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Keeping score, even though it's not a game...

Friday, May 30, 2008
 
A new HEALTH CARE BUDGET CUTS SCORECARD is now available on the Health Access website, at:
http://www.health-access.org/preserving/Docs/Health%20Access%20-%20BudgetScorecard%20053008.pdf

It details the various cuts, the impact on the budget, the number of people impacted, as well as the actions the Legislature took earlier in the year, and what the Assembly and Senate did today in their current deliberations.

We'll keep polishing it, but it's a useful side by side, especially as we head into conference committee and "Big Five" negotiations.

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posted by Anthony Wright | Permalink | 5:17 PM


 
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The first 100 days...

 
It's a busy day blogging on the budget, but I would be remiss if I didn't point out a statement by Sen. Barack Obama made last night in Denver, as reported by Marc Ambinder of the The Atlantic.

So after he meets with the Joint Chief of Staff to determine a course of action in Iraq, Obama wants to "[G]et our health care plan moving. We need a bill...by March or April to get going before the political season sets in."

Ezra Klein of The American Prospect is elated, citing that the previous Clinton effort suffered because it was pushed back and not considered in the first 100 days. But we health advocates still have a lot of work to do, to make sure that health reform, and the right reform, is the top priority in Washington, DC, as well as Sacramento.

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posted by Anthony Wright | Permalink | 5:03 PM


 
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Budget Ax-tions and Non-Ax-tions

 
We'll file a more complete report later, but we wanted to get this out into the ether for our non-Sacramento allies who are interested.

Both the full Senate Budget Committee, and the Assembly Budget Subcommittee that oversees the health budget, voted on a number of items in the budget today. I watched the Senate, so I'll only have the Senate votes right now, but here's how it shakes down (with some parenthetical comments):

  • Healthy Families payment to health plans reduced by 5 percent: Approved 11-0.
  • Increase in Healthy Families Program premiums for some enrollees: Modified -- the committee halved the amount of the premium increase to subscribers (more details to come) 8-3 (Republicans wanted the original governor's proposal, which had higher rate increases.)
  • Increase Healthy Families co-payments: Rejected 8-3 (Republicans supported the copayment increase).
  • Limit dental benefits in Healthy Families: Modified (Rather than a $1,000 annual cap, the committee approved a $1,500 annual cap).
  • Use Prop.99 tobacco money to keep rural health projects in Healthy Families: Approved
  • Quarterly status reports for children: Rejected/Modified 9-0 (would be semi-annual status reports resulting in fewer disenrolled children. Republican went along, but preferred quarterly status reports).
  • Quarterly status reports for parents: Rejected 8-3 (Republicans preferred quarterly status reports)
  • Eliminate state payment of Medicare Part B premiums for extremely low income seniors on Medi-Cal: Modified 8-3 (more details to come)
  • Denied Medi-Cal eligibility for working parents: Rejected 8-3
  • Reduce Medi-Cal services for legal immigrants: Rejected 8-3
  • Require undocumented immigrants to re-establish restricted Medi-Cal eligibility every month: Rejected 8-3
  • Reduce Medi-Cal provider rate reimbursements by 5 percent -- rather than 10 percent as previously approved and signed: Approved 7-2
  • Elimination of adult dental benefits: Rejected/Modified (to retain a $1,800 annual cap on dental services) 7-2
  • Elimination of Medi-Cal vital benefits, such as eyeglasses, incontinence creams and washes, podiatrist, optometrist, etc.: Rejected 7-2
  • Increase the taking away of more federal money from public hospitals: Rejected 8-0
  • 10 percent payment reduction for private and district hospitals: Rejected 8-0
  • Reduce payments to hospitals that don't contract with the state: Approved 7-2
  • Reduce funding for California Children's Services: Rejected 7-1
  • Modify Rate reduction fo Genetically Handicapped Persons Program to five percent: Approved 7-1.

posted by Hanh Kim Quach | Permalink | 1:41 PM


 
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Quarterly Status Report Debate

 
Lots of invective discussion in the Senate Budget Committee this morning on governor's budget proposal to impose Quarterly Status Reports -- which are a passive aggressive way for the state to kick children and adults off of Medi-Cal if they don't return a report form every three months that lets the state know that they're alive, haven't moved and their income hasn't changed.

Some quotes:

Sen. Steinberg: "Let’s be frank. On cost-savings…the motivation of this is not to detect fraud. The motivation is to hope that people won’t show up and therefore lose their eligibility.’’

Sen. Gloria Romero points out that nearly 500,000 children would lose their health coverage once the reports are fully implemented. “That’s not ‘falling through the cracks.’ ….It seems, to me, that the net hope is that these children will just ‘go away’ and that’s the anticipated savings for the state of California. What I’d like to ask is, ‘Are you concerned about this?’’’

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posted by Hanh Kim Quach | Permalink | 11:27 AM


 
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...but some key cuts made.

 
The Senate Budget Committee, chaired by Senator Denise Ducheny, rejected the major eligibility cuts to Medi-Cal, and the elimination of benefits. It is adopted semi-annual reporting for children and parents, the increase in premiums and co-payments in Healthy Families, and the cut to Healthy Families plans, and other cuts.

Again, more detail shortly...

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posted by Anthony Wright | Permalink | 10:51 AM


 
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Rejecting the big cuts...

 
The Assembly Budget Subcommittee on Health and Human Services, chaired by Assemblywoman Berg, has just voted to reject the major eligibility cuts in Medi-Cal, the elimination of optional benefits, and even to restore some of the provider rate cuts made earlier in the year. This is very good, a clear statement that these cuts are too severe... a determination that prior Legislatures made about these same proposed cuts.

There are cuts that they are expected to approve: cuts to public and private hospitals in a couple of ways, county administration, a modified cut on Medicare part B premiums for some seniors, cuts to Healthy Families plan rates, an increase in Healthy Families premiums and co-pays, and a cap on dental coverage in Healthy Families.

More later...

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posted by Anthony Wright | Permalink | 10:41 AM


 
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Why today matters...

 
Later today, both the Assembly and Senate budget committees will be considering and making decisions on many of the health care cuts proposed by Governor Schwarzenegger. And with that, the budget debate goes into full gear.

This is still an early stage: any decision made at this point can still be reversed. Given the massive deficit, and the major effort it will take to raise revenues, it is likely that cuts that the both the Assembly and the Senate agree with the Governor on are close to final. Yet the rejection of those cuts does not mean we can breath easy. Unless there are revenues or taxes to fill the gap, those cuts still loom as possibilities. So this is a day where we can't win, but we can surely lose.

However, while these are not final decisions, the actions made today in the Assembly and Senate are hugely important. The decision to reject health care cuts will set the stage for the budget negotiations. It will send the clear signal: some cuts are too severe, and we need to raise revenues to prevent those cuts. And then we have the debate, with those legislators who want a cuts-only budget, rather than a budget solution that includes some revenues or taxes.

It's important that the majority of legislators make this stand, so that the choice is clear, between denying children and parents health coverage, defunding doctors and hospitals, eliminating dental and other benefits, etc... and raising the revenues needed to prevent those cuts.

To follow along, here's a health budget cuts scorecard, which details the cuts impacting access to health care, and what their status is with the Governor, the Assembly, and the Senate. We'll update it after today.

We'll be posting through the day on the action.

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posted by Anthony Wright | Permalink | 9:44 AM


 
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Two more passed...

Thursday, May 29, 2008
 
Two more bills of interest to health advocates passed:

AB 2942 (Ma) which would require all hospital (both for- and non-profit) to show how their existence is a community benefit in order to be licensed. That includes providing health services that are important to the community it serves, including care for the most vulnerable. (Passed 43-35.)

SB 1633 (Kuehl) which would protect low-income patients receiving dental work from high-interest credit card schemes promoted by their dentists. (I'll post the vote later)

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posted by Hanh Kim Quach | Permalink | 4:58 PM


 
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Never-never land...

Wednesday, May 28, 2008
 
One more bill passed today of interest to health advocates: 2146(Feuer), so that health care providers would not charge for "never events"--events that should never happen. These include surgery performed on the wrong body part; surgery on the wrong patient; deaths from medication errors; etc.

The bill got a 42-21 vote, with most Democrats in support, with Soto absent, and De La Torre, Dymally, Galgiani, Hernandez, Krekorian not voting.

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posted by Anthony Wright | Permalink | 6:30 PM


 
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Hearings Hearings

 
Budget hearings in both houses later this week. The Assembly Budget Subcommittee #1 on Health and Human services will review the May Revision to health programs on Thursday (more details on time and place to come).

On Friday morning, the full Senate Budget committee will review health budget changes at 10 a.m. in Room 4203.

Busy busy.

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posted by Hanh Kim Quach | Permalink | 5:50 PM


 
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What constitutes coverage?

Tuesday, May 27, 2008
 
As the Democratic presidential candidates debated whether their "universal coverage" plans were "universal"--and what that meant--there wass surprisingly little debate about the definition of "coverage."

What makes "coverage" coverage?

It's a good question, as Florida Governor Charlie Crist just signed a so-called health reform that doesn't expand coverage one bit, but rather strips down the definition of coverage to make the premium cheaper. Critics say that as insurers water down the benefits, at some point the value of the coverage is so little that it's not worth paying premiums for in the first place.

It seems people get coverage to prevent the real health and financial consequences of being uninsured. They literally pay a premium to 1) get the care they need, and 2) not face financial ruin as a result.

There are some products out there that don't meet this basic definition. For example, we've heard of products--some sold by disreputable outfits, sometimes on TV at 3am--that say they provide hospital coverage, but only reimburse $200/day. Only if you've been to a hospital do you know that such a plan doesn't begin to cover an overnight stay, and that such "coverage" from a masssive hospital bill is merely an illusion. It's "junk" insurance.

SB1522(Steinberg), which passed the California Senate Tuesday, would set a minimum standard for coverage as well, in two basic ways:

* It would set an overall cap on out-of-pocket costs, so people paying premiums would not face unlimited financial liability when they get sick or have an emergency. This won't eliminate your standard high-deductible plans, may be a (not great) option for a healthier, wealthier person who wants to save on the premium and who has the ability to self-insure a few thousand dollars of a deductible. But it would eliminate those plans which cover so little or impose so much cost-sharing on the patient that the person continues to be at risk of banktruptcy.

* It would requires that a plan should include doctor, hospital, and preventative care, preventing hospital-only coverage. This would prevent hospital-only plans that leave patients in a situation where cancer isn't covered, since most of the treatment is in a doctor's office, rather than a hospital. Even worse, you don't want an perverse incentive for people to want the more invasive, more expensive hospital treatment unless they need it. Again, these plans often provide a false security to patients--until its too late.

These "junk" plans, because they collect premiums but are far skimpier in paying out benefits, can be very lucrative for the insurers who sell them. But they have the capacity to undermine the very notion coverage altogether. What's the point of paying for coverage, if you still face financial ruin?

People are growing more and more concerned that their coverage will not be there for them when they need it. They are frightened that even if they are insured, there will some loophole or provision that leaves them with significant medical debt. That's why SB1522(Steinberg) and other efforts are so important, to make the definition of coverage mean something. Consumers with coverage deserve some security that with their premium, they will be protected.

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posted by Anthony Wright | Permalink | 11:52 PM


 
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Health reform lives on in Sacramento...

 
HEALTH ACCESS UPDATE
Tuesday, May 27th, 2008


KEY HEALTH BILLS PASS FLOOR VOTES IN CALIFORNIA LEGISLATURE
* Senate Passes SB1522 (Steinberg), Standardizing Insurance & Prohibiting "Junk" Coverage
* Assembly Passes AB2967 (Lieber), Providing Transparency on Cost and Quality of Care
* Also: Bills Pass to Regulate Insurers on Rescission, Maternity Coverage, Mental Health Parity, and Requiring 85% of Premium for Patient Care

* More on the Legislative Debate and much more at
the Health Access WeBlog (www.health-access.org/blogger.html):


Health reform continues to be a hot topic at the State Capitol. Passing their first floor vote and the half-way point in the California Legislature, key health bills would provide patients with new information and needed consumer protections regarding their care and coverage.

The Assembly and Senate passed several key health care bills, including ones to protect consumers from "junk" insurance; to increase transparency about the cost and quality of care; to regulate the practice of retroactively denying coverage to patients; and to mandate coverage of maternity and mental health services. The health reform conversation is alive and well.


The following bills passed:


INSURER OVERSIGHT

* STANDARDIZING INSURANCE: SB1522(Steinberg), eliminating "junk" insurance and standardizing the insurance market to allow for "apples-to-apples" comparison for consumers. The bill would set a minimum benefit standard for coverage by requiring coverage to have an overall cap on out-of-pocket costs, and cover doctor, hospital, and preventative care. It would sort health insurance policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic." Here's a fact sheet, and a patient story that illustrates the issue.

Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing. The bill would also prevent consumers from not understanding their coverage, or having "junk" coverage where they are paying a premium by are still facing unlimited financial exposure. Sponsored by Health Access California. (Passed by the Senate 22-16 with most Democrats in support; Ducheny and Ridley-Thomas not voting; Correa voting no.)


* MEDICAL LOSS RATIO: SB1440(Kuehl), to require that at least 85% of premium dollars go to patient care, rather than administration, marketing and profit. The proposal seeks to ensure that consumers are getting value for their dollar. (Passed by the Senate 22-16, with most Democrats in support, with Machado and Simitian not voting, and Yee voting no.)

* RESCISSIONS: AB1945(De La Torre), to require insurers to get an independent review before retroactively denying coverage from patients. (Passed the Assembly 57-16, with significant bipartisan support.) Also passing was AB2549(Hayashi) which sets a six-month time limit for insurers to rescind once consumers' applications are approved. (Passed the Assembly 44-26.)

BENEFITS


* MENTAL HEALTH: AB1887(Beall) to expand the requirement on insurers to cover mental health services. (Passed by the Assembly 44-26, with most Democrats in support, and with Arambula, Mullin, Calderon, Galgiani not voting; Soto absent.)

* MATERNITY: AB1962(De La Torre), to require insurers to cover maternity benefits. (Passed the Assembly 44-31, with most Democrats in support; Soto absent; Galgiani not voting; and Calderon and Parra voting no.)


PROVIDER OVERSIGHT

* TRANSPARENCY: AB2967(Lieber), to require better data from health providers and plans to increase the transparency of the cost and quality of care. This effort has yielded one of the most interesting coalitions, with strong support by prominent consumer, labor, and business groups--all purchasers of health care trying to get a better sense of what they are getting for their money. (Passed by the Assembly 41-32, with most Democrats in support but Soto absent; Fuentes, Krekorian, Ruskin, Portantino, Solorio not voting; and Arambula voting no.)

* DISTRICT HOSPITAL TRANSACTIONS: SB1351(Corbett), to require Attorney General oversight over district hospital sales and closures. (Passed the Senate 24-14, with most Democrats in support, and Scott not voting.)

Health Access will continue to track these and other bills on our website, at
http://www.health-access.org/advocating/2008_bills.html

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posted by Anthony Wright | Permalink | 7:46 PM


 
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A quick floor report...

 
Busy and productive day in the Assembly and Senate on many of the key health care bills. The health reform conversation is alive and well...

Here's what passed (partial list--we'll have a fuller update later today):

* SB1522(Steinberg), eliminating junk insurance and standardizing the insurance market to allow for "apples-to-apples" comparison for consumers. (Passed by the Senate 22-16 with Ducheny and Ridley-Thomas not voting; Correa voting no.)

* AB2967(Lieber), to require better data from health providers and plans to increase the transparency of the cost and quality of care. (Passed by the Assembly 41-32. Party line vote with Fuentes, Krekorian, Ruskin, Portantino, Solorio not voting; Soto absent; Arambula voting no.)

* SB1440(Kuehl), to require that at least 85% of premium dollars go to patient care, rather than administration, marketing and profit. (Passed by the Senate 22-16, with Machado and Simitian not voting, and Yee voting no.)

* AB1945(De La Torre), to require insurers to get an independent review before rescinding coverage from patients. (Passed the Assembly 57-16, with significant bipartisan support.) Also passing was AB2549(Hayashi) which sets a time limit for insurers to rescind. (Passed the Assembly 44-26.)

* AB1887(Beall) to expand the requirement on insurer to cover mental health services. (Passed by the Assembly 44-26, with Arambula, Mullin, Calderon, Galgiani not voting, Soto absent.)

* AB1962(De La Torre), to require insurers to cover maternity benefits. (Passed the Assembly 44-31, with Galgiani not voting; Soto absent; and Calderon and Parra voting no.)

* SB1351(Corbett), to require Attorney General oversight over district hospital sales and closures. (Passed the Senate 24-14, with Scott not voting.)

Good things. Good day for consumers.

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posted by Anthony Wright | Permalink | 5:59 PM


 
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The debate on SB1522...

 
Senator Steinberg just presented SB1522 on the Senate floor. The preliminary count is that it passed, 21-14, largely on party lines.

Senator Cox was the only other speaker, in opposition. An insurance agent, Cox suggested that "Senator Steinberg should find himself a good agent," and that an agent could provide the information to help a consumer decide what coverage to get.

He argued that with the classification of health plans into five tiers, "you've taken away the flexibility" which will lead to a "higher-premium program with fewer enrollees."

In fact, the five tiers allow for lots of variation and flexibility within those tiers. Above some minimum standards (see below), there is total flexibility in benefit design. The tiers will simply provide consumers some guideposts, so they are better be able to make comparisons between insurers.

SB1522 does seek to eliminate some "junk" insurance that leaves patients with unlimited financial exposure, undermining the point of coverage in the first place. Coverage would have to have some overall cap on out-of-pocket costs. The minimum standard for coverage would need to include doctor, hospital, and preventative care, effectively restricting doctor-only or hospital-only health coverage--as if people can guess that not just the type of ailment they will have, but the type of treatment as well.

But other than that, there's lots of flexibility. As Senator Steinberg said in closing, the basic point of the bill is to have clear information. And, he asked, while many people may benefit from "a good broker like Senator Cox," what's the harm in providing everyone as much information as possible? "Information is a good thing, and provides greater flexibility" for consumers.

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posted by Anthony Wright | Permalink | 3:43 PM


 
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When cancer isn't covered...

 

SB1522(Steinberg), sponsored by Health Access California, is up for a full Senate vote this week.

The bill would standardize the individual insurance market, so that consumers have a better sense of the coverage they are buying, and allow for "apples-to-apples" comparisons between plans. It would create clear categories so that people would have a better sense of how comprehensive their plan was, and would set a minimum standard for benefits to include doctor, hospital, and preventative care, and have a overall cap on out-of-pocket costs. This would eliminate the "junk" insurance that leaves people to believe they are covered but finding out later they have significant financial exposure.

Below is the testimony of Susan Braig (pictured above, with Senator Darryl Steinberg, author of SB1522). With a limited income to pay premiums, she understood she was buying catastrophic coverage... but not that her "hospital only" plan wouldn't cover the significant costs of being treated for breast cancer, because most of those treatments were not in a hospital.

This is a excerpt of her testimony in the Senate Health Committee earlier this year:
I am a self-employed grant writer, whose Stage 2 Breast Cancer has, thankfully, not metasticized, though my credit card debt has.

In 2001, after a year with no health insurance, my 50th birthday sent me comparison shopping, and I went to Blue Cross. I purchased what I considered to be a “catastrophic” policy, their lowest tier, their BASIC PPO 1000. I thought my out-of-pockets costs would be limited to $3,500, comprised of a $1,000 deductible, plus a $2500 co-payment requirement before full coverage kicks in.

Blue Cross made it clear up front, this plan did not cover doctor visits, tests or prescriptions; I rationalized that, since I was healthy and rarely needed a doctor, why sweat the "small stuff?"

The important thing was, Blue Cross said they would cover 80% the big stuff: surgeries, emergencies, and hospitalizations, and with the big stuff, I would quickly spend $3500, and then Blue Cross would pay 100% of my care for the rest of the year.

Prior to my 2004 diagnosis, I assumed fighting a catastrophic disease like cancer involved the big stuff.

* What I didn’t realize then, but I know now, is that during the next 11 years, most of my medical services I would need in my battle with cancer would involve things not covered—specialist exams, ultrasounds, an $8,000 MRI, lab tests, prescriptions.

Even my chemotherapy treatments were considered doctor visits, unless I had the identical treatments an hour from home in a hospital.

* I also didn’t realize that the way deductibles and co-pays are calculated meant they didn’t count any of these non-hospital expenses to meet my deductible, and I would almost never reach my annual $3500 cap, no matter how much I spent.

It’s true that after I met my deductible, Blue Cross did cover 80% of in-hospital services, such as my Lumpectomy and a 3-day emergency hospitalization in 2004… although by the time I paid off my $1000 deductible, my various 20% co-payments fell $30 short of the $2500 co-payment requirement to get full coverage.
* For a time, due to my low income, I got help with the costs that Blue Cross didn’t cover from the state’s Breast and Cervical Cancer Treatment program. That was a lifesaver—even though I was still paying premiums to Blue Cross.

* I still have significant follow-up treatments. In each of the last few years, I have paid out over $5,000 a year in out-of-pocket costs, on top of what I pay in premiums, yet my insurance pays nothing. I expect these treatments—and these costs--to go on for several more years. I already have over $40,000 in credit card debt, mostly stemming from my illness and medical care.

With the ongoing costs of follow-up care, I begin to wonder, "I'm paying insurance premiums for WHAT?"

When people seek coverage, they should know what their options are, and what they are getting. When they have coverage, they should have the confidence that it will actually provide protection against financial ruin and bankrtupcy. SB1522(Steinberg), if it passes the Senate floor this week, will take a major step in providing that clarity and security.

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posted by Anthony Wright | Permalink | 9:32 AM


 
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Phase one: stop the cuts...

Monday, May 26, 2008
 
Last week, Governor Schwarzenegger's staff met with a variety of health stakeholder groups, on the subject of continuing the effort on health reform.

What was newsworthy was that the Governor signalled his strong commitment of coming back to health reform; and that as part of that, he showed his interest to pass, sign, and implement elements of health reform this year.

Of course, the budget crisis hung over the entire conversation.

Many of the concepts and issues that the Governor's staff expressed interest in--in the broad areas of cost containment, prevention, and consumer protection--are worthy goals, both as a foundation for future health reform, and in their own right, to provide immediate help to many health care consumers.

The connection between the goals for this year is that they all have one thing in common, explicitly--none would have an impact on the general fund.

It's not just that the budget crisis prevents movement on the heart of health reform--coverage expansions, provider rate increases, guaranteed issue, etc. It's that the Governor's budget proposals go in the exact opposite direction of the reforms and coverage expansions proposed earlier this year. The very logic of health reform, of reducing the "hidden tax" and fixing the "broken health system," argues against the cuts to eligibility, enrollment, benefits, and provider rates that the Governor proposes.

It's good that the Governor is still interested in health reform. We should take him up on passing consumer protections and other reforms this year, but push him to abide by the urgency and logic of his statements about health reform from last year. He made a decision last year, to agree that we needed to raise revenues to pay to expand health coverage... We need revenues this year, just to maintain the health coverage California currently provide to children, working parents, seniors, and people with disabilities.

It seems that phase 1 of health reform includes defeating the Governor's health care budget cuts and work for an alternative to a cuts-only budget. It also includes defeating the Governor's power grab proposals to change the budget process so that it would be nearly impossible to pass and maintain health reform into the future.

We should be consistent with our goals, even if the Governor isn't.

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posted by Anthony Wright | Permalink | 2:23 PM


 
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A big week for legislation...

Saturday, May 24, 2008
 
HEALTH ACCESS ALERT
Saturday, May 24th, 2008


FLOOR VOTES NEXT WEEK FOR KEY HEALTH BILLS
* All bills must clear first floor vote by May 30th--next Friday.
* Action Alert: Letters/Calls Needed ASAP

Click Here for What's New on the Health Access WeBlog: Update on Appropriations Committee; Getting Ready for Reform, Renewed: The American Prospect's Special Edition; MRMIB's Decision on Waiting Lists and Disenrollments; More on the Budget


Enjoy this three-day weekend; next week promises to be a doozy. While budget committees will work away on various budget proposals, the full Assembly and Senate floors will be active. All bills must pass their first floor vote by May 30st. Many bills supported by health consumer advocates will be up for a vote next week.

BELOW is a list of health consumer bills--it will be updated on the Health Access California website as the session continues, at http://www.health-access.org/advocating/2008_bills.html


For every bill, the list includes the bill number (the author) and A SHORT DESCRIPTION IN CAPS: There's also a longer description of the legislation, Health Access California's position on the legislation, and finally, where the legislation is currently pending.

ACTION ALERT: Voice your support. Submit letters to lawmakers on legislation on either the Senate or Assembly Floor.

*Note: Bills in bold and with an asterisk need letters of support. The other bills have already passed the floor vote of the first house, or were stalled and will not be advancing this year. Those that are in bold and with an asterisk are expected to be considered and face this key hurdle in the next week.

BILL LIST

Insurer Regulations

Insurance Oversight & Market Reforms
+ *SB 1522 (Steinberg) INSURANCE MARKET STANDARDS: Would sort health insurance policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic.’’ Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing, and assist consumers in making apples-to-apples comparisons between plans. Would weed out “junk’’ insurance by developing minimum benefit standards. Sponsor-Support. Location: Senate Floor.
+ AB 1554 (Jones) RATE REGULATION: Would regulate insurance rates. Amend. Location: Senate Health.
+ *SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care. Support. Location: Senate Floor


Rescissions
+ AB 1150 (Lieu) BONUSES: Would outlaw the industry practice of paying bonuses to insurance company employees when they rescind policies, for setting targets for rescinded policies and/or setting financial goals based on savings on health care claims. Support. Location: Senate Health.
+ *AB 1945 (De La Torre) INDEPENDENT REVIEW: Would require approval by Department of Managed Health Care or Department of Insurance for each individual rescission. Support. Location: Assembly Floor
+ *AB 2549 (Hayashi) TIME LIMIT: Would impose a six-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved. Support. Location: Assembly Floor


Benefit Mandates
+ *AB 1887 (Beall) MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses Support. Location: Assembly Floor
+ *AB 1962 (De La Torre) MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services. Support. Location: Assembly Floor
+ SB 1198 (Kuehl) DURABLE MEDICAL EQUIPMENT: Would require group health plans and insurers to offer coverage for durable medical equipment, such as wheelchairs and shower seats. Support. Location: Assembly Health.


Improved Insurance Options
+ AB 2 (Dymally) HIGH RISK POOL: Would reform the Managed Risk Medical Insurance Program, which provides coverage for “un-insureables” who have “pre-existing conditions.’’ Efforts would make the high risk pool more affordable and available. Support Location: Inactive, Senate Floor
+ SB 1622 (Simitian) PUBLIC INSURER: Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices. Support Location: Held in Senate Appropriations Committee.


Health Care Providers

Transparency: Cost and Quality Data
+ *AB 2967 (Lieber) TRANSPARENCY AND DISCLOSURE: Would require public reporting of cost and quality by doctors, hospitals HMOs and others in the health care industry. Support. Location: Assembly Floor.
+ *SB 1300 (Corbett) CONFIDENTIALITY CLAUSES: Would prohibit confidentiality clauses, which keep secret information on pricing and health care quality from consumers, in contracts between providers and insurers. Support Location: Senate Floor.
Doctor and Hospital Oversight
+ *AB 2146 (Feuer) ‘NEVER EVENTS’: Bans providers from billing patients or insurers when they have made an avoidable mistake, such as operating on the wrong person, prescribing the wrong drugs, or leaving foreign objects inside a surgery patient. Support. Location: Assembly Floor.
+ *AB 2942 (Ma) COMMUNITY BENEFITS: Would standardize what non-profit hospitals report as “community benefits” to justify their non-profit status. Support. Location: Assembly Floor
+ *SB 1633 (Kuehl) DENTAL PREDATORY LENDING: Would prohibit dentists’ offices from offering high-interest loans to patients while they are under the influence of anesthesia. Would also prohibit dental offices from charging lines of credit before services have been rendered. Support. Location: Senate Floor.


Hospital Transactions
+ AB 2400 (Price) HOSPITAL CLOSURES: Would require public notice before closing a hospital. Support. Location: Senate awaiting committee assignment.
+ AB 2697 (Huffman) BOUTIQUE HOSPITALS: Would require so-called “boutique hospitals’’ to asses their impact on a community’s health system annually, specifically whether they siphon doctors, workers, providers from hospitals caring for less affluent populations. Support. Location: Senate awaiting committee assignment.
+ *AB 2741 (Torrico) HEALTH IMPACT ANALYSIS: Would require for-profit hospital sales to undergo health impact analyses to gauge the transaction’s effects on the affected community, health care services, and the community’s public interest. Support. Location: Assembly Floor.
+ *SB 1351 (Corbett) OVERSIGHT: Would require Attorney General oversight into transactions involving district hospitals. Support. Location: Senate Floor.


Balance Billing
+ AB 1203 (Salas) EMERGENCY ROOM BILLS: Would prevent emergency departments – which do not have a contract with a patient’s insurance company -- from directly billing the patient, requiring the hospital to seek payment directly from insurers. Support. Location: Senate Health.
+ AB 2220 (Jones) BINDING ARBITRATION: Requires providers and health plans to resolve contracting and payment disputes through binding arbitration. Watch. Location: Assembly Floor.
+ SB 981 (Perata) ER DOCTOR BILLS: Would prevent emergency physicians – who do not have a contract with a patient’s insurance company -- from directly billing the patient, requiring providers to seek reimbursement directly from insurers. Support. Location: Assembly Health.


Underserved Communities
+ AB 1472 (Leno) HEALTHY COMMUNITIES: Would establish the California Healthy Places Act, and require diverse state agencies and departments to work together assess and reduce health disparities in underserved communities. Support. Sen Appropriations.
+ *AB 2902 (Swanson) COMMUNITY HEALTH WORKERS: Would require the Office of Multicultural Health to encourage the use of community-based health care workers to help facilitate and coordinate better health outcomes in underserved communities. Support. Location: Assembly Floor.
+ AB 3027 (De Leon) LANGUAGE ACCESS: Would require health plans to translate materials into Medi-Cal threshold languages Support. Location: Held in Assembly Appropriations.
+ *AB 2842 (Berg) MARKETING PROTECTIONS: Would protect Californians from insurance agents trying to sell them private Medicare plans through cold calls and bait-and-switch tactics. Support. Location: Assembly Floor.
+ SB 1332 (Negrete-McLeod) MANDATORY MEDI-CAL MANAGED CARE: Would require seniors and persons with disabilities in Riverside-San Bernardino Counties to enroll in Medi-Cal managed care. Oppose. Location: Held in Senate Appropriations.


Coverage Expansions

Working Disabled
+ AB 851 (Brownley) MEDI-CAL FOR WORKING DISABLED: Increases eligibility for those working with disabilities to buy Medi-Cal coverage through the Medi-Cal California Working Disabled Program. Also extends the program, which will sunset 9/1/08. Support. Location: Senate Health.


Children’s Coverage
+ AB 1 (Laird/Dymally) & SB 32 (Steinberg) UNIVERSAL CHILDREN’S COVERAGE: Would expand children’s coverage, including the Healthy Families program, to all children in families up to 300% of poverty ($49,800 for a family of 3). Support. Location: Assembly and Senate Floors, respectively)
+ SB 1168 (Runner) DEPENDENT CARE: Would allow adult dependent children, who are still covered under their parents’ health plan, to stay on that coverage even if the child takes a medically necessary leave of absence from school. Support. Location: Assembly Health.
+ SB 1593 (Alquist) BRIDGING COVERAGE: Would clarify that children currently covered by county health initiatives would be first in line to receive Medi-Cal and Healthy Families coverage once those programs are expanded. Support. Location: Held in Senate Appropriations.


Universal Coverage
+ SB 840 (Kuehl) SINGLE PAYER: Would establish a single-payer health care system in California that would enable all residents to have health coverage. Support. Location: Assm Appropriations


Health Access will keep advocates updated this next week as bills come up on the floor. Stay tuned. For more information, contact the author of this report, Hanh Kim Quach, Health Care Policy Coordinator at hquach@health-access.org

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posted by Anthony Wright | Permalink | 1:59 AM


 
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The new/renewed conversation on health reform...

Friday, May 23, 2008
 
“When you come to a fork in the road, take it,” said Yogi Berra.

It’s a lesson that health reformers can take to heart after reading the May issue of The American Prospect, which has a special section on “the path to universal health care.” The articles reflect heated debates, some spanning decades, on the preferred type of health reform; the best strategies and messaging; whether to pursue reform at the state or federal level; and how prevention can be a cornerstone for reform. My sense is we need all of the above: multiple efforts on different tracks and different venues—to meet this challenge.

There’s agreement on a couple of things, including the absolute urgency for reform. Many people are uninsured, or concerned their coverage won’t be there for them when they need it. Lack of adequate health coverage has direct health and financial consequences. The uninsured—and underinsured—live sicker, die younger, and are one emergency away from financial ruin.

A couple of the articles debate the kind of health reform to pursue and point out issues with experiments like the Massachusetts reform and Medicare. I was privileged to contribute an article on some of the lessons learned from the debate in California, and about how we can be ready for the next round.

We have a new window of opportunity in 2009 to confront these issues, with a new President and new Congress. While California had a health reform effort stall recently, there is enough support and momentum that the window for comprehensive reform will re-open at the state level as well, with new legislative leaders and a Governor who still wants to pursue big reform in his last two years. In California we have an opportunity to pursue state reform, to both bolster and shape federal efforts, alongside our own direct pursuit of a national solution.

So will we be ready? Yes, if we learn lessons from our multiple-year experience in California, and help educate our friends around the nation. We Californians have much to tell: no other state has had such a robust discussion of health reforms in the past five years. Our legislature has advanced multiple reforms—expansions of job-based coverage, universal children’s coverage, a single-payer system, and a comprehensive “shared responsibility” approach—and all these ideas are still on the table.

To be ready, we need to lay the foundation this year. Proposed budget cuts would take us backwards in terms of access to health care. The budget—and current programs like Medi-Cal and Healthy Families--are the foundation on which health expansions will be built. While shoring up the budget with new revenues, we can also pass other policy reforms that are building blocks toward universal coverage.

Most of all, we need to plan and prepare for the next stage of the great health debate—as previewed in The American Prospect. We have a real opportunity in the next year or two and we need to take it.

(Cross-posted at Bob's Blog, as a guest post on the new and renewed conversation on health reform, at the website of The California Endowment, an important funder for the Health Access Foundation and many key health programs and organizations in our state.)

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posted by Anthony Wright | Permalink | 12:11 PM


 
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We live to fight another day for drug discounts...

 
Wednesday morning, without taking testimony, the Senate Budget Subcommittee chaired by Senator Elaine Alquist, with Senator Alex Padilla concurring, voted to eliminate funding for the drug discount program.

At noon time, I came back to the office and looked at the blog post by my colleague, Hanh Quach, with that wonderful picture of Governor Schwarzenegger signing the bill, framed on either side by supporters including Anthony Wright, Health Access executive director, and Assembly Speaker Fabian Nunez, who stepped down from that position a week ago yesterday.

I found it hard to believe that only a week after Nunez had stepped down as Speaker, the Assembly would just agree with the Senate and eliminate funding for the drug discount program that every article on his tenure as Speaker cited as one of his major accomplishments.

At 1:30pm, I found out I was wrong. The Assembly Budget Subcommittee convened and we discovered that they too planned to eliminate funding, in the technical language of the legislature, “conforming” to the Senate action. Things can move quickly around the Capitol.

I noticed that somehow the drug companies had found out that they were about to win a delay in this program that they had fought so hard to stop—I saw several of their lobbyists in the back of the hearing room.

Fortunately, the Assembly Budget Subcommittee allowed public testimony. Bill Powers, advocate for California Alliance of Retired Americans (CARA), and I spoke. I pointed out that Health Access had sponsored a ballot measure that Pharma spent $80 million to defeat and that the law was a compromise based on the Legislative Analyst Office (LAO). Consumers and labor supported the law, Pharma bitterly opposed. I said we strongly opposed not funding the program.

Bill Powers spoke about the travesty of the Medicare drug program where Medicare cannot negotiate prices with the drug companies. He pointed out that the State of California negotiates with drug companies for both Medi-Cal and for this new program for the uninsured. Medi-Cal gets very good prices from the drug companies—that is why they opposed this new discount program. If we don’t get the new program, Bill said, we will never know for sure how much we can benefit the uninsured.

And rare in what all too often feels pre-scripted, Assemblymember Patty Berg, the Budget Sub chair, moved to hold the item open, postponing action to another day. The Democrats present, Assemblymembers Jim Beall and Ed Hernandez, concurred. I was so relieved I forgot to notice what the Republicans did.

So we still have a chance to win. But it is a slim one. At any time, the Assembly could agree with the Senate and consumers will be out of luck on drug discounts and the drug companies will have won through the backdoor because of the bad budget year. It seems a poor tribute to the work Speaker Emeritus Nunez has done on health care.

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posted by Beth Capell | Permalink | 10:13 AM


 
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Getting over a huge hurdle...

Thursday, May 22, 2008
 
HEALTH ACCESS UPDATE
Thursday, May 22nd, 2008


FISCAL COMMITTEE REPORT: OUTCOME OF KEY HEALTH BILLS
* In budget crisis, only a third of proposed bills pass Appropriations Committee
* Health bills move to standardize insurance, provide transparency, protect consumers
* Deadline to pass full floor vote in the house of origin is Friday, May 31st


Click Here for What's New on the Health Access WeBlog: Budget reactions; The media's miss in reporting the impact of the health budget cuts; Over 1,000 rescinded patients reinstated; the lessons of health reform for the budget, and vice versa; Big balance billing fight; McCain's high-risk pool highjinks from California perspective; Prescription drug discounts in peril


Today was a big day for the fate of many bills of interest to health advocates, which would provide consumer protections and place needed oversight over health insurers and providers.

For those who follow legislation, the Appropriations Committees in both the Assembly and Senate made decisions about whether to let legislation proceed to floor votes, or to hold them in committee, evaluating them on how much the bills will cost the state's general fund.

The Appropriations Committees in both houses considered nearly 600 bills Thursday. Given the state's $17.2 billion -- and growing -- deficit, only one-third passed. In the Assembly, only 79 of 414 bills survived. In the Senate, it was 99 out of 157 bill passing--and of the only $26 million in general fund spending approved, $23 million was in two bills responding to court orders.

Many health consumer bills in committee--many with no general fund cost--cleared this hurdle, however, and will head to the respective houses next week. All bills must pass their respective houses by May 31st. Many bills face difficult floor votes next week.

BELOW is a list of health consumer bills--it will be updated on the Health Access California website as the session continues, at http://www.health-access.org/advocating/2008_bills.html

For every bill, the list includes the bill number (the author) and A SHORT DESCRIPTION IN CAPS: There's also a longer description of the legislation, Health Access California's position on the legislation, and finally, where the legislation is currently pending.

Health Access will send out another list Friday of all bills pending on the Assembly and Senate floors for a vote. Coverage of the floor votes will be available on the Health Access blog, at: http://www.health-access.org/blogger.html


Health Access California -- Selected Bill List

INSURER REGULATIONS

Insurance Oversight & Market Reforms
· PASSED- SB 1522 (Steinberg) INSURANCE MARKET STANDARDS: Would sort health insurance policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic.’’ Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing, and assist consumers in making apples-to-apples comparisons between plans. Would weed out “junk’’ insurance by developing minimum benefit standards. Health Access California is the sponsor. Support. PASSED Senate Appropriations. To Senate Floor.
· PASSED- SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care. Support, seek amendments. PASSED Senate Appropriations. To Senate Floor.

Rescissions
· PASSED- AB 1945 (De La Torre) INDEPENDENT REVIEW: Would require approval by Department of Managed Health Care or Department of Insurance for each individual rescission. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- AB 2549 (Hayashi) TIME LIMIT: Would impose a six-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved. Support. PASSED Assembly Appropriations. To Assembly Floor.

Benefit Mandates
· PASSED- AB 1887 (Beall) MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- AB1962 (De La Torre) MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services. Support. PASSED Assembly Appropriations. To Assembly Floor

Improved Insurance Options
· HELD IN COMMITTEE- SB 1622 (Simitian) PUBLIC INSURER: Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices. Support. HELD. Will not advance this year.

HEALTH CARE PROVIDERS

Transparency
· PASSED- AB 2967 (Lieber) TRANSPARENCY AND DISCLOSURE: Would require public reporting of cost and quality by doctors, hospitals HMOs and others in the health care industry. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- SB 1300 (Corbett) CONFIDENTIALITY CLAUSES: Would prohibit confidentiality clauses, which keep secret information on pricing and health care quality from consumers, in contracts between providers and insurers. Support. PASSED Senate Appropriations. To Senate Floor.

Doctor and Hospital Oversight
· PASSED- AB 2146 (Feuer) ‘NEVER EVENTS’: Bans providers from billing patients or insurers when they have made an avoidable mistake, such as operating on the wrong person, prescribing the wrong drugs, or leaving foreign objects inside a surgery patient. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- AB 2942 (Ma) COMMUNITY BENEFITS: Would standardize what non-profit hospitals report as “community benefits” to justify their non-profit status. Support. PASSED Assembly Appropriations. To Assembly Floor.

Hospital Transactions
· PASSED- AB 2741 (Torrico) HEALTH IMPACT ANALYSIS: Would require for-profit hospital sales to undergo health impact analyses to gauge the transaction’s effects on the affected community, health care services, and the community’s public interest. Support. PASSED Assembly Appropriations. To Assembly Floor.
· PASSED- SB 1351(Corbett) OVERSIGHT: Would require Attorney General oversight into transactions involving district hospitals. Support. PASSED Senate Appropriations. To Senate Floor.

Balance Billing
· PASSED- AB 2220 (Jones) BINDING ARBITRATION: Requires providers and health plans to resolve contracting and payment disputes through binding arbitration. Watch. PASSED Assembly Appropriations. To Assembly Floor.

UNDERSERVED COMMUNITIES

· PASSED- AB 2902 (Swanson) COMMUNITY HEALTH WORKERS: Would require the Office of Multicultural Health to encourage the use of community-based health care workers to help facilitate and coordinate better health outcomes in underserved communities. Support. PASSED Assembly Appropriations. To Assembly Floor.
· HELD IN COMMITTEE- AB 3027 (De Leon) LANGUAGE ACCESS: Would require health plans to translate materials into Medi-Cal threshold languages. Support. HELD in Assembly Appropriations. Will not advance this year.
· HELD IN COMMITTEE SB 1332 (Negrete-McLeod) MANDATORY MEDI-CAL MANAGED CARE: Would require seniors and persons with disabilities in Riverside-San Bernardino Counties to enroll in Medi-Cal managed care. Oppose. HELD in Senate Appropriations. Will not advance this year.

COVERAGE

· HELD IN COMMITTEE: SB 1593 (Alquist) BRIDGING COVERAGE: Would clarify that children currently covered by county health initiatives would be first in line to receive Medi-Cal and Healthy Families coverage once those programs are expanded. Support. HELD in Senate Appropriations. Will not advance this year.

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posted by Anthony Wright | Permalink | 9:35 PM


 
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Senate Bill update

 
Senate Appropriations ran through their suspense file. Here is the outcome for bills tracked by health consumer advocates:

  • SB 1522 (Steinberg): Standardization of the Individual market -- PASS
  • SB 1440 (Kuehl): Requires insurers to spend at least 80% of premium dollars on health care -- PASS
  • SB 1351 (Corbett): Requires attorney general oversight into transactions involving district hospitals -- PASS
  • SB 1332 (Negrete-McLeod): Pilot Medi-Cal managed care program -- FAILED
  • SB 1622 (Simitian): Would knit together local county initiatives to create a public insurer that would compete with private health plans -- FAILED

SB 1522, SB 1440 and SB 1622 are all bills that came out of AB x1 1 from the Year of Health Reform and would begin to lay a foundation for comprehensive health reform.

Those bills that pass today will need to pass floor votes by next Friday.

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posted by Hanh Kim Quach | Permalink | 2:58 PM


 
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Senate Committee says No to Prescription Drugs

Wednesday, May 21, 2008
 
The Senate budget subcommittee that oversees the state's health budget voted to eliminate funding that would have implemented the California Discount Prescription Drug Program.
By eliminating the $5.8 million in funding for this program, the work that state officials have done the past two years in negotiating lower rates will go to waste.


As many may recall, health advocates went through a bruising battle against Big PhRMA in 2005 ($80 million spent against us) on the ballot, and then won a year later when Gov. Arnold Schwarzenegger signed the bill and even had a fancy signing ceremony in the Capitol Rotunda.

The discount drug program would have allowed the state to negotiate discounted drug prices from pharmaceutical company, helping approximately 5.4 million uninsured families -- the people who now pay FULL PRICE for prescription drugs -- buy drugs at fairer prices. If drug companies did not give satisfactory discounts, then the state could have used the purchasing power of Medi-Cal to leverage lower prices.

Californians below 300% of poverty ($63,600 for a family of four) would have been able to buy drugs at 40-60% off the sticker price. While that's still more than many of us pay for our drugs (insured Californians often pay a fixed co-pay), it's still a lot less than what they pay without the program.

So that means middle-income and low-income Californians, who are already seeing the substantial reductions in their health benefits through public programs for their children, and schools, will now have to pay more for drugs.

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posted by Hanh Kim Quach | Permalink | 11:22 AM


 
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More on high risk highjinks...

Saturday, May 17, 2008
 
Our post on the state of California's high-risk pool, MRMIP, has gotten web attention by the new Health Wonk Review, hosted at the Healthcare Economist this week, and by multimedia globetrotting journalist Sarah Arnquist at The Health Care Blog, on a post about people so desperate for coverage--and yet denied in in the individual market--that they'll marry in order to get good group coverage.

Again, the focus here is the key. Consumer advocates are actively working to improve the sorry state of the individual market--Health Access has a bill, SB1522(Steinberg), to better standardize the market, so that people have a better sense of what they are getting. AB1945 (De La Torre) has provisions to place oversight over any rescissions, and in fact to standardize the underwriting procedures of insurers, such as the dreaded questionnaire. And then there's AB2 (Dymally) to improve the high-risk pool for those who are denied because of pre-existing conditions.

While all these reforms are needed in the individual market, a preferred solution is to avoid these problems altogether by having people come together in groups (whether through employers, public programs, or large purchasing pools) to get coverage. In contrast to the Obama, Clinton, Edwards, Hacker, Kuehl, and Nunez/Schwarzenegger plans, the McCain plan actively works to shift people from group coverage into the individual market, and that's the fatal flaw. McCain may offer some support of state "high-risk" pools as a way to "solve" the problem--a worthy effort by itself--but the very nature of his proposal makes the problem that needs to be solve--people facing denials for "pre-existing conditions"--much worse, and his solution doesn't begin to undo the damage.

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posted by Anthony Wright | Permalink | 8:46 AM


 
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Guest blog on balanced billing from a veteran health advocate...

Friday, May 16, 2008
 
Beth Capell, Health Access' contract lobbyist extraordinaire, has been advocating for consumers for more than two decades. She offers these thoughts on balance billing, an insidious practice of some doctors and hospitals who decide to threaten insured consumers with aggressive collection agency if the consumer does not pay the “balance” between the insurer or HMO paid for their care and what the doctor or hospital wanted to be paid. (Relatedly, we blogged on a recent and egregious example of the Prime/Kaiser situation. 5/17 UPDATE: There's a new development, where a legal injunction has been ordered, as reported in the Orange County Register on balance billing. The LA Times also has a story.)

“Balance” billing has been illegal for Medicare and Medicaid enrollees for decades. It is illegal for HMO enrollees if they go to a contract facility. And until a few years ago, we probably would have said balance billing was illegal when an insured consumer got emergency care, even at a non-contract hospital.

As consumers, we are sympathetic to doctors and hospitals who feel badly treated by HMOs and insurers. We know what that’s like.

But as consumer representatives, we are pretty impatient with doctors and hospitals that treat consumers badly. We don’t like that either. And when it is all about a billing dispute between providers and plans, we say a pox on both their houses: get consumers out of the middle.

Well, this week DMHC had a hearing on a regulation to do just that: to say that if a consumer with coverage regulated by DMHC gets emergency care, then the consumer is only responsible for applicable copays or deductible, not for the difference between what the emergency doctor or the hospital wanted to be paid and what the HMO paid. Health Access is fortunate that our representative at this hearing is Elizabeth Abbott, who formerly headed the federal Centers for Medicare and Medicaid Services (CMS) in the western region of the United States: she has heard plenty of plan-provider disputes in her day and has no surfeit of patience with whining. She reports that doctors are furious at the proposed regulation.

As we said, we are sympathetic to doctors and hospitals fighting with HMOs. And indeed we as well as the Department have spent endless hours listening to the complaining of doctors and hospitals.

After all that, we know several things: first, consumers deserve to be protected from bad behavior by doctors and hospitals as well as HMOs and insurers. Second, under California law, doctors and hospitals that do not have a contract with the consumer’s HMO do in fact get paid and usually get paid in a reasonable period of time (less than 60 days). So what are the doctors and hospitals fighting with the HMOs about? It turns out it is not just about the amount of the payment but also what counts how.

You would think that it would be easy to decide that when an ER doc takes care of you because you have a broken bone, he should be paid for reading the x-ray or MRI, but it turns out whether that is part of the bundle of services or not is part of what providers and plans fight over. And they fight over it partly because there is no standardization of bundling. The docs, not surprisingly, want the bundling system the docs have developed (called the AMA/CPT code, if you care). But Medicare decided a long time ago that letting the docs set the rules by which they are paid does not make much sense and ditto with Medi-Cal.

And we made it lots more complicated in California when we allowed the development of the “delegated medical model”. (If your eyes are crossing, welcome to my world.) That means that Blue Shield does not just contract with individual docs, but instead contracts with Sutter Medical Group or Hill Physicians or Beaver or Scripps or some other outfit with thousands of docs and hundreds of thousands of patients. So if you are a Sutter Medical Group patient but you end up at UC Davis emergency room because that is where the ambulance took you, what are the rules for bundling the claim? Is that thing-y they put on your finger to check your blood oxygen in or out of the bundle? Is it the Medicare rules? The Sutter group rules? The Blue Shield rules? Or are you actually HealthNet? And why do you care? Well, probably you will when the ER doc or the hospital loses their
patience with the HMO and just decides to send you to collections and let you
fight it out with the HMO.

And yes, this is yet another way in which our current system piles on administrative overhead for no good reason. So in addition to fighting to prohibit balance billing of consumers, we are trying to help figure out how to minimize the provider-plan disputes by supporting a single set of rules for bundling as well as other changes.

The need to end balance billing got a lot more obvious this week when we found out that one hospital system in Southern California, Prime Healthcare, had sent over 6,000 Kaiser members to collections because Kaiser would not pay whatever Prime Healthcare wanted to charge for their emergency care. Prime Healthcare is a system that refuses to contract with most insurers---so it is not just Kaiser members who are at risk: it is anyone with insurance who walks into their emergency room. It looks as if Prime Healthcare took on Kaiser first but nothing prevents the hospitals from doing the same thing to consumers covered by other insurers that Prime fails to contract with. And Prime also seems to be engaged in the same old game that for-profit Tenet used to play of turbo-charging the charges for care so that the sticker price goes up and up.

As well as the proposed regulations, we are working on AB1203 (Salas) and SB981 (Perata) to prevent balance billing of patients who get emergency care. While both these bills are still in progress, we hope this year we can get consumers out of the middle of these provider-plan disputes.

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posted by Hanh Kim Quach | Permalink | 4:53 PM


 
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...and don't forget health reform

 
In Schwarzenegger's presentation on the budget Wednesday, when being grilled by the media on the specifics of his lottery proposal and other elements of his budget, he made a point to invoke his "don't forget health reform" pitch: he indicated it was a shame it didn't pass earlier in the year, and how he is still committed to doing health reform in his term.
"As you know, we have made severe cuts in health care. And when it comes to health care, what is even more painful is that we didn't get health care reform done, because that would have given Medi-Cal an additional $4 billion dollars. So we are going to go and continue staying on that subject of health care reform, and continue working with the stakeholders together to get this done."

Some, especially those in the Senate, used the budget crisis as an excuse to stall AB x1 1, the negotiated plan between the Governor and the Speaker, saying it wasn't the right time for such an ambitious effort in the middle of a budget crisis. Others, especially in the Administration, stated that the budget deficit only reinforced the urgency of health reform.

My take: Passing health reform would not have prevented the tough choices presented by the budget crisis, but it would have provided additional--and better--options for a solution.

What would have happened if the plan passed? AB x1 1 and its companion ballot measure would have raised $15 billion in new revenues for health care coverage expansions and provider rate increases.

There's no doubt that the cuts announced today and back in January take us in the absolute opposite direction--a cut of $2 billion plus in both state and federal funds. Instead of raising $15 billion with AB x1 1, we are facing gruesome cuts:

* Instead of expanding Medi-Cal coverage and broadening the eligibility rules, the Governor has proposed restricting eligibility.

* Instead of raising provider rates, the Legislature and the Governor has already cut those rates, so millions now have less access to doctors and hospitals.

* Instead of streamlining and simplifying these programs, the Governor proposes making them more bureaucratic and cumbersome.

* Instead of bringing in more federal matching funds, the Governor proposes making cuts and thus losing those matching funds, leaving even more federal money in DC.

* Instead of dramatically reducing the number of uninsured Californians and the resulting "hidden tax" on the health system as a whole, the Governor's proposal would markedly increase the rate of uninsurance, for children and families.

If we had passed health care reform and still had to deal with $2 billion in cuts, then that would have meant that we only had $13 billion for health care expansions and improvements--and so then we would have the choice of raising additional revenues to make the new expansions and commitments whole again, or restructure the proposal to work with the $13 billion (rather than $15 billion) raised. Any of those choices, while tough, would have been preferable to what we have now.

If adopted, the Governor's proposed cuts take us further from the goal: it digs a bigger hole, that will need to be filled before embarking on additional expansions.

Medi-Cal and Healthy Families are the foundation for health reform, on which additional expansions are built atop--but that only works if the budget that funds them are strong and sustainably funded.

We will also be pursuing legislative and policy reform that we believe lays a foundation for reform in 2009-10, and we are pleased that the Governor have indicated an interest in such efforts. But the budget is also a key foundation that needs a resolution this summer.

Even with these ugly budget cuts hanging in the air, I have to hope that the Legislature will once again decide to reject these health cuts as too severe, as they have in the past. I have to hope that constituents in rural and "red" areas care about their schools, emergency rooms, seniors and children as much as anyone else.

And I have to hope that the logic of health reform will prevail upon this Governor: that the best arguments against these cuts, and for revenues to prevent these cuts, were all made by this Governor last year as he stumped for health reform:

* that California is visionary enough to get everybody covered, and not leave people to be uninsured;
* that Californians are willing to contribute to support and expand health coverage;
* that we need to invest in our health care system, for its own sake and to bring in new federal matching dollars that are left in DC; and
* that investments in health care have broader benefits, including positive health, societal, and economic implications.

Finally, it's worth remembering that part of the Massachusetts health reform was a deal to restore of several key cuts to that's state's Medicaid program (for example, to benefits) made in previous years. Our work this year will be to prevent such cuts, so they won't have to be restored in the first place when we pursue comprehensive health reform in the near future.

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posted by Anthony Wright | Permalink | 12:20 PM


 
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Over a thousand patients reinstated...

Thursday, May 15, 2008
 
Major news today from Los Angeles, where the Department of Managed Health Care (DMHC) announced settlement agreements with Kaiser Permanente and HealthNet to automatically restore coverage to over 1200 patients who had their coverage rescinded.

Lisa Girion of the Los Angeles Times, who's been on this story like a hawk, has an early story.

Here's the Department of Managed Health Care's press release and text of the actual settlements with the two insurers. Kaiser had the bulk of the rescissions--over 1,000, even though they stopped the practice two years ago. The real question now is whether the other leaders in the individual market--Blue Shield, and especially Blue Cross, will also come to terms.

A few weeks ago, consumer advocates stood with the DMHC Director Cindy Ehnes when they announced that all of the 5,000+ people who had their coverage retroactively rescinded since 2004 would be provided an independent review process so that they can get their past treatments paid for, get appropriate restitution, and get reinstated for coverage going forward.

These settlements go beyond that, in getting the plans to reinstate the patients without the uncertainty and administrative hassle of a review, and with the agreement not to challenge the reinstatement in court--something that some plans were threatening.

We appreciate the Department's focus on getting people their care and coverage first and foremost. We are pleased that over a thousand patients will get reinstated without further procedural barriers and heartache. The patients will appropriately be made whole for the expenses they have had to bear, but also ensured coverage so that are not left alone and abandoned, uninsured and uninsurable because of their so-called pre-existing conditions.

And while we think the fines don't match the scale of the insurer's wrongdoing, the priority is to make the patients whole, and to make sure they have coverage. We appreciate the focus on back-end enforcement of this settlement and the possibility of much steeper fines, and hope the Department adopts a 'zero-tolerance' policy for further bad behavior by these insurers.

Thousands of other patients are waiting to see if their health plan will agree to a settlement, or if they will have to go to a more cumbersome process to get coverage, either through the Department or in court. It's sad that after all the attention on this reprehensible practice by insurers, we don't have the entire industry seeking to make this right.

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posted by Anthony Wright | Permalink | 8:43 PM


 
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It's worse than what you read...

 
The news coverage of the budget, if anything, has downplayed the impact of the budget on health care. Let me focus on what we consider is the biggest of the cuts newly announced yesterday, that would impact the most number of people.

The San Francisco Chronicle mentions that the Medi-Cal eligibility cut would mean that "40,000 poor working parents, who now receive comprehensive Medi-Cal coverage, would have their benefits reduced if they earn more than about $12,000 for a family of three."

Actually, these parents, who would make roughly $10,736-$17,600/year for a family of three, would lose access to Medi-Cal coverage. Some might be eligible for other programs, but many would simply become uninsured.

More to the point, the 39,000 people impacted in the first year is only the beginning. In a few years, after full implementation, the cut would deny coverage to 439,000 Californians.

The Los Angeles Times described it in this way, that the budget would "Deny thousands of impoverished parents healthcare coverage that they now have through the state's Medi-Cal program. Under the change, a single parent with one child who earns more than $8,540 a year would no longer be eligible." Tha was correct, but downplayed the massive scale of the cut--that the impact was eventually deny *hundreds of thousands* of Californians.

The Sacramento Bee has an article that doesn't go into the specific horror of the cuts.

The sidebar that describes the budget "highlights" doesn't even mention this cut to Medi-Cal eligibility--even though it is the health cut with the biggest impact in the May Revise. That sidebar does list some of the bad cuts, but also neglects to mention a major-dollar proposed cut from January, that would also eliminate key benefits, like dental, optometry, and podiatry, for millions of adults on coverage. It's unclear why some cuts were included and other, bigger cuts were not.

Let's hope that future coverage of the budget goes into the full implications of what is being proposed here. The cuts are bad enough that they don't need embellishment, but they do need coverage, so Californians can understand the stark choices, and how they would impact our fellow citizens and our health system.

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posted by Anthony Wright | Permalink | 10:19 AM


 
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Other reactions to the health budget...

Wednesday, May 14, 2008
 
Shane Goldmacher at the Sacramento Bee's Capitol Alert has a useful compilation of some of the reactions to the budget. Here's some that touch on the health budget, from Health Access board leaders, member organizations, allies, and others:

Marty Hittelman, president of the California Federation of Teachers: “The governor’s budget revision tries to protect education, but lacks the funding to do it... Shifting the bulk of the cuts to health and human services is a disguised cut to education. These programs aren’t isolated from schools. Our students need to come to school ready to learn, and they can’t do that hungry or sick.” “School kids did not cause this crisis,” said Hittelman. “Their teachers and school staff are being confronted with uncertain futures. It’s time to put in place a fair, stable and progressive funding source for education and other vital services.”

Ted Lempert, president of Children Now: “It’s mind-boggling that too many of our state's leaders still can’t see the shortsightedness of cutting children’s health, education and economic support. California’s children currently are well behind national average measures of well-being and per-child funding. It’s also clear that investment in these programs today will reduce the state’s future costs and increase its future revenues. Yet California continues to make decisions that are leading us closer and closer to a next generation that can’t support our human capital needs and increasingly overburdens public costs. We’re shortchanging our future in big, bad ways.”

Annelle Grajeda, president of SEIU California State Council and SEIU Local 721: “We need our elected leaders to understand that the people of California will not accept cuts that hurt our children, seniors, and communities. The proposed budget reflects a short-term mentality, but we’ve got a long-term problem on our hands. Cuts that yield quick savings now but create costly problems later are unwise. This budget is a missed opportunity to move the ball forward."

Cathy Maupin, interim executive director of the California Children's Defense Fund: “In a state with the 8th largest economy in the world, it is a moral outrage that cuts to foster care, health coverage, cash assistance for children, and food programs are even being considered. Our policy makers must recognize that every step taken to improve the lives of children improves the lives of all Californians. Instead of structuring our state budget to address the urgent needs facing millions of California’s families, the Governor proposes once again to balance the budget on the backs of our state’s most vulnerable population: children. In many cases one family will feel the effects of multiple cuts simultaneously. For example, the same child receiving CalWORKs may experience a freeze in her cash benefits, be disenrolled from health care, and have her food assistance benefits reduced."

Tom Porter, California state director AARP: "AARP is extremely disappointed with the Governor’s 2008 May budget proposal, announced today. Far from improving upon his initial budget proposal, the Governor’s budget revision proposes even deeper cuts to critical services to the most vulnerable Californians.

AARP believes that highest priority in the budget process should be given to programs that serve the state’s most vulnerable populations – specifically low-income children, as well as disabled and older adults. The budget should not be balanced on the backs of these most vulnerable Californians. We believe our elected leaders should fully fund the “safety net” programs that are critical to the well-being of those who cannot care for themselves. Further, our health care system is failing. Drastic cuts have already weakened these critical programs. If approved, the Governor’s new proposal means fewer people will have access to services and the health care crisis will simply get worse. AARP believes that policymakers should consider revenue enhancements rather than cut services to California’s most vulnerable persons."

C. Duane Dauner, president of the California Hospital Association: "The May Revision of the Administration’s proposed 2008-09 State Budget contains bad news for health care consumers across California. With the state facing a projected $17.2 billion deficit, the proposal released today would result in crushing, disproportionate cuts to the Medi-Cal program - including up to $184 million in cuts to hospitals caring for the most vulnerable in our state. Adding insult to injury, these proposed cuts come on top of more than $1.3 billion in Medi-Cal reductions to all health care providers that were enacted earlier this year and are scheduled to take effect on July 1, 2008.

The additional payment cuts proposed in the May Revise include $22 million for inpatient services provided at hospitals that do not contract with the Medi-Cal program; $54 million in cuts to some public hospitals through the Safety Net Care Pool; and approximately $12 million in payment reductions in the Medi-Cal managed care program. Additionally, hospitals may experience up to an additional $96 million in losses as a result of changes being proposed to Medi-Cal eligibility and benefits.

If these additional cuts are adopted into law, more patients covered by the Medi-Cal program will not receive needed health care services. Some hospitals cannot meet payroll beginning in late June as a result of the 10 percent cuts and payment delays already enacted; other hospitals will be severely affected. It is a lose–lose proposition for both patients and hospitals.
California’s hospitals have a long-standing commitment to ensuring that every Californian should have equitable access to safe, affordable, high-quality, medically necessary health care. But this goal is endangered by the proposed slashing of the Medi-Cal program. California already ranks dead-last in the nation when it comes to funding health care for Medicaid patients. Further reductions only serve to fracture an already broken health care system, while at the same time costing the state in lost matching federal dollars."

Dr. Richard Frankenstein, president of California Medical Association: "These budget cuts will devastate access to health care for millions of poor Californians and will wreak havoc on the ability of middle class Californians to meet their health care needs. If this budget somehow passes and even a fraction of these cuts go into effect, Governor Schwarzenegger's legacy to the people of California will not be the health care reform he has promised, but instead a health care system damaged beyond belief.

All Californians should sit up and take notice. These cuts will not just take wheelchairs away from the disabled, deprive poor children of access to their critical health care needs, and leave seniors stranded. The cuts will also raise the costs of health care for employers and families, undermine the quality of care in emergency rooms, and shut down doctors' offices, hospitals, pharmacies, and clinics in communities across California. The health and well-being of all Californians will suffer under this budget.”

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posted by Anthony Wright | Permalink | 11:59 PM


 
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A deeper wound for our health care system...

 
HEALTH ACCESS UPDATE
Wednesday, May 14th, 2008


GOVERNOR'S MAY BUDGET REVISION MAKES DEEPER HEALTH CUTS

* Budget shortfall projected at $17.2 billion; Governor continues "cuts & borrow" approach
* Health cuts keep in place January proposals, goes further in directly denying coverage
* Hundreds of thousands of the poorest working families would lose coverage

Click Here for What's New on the Health Access WeBlog: Much more on the budget cuts; Welcome, Speaker Bass; Bass and health reform; Balance billing; Canadian health care; Underinsurance; Who gets hurt by a cuts-only budget?; High deductible health plans for who?; MRMIP's waiting list; McCain's risky high-risk pool proposal; The new opportunity for health reform; Big Tobacco's track record on reform; More on the McCain health plan.


SACRAMENTO--Gov. Arnold Schwarzenegger released the revised version of his budget proposal today, which makes deeper cuts in health and human services programs in order to address the state’s shortfall, which has grown by nearly $3 billion since he first released the budget in January. Altogether, the $100 billion general fund budget is $17.2 billion short.

“The crisis is very real and it is very serious,’’ the governor said. His proposal would attempt to bring in $11.7 billion in new money ($3.5 billion from deficit bonds of years past), and another $5 billion by selling the lottery’s income to Wall Street. Schwarzenegger would cut an additional $12.5 billion from state programs, on top of the $1 billion that was cut earlier this year to help minimize the deficit.

“We had to make very difficult cuts. No one wanted to do this. But because health and human services was the second largest part of the budget, this is where we had to cut,’’ Schwarzenegger said. Twenty percent of the cuts imposed come from Health and Human services, reported Director of Finance Mike Genest. Deficit aside, Schwarzenegger restored funding to some of his original cut proposals in January and will now keep parks open and will not release inmates nearing their release date early.

View the full May Revision at the website of the Department of Finance here: www.ebudget.ca.gov.

The Health and Human Services Agency has their summary of the health and human services cuts here, at:
http://www.chhs.ca.gov/Documents/HHS%20Budget%20Facts%20Final%205%2008.pdf

THE CUTS

CUTS ALREADY MADE (PROVIDER RATES): Health programs were already dealt a blow earlier this year. Medical providers that treat Medi-Cal recipients will see their reimbursement rates cut by 10% as a result of a budget cut package already approved earlier in the year. Already California ranks near the bottom for reimbursement rates for doctors caring for Medi-Cal patients. That cut -- saving the state $544 million (and losing an equivalent amount in federal matching dollars) -- will begin July 1st.

CUTS ALREADY PROPOSED AND STILL PENDING (MEDI-CAL BENEFITS, QSRs): Still pending from the Governor's January proposal are a range of cuts, such as eliminating benefits for adults on Medi-Cal, including dental coverage, optometry, podiatry, and other services. The pending proposals also included imposing additional paperwork burdens on children and families so hundreds of thousnads enrollees fall off the program (known as quarterly status reports).

NEW MAY REVISE CUTS: The Governor's May revision retain all cuts to health care proposed in January, that would make it harder for the 6.6 million children, parents, seniors and people with disabilities on Medi-Cal to get the care they need--by reducing access to providers, by eliminating benefits, by increasing paperwork so that it is easier to fall off coverage. The May Revision also does the one major type of cut that the January budget did not do--directly deny people coverage by changing eligibility rules. The May revision cuts of interest to health advocates are as follows:

* DENIAL OF COVERAGE TO LOW-INCOME WORKING PARENTS: Parents earning very low wages (roughly between $11,000 and $18,000/year for a family of three) would no longer be eligible for Medi-Cal coverage.

Under the new proposal, a family of three would need to earn even less: $891 a month, and work fewer than 100 hours a month. The cut is expected to reduce spending by $31.2 million this year, but increase to $342.5 annually in three years. In the first year of implementation, 39,000 parents would be denied coverage. After a couple of years of full implementation, over 429,000 Californians would be denied Medi-Cal coverage.

This proposal was also proposed for the 2003-04 budget by then-Gov. Gray Davis, but rejected. Earlier reform expanded coverage to these parents as part of welfare reform, so that families working their way off of welfare would not lose health coverage as they found jobs (that likely did not provide health benefits). If this cut stands, then the potential incentive is to work less, in order to keep coverage.

* CONTINUED BUREAUCRATIC ENROLLMENT PROCEDURES: The Administration, which had championed efforts to make it easier for families to enroll in public programs, is now further seeking to delay the implementation of SB437 (Escutia) of 2006, which would have streamlined and fast-tracked enrollment for children into Healthy Families or Medi-Cal. This delay saves the state $13 million.

* ADDITIONAL BENEFIT CUTS: Qualifying low-income legal immigrants who permanently live in the US will lose various benefits, including prescription drugs and dental coverage, and only get four services: emergency care, pregnancy-related coverage, certain long-term care services, and some cancer treatments. This would be a $86.7 million cut.

* MORE PAPERWORK FOR EMERGENCY SERVICES: The limited emergency services coverage that Medi-Cal provides to undocumented immigrants would be more limited, through the implementation of a monthly eligibility process. The savings would reduce state payments to California health providers by $42 million.

* CUT TO NON-CONTRACTING HOSPITALS: Hospitals that don't contract with Medi-Cal would face a rate cut of either 5% of regional contracted rates, or 90% of cost, whichever is lowest. This would provide $11.2 million in savings.

* COST AND QUALITY DATA: The budget proposes to take money from the state’s Health Data and Planning Fund, which would be used to give consumer a glimpse of providers’ prices, error rates and other key information that would help health care purchasers make informed choices. This cut saves $12 million.

Again, these cuts come on top of more than $1 billion cuts proposed in January. The governor had previously proposed higher premiums and co-pays for Healthy Families enrollees, requiring families to report changes to their income every three months in order to remain on Medi-Cal, and the elimination of essential benefits, such as adult dental care and incontinence creams and washes for aged, blind and disabled Californians.

View the fact sheet and previous reports here and here.

WHAT'S NEXT

With the latest budget figures, the Legislature can now begin making decisions and negotiating on the budget in earnest. Many decisions had been postponed -- in part because it was unclear how much money the state had to work with, and in part, because the cuts were so untenable. Next week, budget subcommittees will continue to hammer out details. Health Access will monitor the status of the health budget proposals and keep advocates informed.

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

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posted by Anthony Wright | Permalink | 7:03 PM


 
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By The Numbers

 
Gov. Arnold Schwarzenegger's budget will impact tens of thousands of Californians. Here's a compilation of the cuts and lives affected:
  • Quarterly-status reports: 160,000 children; 15,000 adults impacted in 2008-09. Two-year total is 300,000 children impacted. Five-year total is 471,000 impacted. Requires families to justify every three months that their income has not changed. If they fail to do so, they would be dropped from Medi-Cal.
  • Elimination of essential benefits, such as dental, speech therapy, eyeglasses and optometrist services and incontinence creams and washes.
  1. Dental: 900,000
  2. Optometrists: 214,000
  3. Eyeglasses and Contact lenses: 457,000
  4. Podiatrists: 85,000
  5. Incontinence creams and washes: 66,000
  6. Acupuncture: 33,000
  7. Hearing aids: 28,000
  • Seniors and Medicare premiums: Requiring some low-income seniors (earning, at most, $1,100 a month) to pay $97-a-month co-pay on for their Medicare coverage for doctors visits. 57,000 seniors affected.
  • Low-income working families: Would deem families earning very meager wages ($1,500 a month for three people) too wealthy to qualify for Medi-Cal. Such a family would need to drop its income to $895 a month -- and work no more than 100 hours a month -- in order to qualify. Numbers of people affected by this are unclear. We do know that 429,000 adults with children are on Medi-Cal now. About one-third of those are single moms.

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posted by Hanh Kim Quach | Permalink | 5:16 PM


 
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Ugly.

 
The Governor’s budget cuts will result in closing the doors to coverage and care for hundreds of thousands of Californians, and further unravel the broken health care system that we all rely on.

We need to remember: The new cuts that block people from getting coverage is on top of severe cuts already made this, and others still pending, that would reduce access to doctor and hospitals, eliminate basic benefits like dental care, and have people dropped from coverage. As a result, millions of Californians, including children, parents, seniors, and people with disabilities will live sicker and die younger as a direct result of these budget decisions.

THE BIGGEST CUT: The biggest of the new cuts is the "1931b" eligibility cut that would mean that a parent in a three-person family with a $11,000/year income would no longer be able to get Medi-Cal coverage. Such a cut is calculated to save $342.5 million a year in state funds, although it would also mean an equivalent loss of federal matching funds to our health system.

Developing...

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posted by Anthony Wright | Permalink | 2:01 PM


 
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Closing the doors to coverage and care...

 
The cuts are here, and they are bad. The Governor is proposing major new cuts to health and human services.

In Medi-Cal, the major new cut is to eligibility: changing the rules so that people will no longer be able to get coverage. Our back-of-the-envelope proposal is that hundreds of thousands of people would no longer be able to get health coverage...

More soon...

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posted by Anthony Wright | Permalink | 1:13 PM


 
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Bass fishing...

Tuesday, May 13, 2008
 
It was a moving ceremony today to install the new Speaker of the Assembly, Karen Bass.


Some common points were made in the various speeches and comments: her position is historic, as the first African-American female to lead a legislative body in the U.S.; her background in community organizing; her courage in the face of a recent tragedy of losing her daughter; and her personal interest in and advocacy for foster care children. She gave a beautiful speech as well.


Through the day, the topic that loomed was, predictably, the state budget. It's the task at hand, and one that will impact everyone in California, and every issue. And especially health care, given that health care is second only to education in its claim on the state budget.


Jon Myers at KQED Capitol Notes has an interview and asked about the future of health reform. While the new Speaker made clear that the budget was (appropriately) the first, second and third priority, she said, in reponse to Myers' questions, "I don't think it is dead at all... I absolutely want to get back to health care reform, but we have to deal with the budget first.... There will be time left in the legislative year to address health care reform.... No, I don't think it was too much bitten off.... I would very much like to tackle the whole issue."


Important signal. Shoring up the budget is an important foundation for health reform, but we have a Speaker that is willing to move forward this year and next, in order to win elements of a comprehensive reform package.


And so congratulations to Speaker Bass: she also now gets her own label on this blog, so that people can click on her below, and get most of this blog's posts related to her and health care.

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posted by Anthony Wright | Permalink | 10:45 PM


 
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The Quiet before the Storm

 
There's the steady drone of doom and gloom emanating from the Capitol, but Sacramento is collectively holding its breath, waiting for Gov. Arnold Schwarzenegger to release his updated budget proposal tomorrow in what's known in Capitol parlance as the "May Revise.''

This second version of the budget comes out a month after tax day, when the state has a better idea what kind of income it has to work with the following year ....and by all accounts, it has not been pretty. Estimates of the deficit -- which started at $14.5 billion in January -- are more like $16 billion to $20 billion now.

While the entire state budget is $140 billion -- the general fund, where we have the shortfall -- is $100 billion. That means the deficit is nearly one-fifth of our budget.

Accompanying the bad figures are equally as bad rumors: Cuts, cuts and more cuts. On the flip side, precious little in new income for the state.

For most of this decade, we have grappled with multibillion dollar deficits larger than the entire budgets of many of the states in the US. And what have we done? We've borrowed and cut.

And now, we're down to the bone. Many of you may recall -- and here's a reminder -- that the governor already proposed more than $1.1 billion in health program cuts, which will mean:
  • 500,000 children losing health coverage over the next five years because the state will require that their families report every three months any changes in their life.
  • People with disabilities, who live on (at most) $997 a month, could develop infections and sores on their body and other sensitive areas because they lose coverage for incontinence creams and washes.
  • The poorest adults will lose their dental care -- and many with already poor dental health will not treat their cavities, develop gum disease, abscesses and possibly lose their teeth.
We will all know at 1 p.m. tomorrow what the total damage will be. But this we know -- There are only three ways to cut Medi-Cal:
  • Reimbursement rates for providers -- Check. That was already proposed in January and approved by the Legislature months later to go into effect July 1.
  • Benefits to recipients -- Check. See a couple of the bullet points above.
  • Eligibility -- Quasi - check. Requiring families to justify their income every three months is a passive aggressive way to knock people off of the Medi-Cal rolls. The state is secretly hoping that families will be too overwhelmed, their life in too much chaos, they will lose or somehow fail to complete the form and send it in. Of course, that means 500,000 children won't get health care....

By process of elimination, a direct cut to eligibility is the only thing left for the state to do to the Medi-Cal program.

Let's cry ourselves to sleep and see what's in store for us tomorrow.

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posted by Hanh Kim Quach | Permalink | 6:38 PM


 
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Monetary Melancholy

Monday, May 12, 2008
 
Gov. Arnold Schwarzenegger is expected to release his May revision of the budget on Wednesday. In January, we had a $14.5 billion hole. By all accounts, it's at least larger than $16 billion now -- and possibly approaching $20 billion.

That's bad news for all of us. (See a list of health services cuts Health Access is tracking here.) Marty Omoto at the California Disability Community Action Network does a good job of laying out what's at stake here.

And San Francisco Chronicle has a story today about the big bad picture. California Progress Report also has an analysis.

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posted by Hanh Kim Quach | Permalink | 11:29 AM


 
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The timing could not have been better...

Friday, May 09, 2008
 

Dr. Prem Reddy, owner of Prime Healthcare Services, is running around terrorizing 6,000 Southern California Kaiser Permanente members -- sending them enormous hospital bills (via an aggressive collection agencies) and telling them to pay up, or ruin their credit. See the story here. One patient featured is being asked to pay $50,739.70 in full by June.


The company, with 9 hospitals Southern California, is demanding payment for emergency services that are currently under dispute with Kaiser. The patients are being told they must come up with the money to pay for their treatment (the portion that Kaiser is disputing and has not agreed to pay).


The tactic being used by the hospital chain is called "balance billing,'' where patients are asked to pay the difference between what the hospital billed, and what the insurance company paid. The Schwarzenegger Administration has been working on regulations to ban this practice, and in a strongly worded notice releasing their proposed rules, accused providers -- such as hospitals and physicians -- who engage in this behavior of using "innocent enrollees'' as "bargaining chips in an unfair provider billing pattern'' that leads to "long-term harm o the enrollee's health, safety and financial stability.''

Coincidentally -- the Administration's Department of Managed Health Care will hold a hearing on this very issue in Irvine on Wednesday, the heart of Orange County where three of Prime's hospitals are located (and presumeably many of the recipients of these giant bills.)

Testimony anyone?

(Relatedly, AB1203 by Mary Salas would ban this practice.)

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posted by Hanh Kim Quach | Permalink | 12:56 PM


 
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Rebuilding our muscle

Thursday, May 08, 2008
 
American manufacturers pay more than twice as much per hour for health benefits as the manufacturers in countries we regularly trade with, according to a new report by the New America Foundation that found for every $2.38 an hour paid for benefits by US manufacturers, others pay about $0.96. It's a losing proposition all around that:
  1. Makes our products more expensive -- read: less competitive. (ie. an American-made car costs $1,500 more due to health costs versus $900 more by foreign competitors.
  2. Results in American businesses trying to ratchet down what they pay in health care costs, and resulting in crappier coverage for their workers. (for more money, I might add)

  3. Results in jobs going overseas -- like Ford going to Canada as reported earlier this week.

The report runs through a litany of interesting stats, including:


  • In 1960, health benefits were only 1.2% of payroll. Now, it's more like 9.9% (averaged across all businesses, including those that *don't* provide coverage).

  • Since 2000, fewer employers are offering coverage (from 69% to 60%). But for workers that *do* get coverage on the job, it's costing more -- 102% more (from $135 to $273 monthly premium).

It also acknowledges that not all costs can be shifted to workers, either in higher premiums and out-of-pocket costs or lost wages, because it would affect a business' ability to be competitive in hiring good quality employees -- something all businesses must grapple with in order to stay competitive. And that the cost of health care can't depress wages -- particularly for those already making minimum wage ($5.85 or $8 in CA), or in cases where a labor contract acts as a backstop.

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posted by Hanh Kim Quach | Permalink | 2:24 PM


 
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Healthcare Armageddon

Tuesday, May 06, 2008
 
The New York Times had an excellent article this weekend about workers, who have health coverage through work, feeling financially strained.

The reason: businesses - unable to absorb higher health care costs - have decided that workers need to absorb more of these costs. Businesses are buying crappier coverage (this doesn't mean cheaper premiums, just cheaper than more comprehensive plans, but still expensive) and asking workers to pay a greater share of the premium. So not only are premiums for workers increasing, but the plans that they are getting are getting worse, which means higher copays, deductibles, and less coverage.

It used to be that worrying about how to pay for health care happened mostly if you didn't have insurance. Then, it started creeping into the ranks of the insured -- but only those who bought insurance on their own, without the benefit of a group buying in bulk to negotiate lower rates. Now, though, health cost worries are hitting the employer market -- where most Americans get their coverage.

One *insured* worker said he was losing the equivalent of a month's worth of pay with the higher premium and deductibles. That's in addition to the fact that the coverage isn't very good.
Another *insured* worker, who has diabetes, doesn't monitor her blood sugar regularly and can't afford to see an eye doctor on top of other normal everyday expenses.


The Times characterized these plans as "health insurance in name only.'' I like that: essentially people are paying to be uninsured under these plans.

My health plan colleagues would argue that having some kind of coverage is better than being uninsured. No?

But is it really? At what point does debt become so crushing that it doesn't matter if the number is $60,000 or $200,000 in debt, and accruing interest. Especially considering that families that are insured, earning more than 300% of the poverty level actually have negative (-$600) net financial assets according to the latest study by Health Affairs. On an annual income of $60,000, either way, you're screwed.

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posted by Hanh Kim Quach | Permalink | 2:01 PM


 
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A cuts-only budget harm knows no party...

Monday, May 05, 2008
 
The California Budget Project has an excellent resource on its website, showing the local impact of proposed budget cuts by county and by legislative district.

The county numbers are interesting, but you need to know the context of how big/small the counties are to begin with. (Alpine County has only 160 Medi-Cal recipients, and 2 children on Healthy Families; Los Angeles has 2.2 million on Medi-Cal, 250,000 kids on Healthy Families).

The legislative districts numbers are interesting because they are more comparable, having similar (although not the same) numbers in each district.

TOP FIVE DISTRICTS IMPACTED BY MEDI-CAL RATE CUTS: Five Senators have more than a quarter of a million constituents on Medi-Cal coverage--largely children, parents, seniors, and people with disabilities--who would lose access to key doctors and hospitals as a result of the proposed Medi-Cal provider rate cuts already adopted. These Senators would have hospitals and doctors in their districts lose over $50 million dollars in Medi-Cal funds.

These five (of 40 total) Senators are:
1) Florez (D-Fresno/Bakersfield): 306,820 on Medi-Cal; $62 million lost funding
2) Vincent (D-Los Angeles): 290, 260 on Medi-Cal; $59 million lost funding
3) Cedillo (D-Los Angeles): 278,180 on Medi-Cal; $56 million lost funding
4) Cogdill (R-Fresno/Ripon): 270,320 on Medi-Cal; $55 million lost funding
5) Ashburn (R-Bakersfield): 253,190 on Medi-Cal; $51 million lost funding

What's interesting about the list is the diversity. We have some districts from inner-city Los Angeles, but also the rural areas of the Central Valley. These districts are represented by Latino, African-American, and white legislators. And they are three Democrats and two Republicans: these budget cuts impact Republican and Democratic areas alike.

While California Republican legislators insist on a cuts-only budget, there are certainly many whose communities will be severely hurt by such a resolution to this budget crisis.

Republican Senators Denham and Runner also have lots of impacted constituents, with over 200,000 people on Medi-Cal in their districts. Of the eighteen (out of 80) Assemblymembers with more than 110,000 constituents with Medi-Cal coverage, eight are Republicans, including La Malfa, Aghazarian, Villines, Fuller, Maze, Runner, Adams, and Garcia.

TOP TEN DISTRICTS ON CHILDREN LOSING COVERAGE: So, as a result of the proposal to increase paperwork and administration burdens on Medi-Cal, here would be the top ten legislative districts that have the biggest number of children fall off coverage by 2010 and become uninsured: Florez (14,420); Vincent (14, 300); Cedillo (14,150); Calderon (11,760); Romero (11, 640); Cogdill (11,570); Ridley-Thomas (10,820); Ashburn (10,510); Padilla (10,490); Correa: (10,280). Again, a diverse crew in region, ethnicity, party, and ideology.

Unlike the other 3/4 of the Senate, these legislators each have over 10,000 children losing coverage as a result of the so-called "quarterly status reports." Sens. Denham and Battin also have high number of impacted children as well; in the Assembly, the list includes Berryhill, Aghazarian, Villines, Maze, Runner, and Garcia, who would have over 2,500 children lose coverage.

MAY REVISE AND BUDGET NEGOTIATIONS APPROACH. The California Budget Project has similar numbers for education, child care, and other programs. I haven't looked closely at those reports, but I imagine that my takeaway would still hold:

The budget crisis knows no bounds. Californians in both "red" and "blue" areas will get hit in a big way, whether cuts to schools, to child care, or to health care--where thousands and thousands of children and adults will have reduced access to doctors and hospitals, if not lose coverage altogether.

We need to come together to find an alternative to a cuts-only budget that would force such cuts.

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posted by Anthony Wright | Permalink | 3:50 PM


 
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Look who's moving to Canada

 
The Associated Press reports that the Canadian Auto Workers have signed a three-year contract with Ford. Chrysler is next.

High health care costs have been a primary source of angst for automakers, who two years ago made headlines by appealing to Washington for some kind of help. Since 2005, though, automakers' health care costs have declined by $2.1 billion. The United Auto Workers agreed to some changes, that resulted in increases costs for retirees and workers.

Salaried workers have seen premiums increase as much as 30%, out-of-pocket maximums increase by 33% to $4,000, and a tripling deductibles from $500 to $1,500.

All this -- and automakers are *still* moving to Canada.

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posted by Hanh Kim Quach | Permalink | 6:01 AM


 
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Who are these made for anyway?

Friday, May 02, 2008
 
Health Affairs has just released an excellent new study, which challenges the notion that high-deductible health plans with their low premiums are offering the otherwise a good alternative to going uninsured. Based on this research, and an updated report from the Government Accountability Office tells us who does benefit from these plans.



The Health Affairs study just confirms what advocates have been saying -- and debunks what insurance companies argue: high deductible plans are not a sound choice for families who are uninsured. One medical emergency would leave these families vulnerable to tens of thousands in medical debt, if not bankruptcy.

UPDATE: Check out Health Access' earlier report on "Thin Protections," also showing how high deductible plans provide little comfort for middle-income families that are often asset-poor.

Among the Health Affairs report's findings:

  • Only 21% of households with one uninsured person could cover a $1,000, along with their other obligations.
  • No more than 9 percent of households with one uninsured person could meet the out-of-pocket maximum of $5,000.

Also interesting:

$300: Uninsured families earning less than 300% of poverty ($63,600 for a family of four) had an average of $300 (!) in liquid financial assets. Incidentally, this is pretty much all they have too.

Higher income assets thin: Even for those families, who were uninsured, earning more than $63,600 -- assets were pretty scant. Gross financial assets -- which include stocks and mutual funds -- totalled $3,600 for these families. Families WITH insurance had more than four times that amount: $16,420.

So who are these high deductible plans for anyway? Well, a new GAO report tells us that:

The Government Accountability Office just updated their 2006 report on Health Savings Accounts, which can only be opened with a qualifying high-deductible health plan.

First -- only about half of the 4.5 million HSA-eligible plan enrollees opened an HSA.

And -- those who opened them have more money. The average income for the enrollees of these plans was $57,000. For those who opened an account, though, the average income was $139,000 -- more than twice as much.

I'm hoping some insurer folks or defenders of high-deductible plans can explain, again, why they still believe in light of this research that these plans are a good idea for the uninsured.

email me: hquach@health-access.org

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posted by Hanh Kim Quach | Permalink | 2:31 PM


 
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But can Mrs. MIP get coverage?

 
With all the talk about the high-risk pools that McCain plans to create, it's a good thing to simply highlight that California already has a high-risk pool, even few people know about it.

It's called MRMIP, the Major Risk Medical Insurance Program.

It has a waiting list of over 500 people right now, according to a chart posted on its website. That's even though the program has never been promoted or advertised.

People who are denied coverage because of "pre-existing conditions" have to pay more than the market rate to get the coverage. It's a lifeline for those who can't get coverage any other way, but it's expensive, and has drawbacks.

The plans offered have a $75,000 overall annual cap on benefits (here's a report on the MRMIP benefit), leaving people with that coverage at risk to significant medical debt, if they happen to be sick.

There's a bill, AB2(Dymally), that Health Access California supports, to reform the program, including getting it more funding so it can provide a better benefit to more people. Its parked from last year, but without full "guaranteed issue" health reform, this issue will continue to be with us.

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posted by Anthony Wright | Permalink | 12:00 AM


 
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More on McCain...

Thursday, May 01, 2008
 
There's a new May Day edition of the Health Wonk Review up at the Medical Humanities blog.

While they spotlight our post on McCain's health "plan," I want to recommend Jonathan Cohn at the New Republic for his analysis, as well as a discussion on Time.com's Curious Capitalist and Swampland, which has lots of links as well.

Basically, the nicest things I've heard about the McCain plan is it won't do any harm because it really isn't a fleshed out plan, and it doesn't have a chance in Congress. However, the majority think it's a radical shift--and not in a good way.

One debate started in Time.com's Swampland here, which quotes health policy expert Robert Blendon.

McCain's--which has some of the features of a plan proposed by George Bush in 2007, which didn't go anywhere in Congress*--actually envisions an entirely new system in which individuals would shop for their own health care coverage, presumably getting a better deal thanks to vastly more competition in the marketplace. "He proposes a vision for the future that doesn't exist -- yet," Blendon says. "His argument is I'm going to change how this thing works. ... In some sense, he has the largest scale what you would call 'reform' of all the candidates."

On the other hand, the assumption underlying the Obama and Clinton plans is the opposite, says Blendon, that "the worst thing that can happen to people is to be by themselves trying to negotiate for insurance. ... The solution is protecting people from being out there by themselves" by pooling them together, either through the workplace or in newly created purchasing cooperatives.


A commentator agrees, and succinctly lays out the three main reasons why not to shift people to the individual market:
1. Individuals have less bargaining power and sophistication than employers.
2. Negative selection.
3. Greater frictional costs from advertising to individuals, etc.

Pretty good, although they are linked. Because the individual has so little power against a big insurer, individuals usually get charged more expensive rates, and insurers profit more from the individual market. Since they lack purchasing power, they also can excluded on a case-by-case basis (as opposed to group coverage, where part of the deal is to take the entire group). And finally, the administrative and marketing costs are far more example when the company is managing and selling the plans one-at-a-time, as opposed to a group.

Individual buying coverage are simply not getting the same bang for their buck as those in the group market. Why Bush, McCain, and others would want to take coverage in that direction is beyond me.

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posted by Anthony Wright | Permalink | 11:26 PM


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