrophic illness befell her.

Well -- shortly after purchasing the policy, she was diagnosed with breast cancer -- and over two years, her credit card debt increased from $5,000 to $45,000.

None of the series of doctors visits, prescription drugs, ultrasounds and lab tests were -- or will be -- covered by Basic PPO 1000. What's worse, it also did NOT count toward her deductible $1,000 deductible.
"Even my chemotherapy treatments were considered "doctor visits'' unless I had the identical treatments an hour from home in a hospital.''

Functionally, Susan is uninsured. This experience has left Susan wondering -- "I'm paying insurance premiums for WHAT?''

So it continues to gall me that the industry makes arguments that the "cost'' of insurance will go up if we weed out plans like Susan's. Up from what? Isn't $40,000 over two years enough already?

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posted by Hanh Kim Quach | Permalink | 4:33 PM


A Busy Day for Bills....

Wednesday, April 8th, 2008

* Insurers would face restrictions in cancelling coverage retroactively
* Patients would be better able to assess hospital cost and quality data
* Other bills on hospital community benefits, boutique hospitals, and others

Click Here for What's New on the Health Access WeBlog: Balancing the Budget; Re-Examining Hillary-Care; Balance Billing; Dennis Quaid and Medical Mistakes; Prescription Drug Gifts to Doctors; PHRMA's Revenge; Coverage Matters; Deaths Due to Uninsurance; The Health Wonk Review Spotlight; The Individual Market; Nuggets from the Medi-Cal Cuts Hearings.

The Assembly Health Committee on Tuesday approved a smattering of bills that would begin to set the foundation for health care reform, providing security to health consumers – both for their coverage and choice of provider.

Two of the bills deal with the insurer practice of retroactively canceling policies after patients become sick and need expensive treatments. These rescissions leave patients tens of thousands – if not hundreds of thousands in debt. Another bill would require medical providers to disclose cost and quality information in order to give purchasers more power in selecting the highest quality and most efficient care.


* AB1945 (De La Torre) would create an independent panel to review cases where an insurance company wishes to rescind a policy. The bill passed on a bipartisan 11-0 votes, with Republicans Alan Nakanishi and Bill Emmerson voting for the bill. In addition to an independent panel, and review by regulators for rescissions, AB1945 would establish a standardized application for consumers to fill out. De La Torre cited recent investigations by state regulators, which found violations in every single instance.“That’s not an accident,’’ he said. Insurers, he said, should not be permitted to “act as judge and jury whenever they want to rescind a policy.’’

SUPPORT: California Medical Association, Health Access, California Alliance for Retired Americans, AARP, Congress of California Seniors, CalPIRG, Consumers Union, California Teachers’ Association, California Academy of Family Physicians and Consumer Federation of California spoke in support of the bill.

INDUSTRY: Industry associations were not completely opposed to the bill, but were concerned about whether the application would give insurers enough information about a potential enrollees condition so that “they can do reasonable underwriting up front,’’ said Charles Bacchi, for the California Association of Health Plans. That means the industry wants to be able to deny for pre-existing conditions, and the questions need to elicit enough detail to do that. Others had concerns about the need for regulator approval of rescissions, and the authority given to the state to revoke the licenses of health plans. Blue Cross of California opposed the measure.

* AB2549 (Hayashi) is a related measure would limit health plans ability to cancel coverage because of a fraudulent application to six months after the application is approved. The bill passed on a party line vote, with Republicans either abstaining or opposing. The industry opined that the six-month period was too short. Current industry practice allows a period of two years for insurers to rescind because an expensive claim may not occur within the first six months – usually the trigger to review an enrollees application.

SUPPORT: Health Access, California Teachers Association, Congress of California Seniros, AARP, California Medical Association, California Academy of Family Physicians, AFSCME, California Psychological Association and Having Our Say!

OPPOSITION: Association of California Life and Health Insurance Companies, California Association of Health Plans, California Association of Health Underwriters.


Another important bill passed by Assembly Health Committee on Tuesday would require medical providers to publicly disclose price and safety information.

* AB2697 (Lieber) would create an independent panel, which would include hospitals, doctors, consumer and labor representatives to recommend a plan that would be continuously updated. The data collected would be scientifically based, consider where providers practiced (urban, rural, affluent or poor communities) and risk adjusted – to account for the fact that some physicians/hospitals would attract higher risk patients. This bill passed 11-5 on a party line vote, with Republicans opposing in spite of small business support.

SUPPORT: Along with a usual cast of consumer groups, the National Federation of Independent Businesses, Pacific Business Group on Health and Small Business California supported the measure. “We all know the challenges small businesses face. A system of comparable statistics is important to helping rectify the situation,’’ said Michael Shaw, with NFIB. Other supporters included Health Access, SEIU, AARP, CalPIRG, California Labor Federation, Consumers Union, Congress of California Seniors, Having Our Say among many others.

OPPOSE: The California Medical Association opposed saying that the state should work on the existing program, rather than create a new expensive one funded by providers. The hospitals also opposed the measure.


The following bills also passed in Assembly Health Committee on Tuesday. For a broader list of interest to health advocates and Health Access California, visit our website, at:

* AB2942 (Ma) would require all hospitals to develop and publicly a community benefit plan, just as non-profit hospitals are currently required to. The plans would need to consider and report what the community needs and levels of charity and discount care. The bill passed 11-3.

* AB2697 (Huffman) requires “boutique hospitals,’’ which tend to serve more affluent patients to assess its impact on the community health system, and whether it siphons dollars and workers from providers and hospitals that take care of sicker or less affluent populations. This bill passed 12-5.

In addition to these and other bills heard this past Tuesday, another bill, SB1633 (Kuehl), passed Senate Business and Professions Committee on Monday. SB1633 addresses the issue of credit cards for dental services. These are offered in dentists offices with little explanation to the patient of their course of treatment or the terms, and interest rates on the cards. Patients are often charged the full amount of services, even before they are rendered and some are asked to sign for the credit line while under the influence of anesthesia. This bill passed with a unanimous vote.

Bills need to pass policy committees by April 18. Health Access will continue to provide updates on actions taken in the Legislature. For more information, contact the author of this report, Hanh Kim Quach, at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 2:14 AM


They say the darndest things...

Tuesday, April 08, 2008
Assemblyman Ted Gaines today said he was concerned that insurers did not like a bill -- AB1945 (De La Torre) -- that would restrict their ability to profit, i mean, prevent insurers from retroactively canceling patients' policies.

“I’m concerned about the insurance industry and want to make sure they’re on board. …I just want to make sure it works from both ends of the spectrum,'' Gaines said.

I'd like to see Assemblyman Gaines mediate that discussion.

On one end is the consumer, who wants reliable health coverage that they're not afraid to use for fear that it might get canceled.

On the other end is the insurer, who, on the one hand, does not want standardized applications to be too long (and inconvenience the consumer) but does not want the applications to be too vague, either, "so that they (insurers can) do reasonable underwriting up front.'' (That means they want to be able to deny you for pre-existing conditions -- that saves them the later step of retroactively canceling coverage.)

Middle ground?

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posted by Hanh Kim Quach | Permalink | 10:51 PM


They are hearing lots of opposition to the cuts...

Tuesday, April 8th, 2008


* Quarterly Status Reports: hundreds of thousands to ultimately lose coverage
* Proposal to eliminate adult dental care could increase ER use, hurt clinics
* Children on Healthy Families would also face cuts

* Click Here for What's New on the Health Access WeBlog, Updated Daily
* Upcoming: Bill Hearings This Week on Rescissions, Transparency, Individual Market Reform

At a public hearing Monday, the Senate Budget Subcommittee, which oversees state public programs, postponed decisions on a number of Gov. Arnold Schwarzenegger’s proposed cuts to the Medi-Cal and Healthy Families Program. The two programs, along with all state departments, are under pressure to cut 10 percent across-the-board in an effort to close the state’s $14 billion shortfall. The two programs provide coverage to nearly 7 million Californians – nearly 20% of the state.

Monday’s hearing was part of the normal budgeting process for the 2008-09 fiscal year, which begins July 1. Lawmakers prefer to delay decisions on major items until after the governor releases his May revision of the budget, which reflects the latest number on income taxes to the state. The Legislature and Governor have already approved a $1 billion mid-year emergency cuts package in February, which included a 10% rate reduction ($544 million reduction) to Medi-Cal providers.

As lawmakers heard testimony for proposals that raised premiums for the poorest residents in the state and capped their coverages, Sen. Alex Padilla commented on the bad timing and irony: “In tougher economic times, the demand for services and workload goes up and here we are debating cuts to services.’’


By far, the biggest ticket items considered by lawmakers was the reinstatement of quarterly status reports for both children and adults on Medi-Cal and the elimination of adult dental benefits from Medi-Cal.

Quarterly Status Reports: The savings behind the increased administrative burden of quarterly status reports (which require recipients to verify income every three months, rather than one year or six months) is that recipients would not return paperwork in time and fall off the rolls, in spite of being eligible. State officials said tactic would save $83.5 million. The cuts would also cause the state to lose an equal amount in federal matching funds.

The state has estimated that approximately 150,000 children and about 14,000 adults would lose coverage through this tactic, though children’s advocates say that twice as many children--nearly 300,000--would lose coverage over a two-year period, when taking into account the cumulative impact.

Advocates also questioned whether that savings could actually be realized given that the it would end up costing more person-hours to reprocess and re-enroll Medi-Cal recipients who fell off and re-applied for coverage.

Dr. Gerry Fairbrother, who has studied the costs of Medi-Cal churning, reported a cost of about $122 per child in paper-pushing costs, on top of higher medical costs that the state would incur because of medical delays that were made more serious. Her estimates are from 2005.

“Quarterly status reports cause eligible children to disenroll. The costs are higher when they come back on and it increases the administrative burden,’’ she said. Others estimated the administrative costs at higher than $200 per person, and did not include an additional $40 to re-enroll people in a managed care plan.

The County Welfare Director’s Association also reviewed statistics on adult disenrollment and found that 70% (and growing) of those disenrolled were re-enrolled in the first year. And 90% of that population that was re-enrolled did so within the first 90 days.

The remaining 30% that did not re-enroll were likely those who had moved or had become not eligible for Medi-Cal, said director Stan Rosenstein, describing the rationale for reinistituting the report. Advocates suggested that even among this group, the issue was more about administrative barriers than not being eligible. Chairwoman Elaine Alquist directed staff to flesh out the numbers.

Elimination of Adult Dental Benefits: The other high-dollar cut proposed was the elimination of adult dental benefits from Medi-Cal, which would save the state $114.9 billion, but also cause the state to lose an equal amount in federal matching dollars. The only services that would not be eliminated included those services that “could be performed by a physician’’ such as extraction.

The department, however, did note that lack of dental treatment did result in higher medical and hospital costs because “people could go to the ER’’ to have dental procedures performed.


Following is a rundown of cuts discussed to the Healthy Families program, and some comments offered by committee members to the Managed Risk Medical Insurance Board – which administers the program.

* Increased premium payments: Families between 151% of the poverty level to 250% of the poverty level would see their premiums increased between $4 and $7/month. For those in the lower income brackets, it works out to a 77% increase over what they are paying now. This would reduce state spending by $43.2 million, but would cause the state to lose $78.5 million in matching federal funds. Lawmaker comments: “Given that we are in a recession and given that people are losing jobs and gas is costing a whole lot more, how does the department determine that a 77% increase is appropriate?’’ asked Sen. Elaine Alquist, who also asked about the impact the increase would have on enrollment. MRMIB executive director Leslie Cummings said she would need to report back on that figure.

* Increased co-payments on “non-preventive services.” Families earning more than 150% of poverty ($26,400 for a family of three) would see an increase in copayments from $5 to $7.50. These higher copayments would be applied to emergency room visits, non-preventive doctors visits, prescriptions, eye exams and glasses, various therapies and dental procedures. This would reduce state spending by $3.4 million, but also cause the state to lose $6.2 million in federal matching funds. Lawmaker comments: “I wonder how many of us in this room would consider those non-preventive services. I think your definition is not exactly accurate,’’ Alquist said.

* Limit dental coverage to $1,000 per child. MRMIB contents that only 5 percent of children need more than $1,000 in dental work done from year to year. This would save the state$5.3 million, but cause the loss of $11.4 million in federal matching funds)

* Reduction in in rates to health plans by 5%. This would save the state $22.4 million, but cost $40.7 million in federal funds

OTHER MEDI-CAL CUTS CONSIDERED: The cuts to the Medi-Cal program senators heard included: The cuts to the Medi-Cal program senators heard included:

* County Processing dollars: Reduction in funds sent to counties to process Medi-Cal applications. This reduction would occur at the same time that processing activities increased if Quarterly Status Reports were approved. The reduction was scored as a $71.1 million savings, with an equivalent loss of federal funding.

* Medicare premiums for very low-income seniors: The state currently pays Medicare Part B premiums for some seniors who are dually eligible for Medi-Cal and Medicare. Those with incomes higher than 129% of the poverty level ($1,118 a month) would now be asked to pay approximately $100 a month for their Medicare premium. The state would save $66.5 million.

* Public Hospitals: The state proposes taking $78.8 million in federal dollars from public hospitals, which will see an increasing number of patients who can't afford to pay for medical services, and use it to pay for programs for largely that same population that would be visiting the public hospitals

* Private hospitals: This proposal would reduce by 10 percent what the state pays to private hospitals. This would save $24 million in state dollars, but cause the loss of an equivalent amount in federal dollars.

While no actions were taken to reduce services to recipients, the subcommittee did approve $5 million in cuts in administrative costs to the Medi-Cal program.

Health Access will continue to report on Budget activities. For more information, contact the author of this report, Hanh Kim Quach, policy coordinator, at 916-497-0923, or hquach@health-access.org.

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posted by Anthony Wright | Permalink | 1:03 PM


Did he really need to announce that?

Also during yesterday's Medi-Cal budget subcommittee Sen. Mark Wyland, R-Escondido, made an unseemly and untimely remark.

It was during discussion about the governor's proposal to stop paying the $100/month Medicare Part B (drs offfice visits) premium for seniors who earn at least $13,416 a year. Here's how the math works out: It means that seniors who receive $1,118 a month would now have to dedicate $100 of their paltry monthly earnings to be able to see a doctor.

Asked whether any lawmakers had questions about the cut, Wyland piped up:

"Just to say, Madam Chair, we do support the governor's proposals."

I have no idea what inspired Wyland to be so enthusiastic about this cut -- particularly after a string of witnesses explained the hardship this population already endures. Or why he thought this was a particularly useful insight that added value to the conversation -- right then.

It was very very strange.

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posted by Hanh Kim Quach | Permalink | 10:13 AM



An interesting comment from Medi-Cal director Stan Rosenstein at the budget subcommittee hearing yesterday on the elimination of adult dental benefits for Medi-Cal recipients.

“…People could go to the emergency room if they’ve got dental pain,’’ he

And they will.

Is that really the best place for a toothache?

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posted by Hanh Kim Quach | Permalink | 9:56 AM


More Medi-Cal Mayhem...

Monday, April 07, 2008
The health news today will be coming from the Senate Budget Subcommittee on Health, chaired by Senator Elaine Alquist. They will be reviewing some of the proposed cuts to Medi-Cal and Healthy Families, including the quarterly status reports and the cuts to dental benefits.

I think there will be surprise at the number of Californians who are projected to lose coverage because of the paperwork burdens of "quarterly status reports." It's well into the six figures!

The dental cut is also sad and potentially tragic. We'll have a full report later, but it's clear that these cuts are simply unacceptable.


posted by Anthony Wright | Permalink | 12:14 AM


I love a good bargain...

Friday, April 04, 2008
And I'm a good bargain shopper. (My prize: 10-piece set of top tier Calphalon pots once for $70) Here are my rules for assessing a good bargain:
  1. Is it a known product (do I know it's a quality product -- like Calphalon);
  2. If it's marked down, is it a good price compared to other similar products;
  3. Lastly, will I use it (because it does me no good to get a good deal on shoes if I'm not going to wear them...and I've done this way too much).

This mental checklist is meant to ensure that the product is of value to me.

Which brings me to the letters submitted by the health insurance industry SB1522 (Steinberg), which create standards for health insurance that would enable any person to go through such a checklist when buying insurance on their own. (See our Fact Sheet on SB1522.)

In short, SB1522 would:
  1. Classify health plans into five "tiers'' so consumers would know what they were buying - i.e. a top tier plan means comprehensive, bottom tier means "catastrophic.'' (Known/quality product)
  2. Insurers would have to have at least one plan in eacth tier, enabling apples-to-apples comparisons.
  3. Establish minimum benefits, which would weed out junk insurance -- such as "hospital only'' plans that barely covers the hospital visit. (will I/can I use it?)

Let's step back a bit. Let's say you don't receive health insurance on the job now and have to go out and scavenge for a decent plan. Go to http://www.ehealthinsurance.com/ and you'll get hit with 107 plans with all manner and range of co-pay, deductible, premium, office visit policies.

The "choice'' argument: Insurers argue that SB1522 will lead to a reduction in consumer choice. First off, their argument is bogus. Choice will still exist, it will just be more organized and limited. And limiting choice for consumers is actually a good thing, according to research on a parallel issue-401(k)s (the research on choice can also be applied to choosing ice cream, jams and insurance policies):

"...Findings from this study show that an extensive array of options can at first seem highly appealing to consumers, yet it can also reduce subsequent motivation to purchase this product...the very act of making a choice from an excessive number of options might result in "choice overload,'' in turn lessening both teh motivation to choose and the subsequent motivation to commit to a choice....''

That research correlates with private polling of uninsured and individual market participants, which also reveals that consumers do not have confidence in their understanding of what the plans provide, nor do they trust the literature that is provided by the plans.

SB1522 would provide choice, but in an organized fashion so that consumers could go through their mental checklist and feel comfortable about a "known product'' and make comparisons against other plans.

Eliminating "lower cost insurance" argument: Lower cost insurance is only lower cost to buy; it's not lower cost to use. In fact, consumers who would benefit from SB1522 are spending twice as much on health care as those who are able to get insurance through their jobs. What insurers really mean here, is they want to get a check from you every month for your premium, but not have to spend any money on you until you've spent $2,000 (or whatever the deductible is) for doctors visits, medicines etc. Don't you love paying for something, just so that you can pay for more things? This violates Rule #3 in evaluating value: will i use it. Research has shown that consumers are half as likely to see the doctor, fill their prescriptions -- actually take care of their of their health.

That sure doesn't sound like a good deal to me.

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


Wonks R Us...

Brian Klepper at The Health Care Blog hosts the new version of Health Wonk Review. It's well worth checking out, even if it didn't includes two Health Access California posts, one on balance billing by me, and another on Senator Clinton's health plan by Hanh.

The whole thing is worth the read, but here's other posts of note:

* Jane Sarasohn-Kahn reviews new health consumerism data at Health Populi, showing little enrollment in so-called "consumer directed" health plans. As Klepper summarizes: "The enrollees in these plans tend not to be born-again uninsureds, but the healthy and wealthy. And still, a lack of information that can provide decision support to these enrollees remains a problem."

* Bob Laszewski at Health Policy and Marketplace Review reports on a General Accounting Office (GAO) review of the individual health coverage market and state high risk pools, and the implications for McCain's health plan.

* Health disparities are the focus of a post InsureBlog, on a Harvard study, suggesting the need for translation services.

* The Medical Humanities blog's Daniel Goldberg responds to a NY Times article citing continuing evidence that wealthier people have fewer health problems than poor people.

* Maggie Mahar, writing at HealthBeat, describes how "the different sensibilities inherent in America’s social class structure are a major obstacle to meaningful political reform."

* Colorado Health Insurance Insider, reviews data showing that a high percentage (59%) of American physicians support a national health insurance program.


posted by Anthony Wright | Permalink | 12:07 AM


Dying for Coverage

Thursday, April 03, 2008
California likes to be first at everything. Unfortunately, according to a new series of state-by-state reports by Families USA, we're also first when it comes to deaths due to uninsurance. You can find this sinister stat at Dying for Coverage in California.

They show that:
  • Every day, more than eight Californias die due to lack of coverage;
  • In 2006, 3,100 uninsured Californians died;
  • Between 2000 and 2006, 19,900 uninsured Californians died.

Other macabre findings include the fact that twice as many people died because they were uninsured than died from homicide. The study augments an early report by the Institute of Medicine, which found 18,000 Americans die annually because of uninsurance.

Why do people die for lack of insurance? Let's see -- in a generic nutshell: They're afraid to go to the doctor because it will cost money. They don't get the proper tests done to make sure they don't have cancer or chronic disease. They don't get the proper prescriptions filled for asthma or diabetes. They get sicker. They feel awful, but are too afraid to seek help because of the cost...then it's too late.

So what to do about this?

Well -- first, we wait about 10 months, according to U.S. Representative Pete Stark of California on a conference call releasing the report this morning. Specifically, we wait 291 days give or take a few hours and minutes to be exact for the departure of our sitting president, who Stark says is the “one individual in the U.S. who has done more to disadvantage people …particularly those with low incomes.’’ Specifically, with respect to regulations on who can qualify for Medicaid (Medi-Cal), expansions of children’s insurance, government negotiation for prescription drugs – you name it.

Next, we laud the seating of either (in no particular order) him or her. And then we see if the federal goverment stops being a hindrance to state efforts to provide universal coverage to children and expanded access to low-income families and adults. We'll have issues with him and particularly his health plan, which would atomize the health insurance market and to essentially raise taxes -- against his promise to do such -- for every American who receives coverage through work.

Then, we get back to work.

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posted by Hanh Kim Quach | Permalink | 11:05 AM


Coverage matters...

Wednesday, April 02, 2008
There are real health consequences to being uninsured.

Because it's in the Metro Section, this article by Steven Magagnini of the Sacramento Bee might be overlooked, but it shouldn't be.

It makes the point by focusing on the death of Melelea Tausinga, a leader in Sacramento's Tongan community, who was uninsured and didn't get the care she needed.

"People who do not have health insurance delay much needed medical care, are more likely to forgo care because of costs, and when they do finally show up for care the conditions they have are often far more severe," James said. "They are more likely to show up with late stage cancer."

That's what happened to Tausinga, said her husband, Tevita Tausinga...

Melelea Tausinga, mother of four and grandmother of seven, not only gave herself to her community, she worked for more than 10 years as motel maid, then as teaching assistant at Susan B. Anthony Elementary, where her granddaughters attend. Neither job provided health insurance.

She kept working even after she started complaining five years ago about severe pain. "She told me to touch her stomach," her husband said.

"It was something like a stone but it was little. The main thing is, we didn't have money. She finally went to a doctor last May after we got Medi-Cal."

The doctor told her she had a cancerous tumor, but it took three months before her daughter-in-law Brianna Tausinga lined up a surgeon who would take Medi-Cal.
"They pretty much said we caught it too late," said Brianna Tausinga

The article further talks of the lack of health coverage in California's growing Asian-American community, referring to a new report by the Kaiser Family Foundation and the Asian Pacific Islander American Health Forum, an important ally and Health Access California board member.

The issue of uninsurance is acute for Latinos and Asian-Americans--but it's a big issue for all of us.

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posted by Anthony Wright | Permalink | 10:57 PM


Balancing priorities on balanced billing...

Tuesday, April 01, 2008
The practice of balanced billing gets the spotlight in an excellent article by Jordan Rau in the Los Angeles Times today. It deserves attention not just in California but across the country.

The piece focuses on the new regulations by the Department of Managed Health Care to ban the practice of "balanced billing," where *insured* consumers are unfairly billed and even sent to collections for going to the doctor or hospital.

The bill should go to the insurer, but because there's a dispute between the health provider and the insurer, the provider also bills the patien--the whole bill or the "balance" of what the insurer won't pay--as a way to leverage the insurer to pay more.

The patient, as a result, either unwittingly pays an bill (often inflated beyond what anybody pays) that is the insurer's responsibility, and even if they don't, they are dragged into this contractual dispute and could be sent to collections--with their credit history and financial future at risk.

Either way, it's not what the consumer was expecting when they signed up for health insurance in the first place. As our Health Access California colleague Beth Capell is quoted, "Consumers who do the right thing and go to a hospital that's in their network should not be leveraged in a fight between doctors and insurers... It's just wrong."

But in deference to our policy advocate, the quote of note comes from the Administration, which illustrates how contentious this issue, describing how regulatory efforts to broker a deal failed after the Schwarzenegger Administration had issued an executive order on this issue in 2005.
The Department of Managed Health Care spent the last two years trying to negotiate a compromise between insurers and providers to work out their payment differences, but couldn't find common ground. So the department decided to simply outlaw the practice through new draft regulations issued Friday.

"We tried to say, when we were young and naive, that we could find a mutually acceptable resolution to make sure physicians were being paid fairly and on time," said Cindy Ehnes, the department's director. "We finally said, we can't solve this marketplace dispute, but what we can do is our core mission of protecting consumers."

The draft regulations would prohibit hospitals and hospital-based physicians from billing a patient for the cost of emergency services that are the responsibility of the patient's health plan.

There will continue to be pending legislation, including by Senate President Pro Tem Don Perata, to see if there is a legislative agreement to settling the contract wars between providers and insurers.

There are issues to work out: these are often cases where a patient goes to an in-network hospital, but has no idea that the ER doctor on call, or the anasthesiologist or other specialists, are not contracted with their insurer. Unlike contracted doctors, there's no negotiated agreement on the rate. The doctor, who was not in a position to refuse the patient, feels the insurer is underpaying. The insurer isn't going to pay the full billed amount by the doctor--a "sticker price" that is more than any insurer pays. So when there isn't an agreement up front, what should be the payment? There's lots of alternatives--and that's what the various legislative proposals seek to address--but the answer shouldn't be to simply stick the consumer with the bill.

But while we are working through those issues, it is appropriate for the Department to focus on what should be the consensus item; to focus on the core issue of protecting consumers from this unfair billing behavior.

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posted by Anthony Wright | Permalink | 6:51 PM


PHRMA strikes back...

Big PhRMA today smothered AB 2821 (Feuer), which would have limited the value of gifts given to physicians to $250 (about one-tenth of what is current practice for many companies), and required them to disclose any gifts (which includes meals, subscriptions, travel, trinkets, etc) of $50 or more. To read more about the bill, and research about pharmaceutical company gifts to physicians, see CalPIRG’s report here, UCSF's research on the issue here, and our previous post about the issue here.

AB 2821 was a far more modest proposal than what the Journal of the American Medical Association had recommended for its community, but not this year and not this bill. It needed nine votes to pass, it got five.

Dr. Michael Steinman, a UC San Francisco medical school professor, spoke of his research, which showed gifts from pharmaceutical companies created an "expectation of reciprocity'' -- that doctors needed to somehow return the favor. His research has also shown how 84% of physicians believed their colleagues were influenced by drug company gifts

CalPIRG staff attorney Mike Russo testified that physicians are visited by drug company representatives an average of 28 times a week – or six times a day. These frequent visits, he said, harmed patient care by increasing the cost of drugs (extra marketing costs and the prescribing of higher-cost drugs when generics would be fine) and creating the appearance of a conflict with the doctor-patient relationship.

Pharmaceutical companies argued -- as is their wont -- that the legislation would be too cumbersome, expensive, yada yada.... The bottom line is, if this type of marketing didn't work, they wouldn't dedicate $19 billion annually to push their drugs to the fore.

The California Medical Association – which was neutral on the bill – said “Sunshine is necessary’’ but believed there were some “differences of opinion’’ about the studies and felt that studies did not suggest that gifts altered their prescribing habits and were offended by the characterizations that maligned doctors and questioned their integrity.

It should be noted that the Journal of the American Medical Association recognizes the potential for the appearance of a conflict of interest and has put forth its own guidelines for self-regulation, which includes a ban on *all* gifts ("eliminating potential gray areas and greatly eases the burden of compliance"), replacing drug samples with a "system of vouchers for low-income patients ...that distance the company and its products from the physician.''

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posted by Hanh Kim Quach | Permalink | 5:56 PM


Drug pushing...

CALPIRG Health Care Advocate Mike Russo (also a Health Access California board member) makes the case for AB2821 (Feuer) in the California Progress Report, and will later today as well at the Assembly Health Committee.

The bill would place a hard cap of $250 of "gifts" to doctors from drug companies, and require better public disclosure of the pharmaceutical companies' marketing practices. These are real cost drivers in our health care system--not only the cost of marketing, but the encouragement to move patients to the most profitable and most expensive drugs, even when more tried-and-true remedies are as effective, if not more so. For everyone who raises the issue of cost containment, this is a simple but important step.

This is part of an ongoing effort by many groups, an "OuRx Coalition," to get a handle on prescription drug costs--such as getting California to use its purchasing power to bargain down the costs of medicines for the uninsured and underinsured, with AB2911(Nunez/Perata) a couple of years ago.

Another consumer-backed bill of a few years ago, SB1765(Sher), had the drug companies create and publish their own guidelines for their marketing practices. A new CALPIRG analysis, "Playing By Their Own Rules," suggests that:
* Drug companies fail to count some meals and other payments as “gifts,” and therefore not subject to the limit;
* Some companies reserve the right to exceed their limits if they so choose;
* Others assert that they are following a limit, but do not disclose what that limit actually is, while a few fail even to post their policies at all.

Clearly, there's a prescription for some stronger oversight.

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posted by Anthony Wright | Permalink | 10:08 AM


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Anthony Wright is the executive director,
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