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Another year, another missed deadline

Monday, June 30, 2008
Big News. Well, really not-so-big. We don't have a budget; it's due today. No one's really concerned, 'cause we're late every year. In fact, since 1968, California has only had 13 budgets that were signed on or before June 30th.

Without a budget -- beginning tomorrow -- Medi-Cal providers begin feeling the 10 percent rate reductions that were passed earlier this year. Current versions of the Assembly and Senate budgets attempts to reverse part of the reduction for some providers.

State Controller John Chiang has a nice list of stuff that he can legally pay and not pay without a budget.

On a purely personal and selfish note: What's been really nice about the past few years, is the Legislature doesn't feel compelled to call floor session on June 15th (their deadline) and today (the big magilla deadline) and pretend to pass a budget even when they know they don't have one. It's a waste of everyone's time and it's silly.


posted by Hanh Kim Quach | Permalink | 10:37 AM


So "never events" never happen...

Jordan Rau at the Los Angeles Times has an important article (with lots of links to primary source documents!) on the key issue of "never events"--those things that should never, ever happen when you get care.

It's a list that includes getting severe ulcers from bedsores, having equipment left in a person during surgery, undergoing the wrong surgery or having the wrong limb amputated, or being given the wrong medication or wrong dosage. Unlike other parts of the art of medicine, these are problems that are preventable if the systems are in place.

The number of these adverse events reported is over 1,000 in a 10-month period. It's a wake-up call--Many in the health care community would not have predicted such a large number. These medical errors are serious--in some cases, deadly serious. By definition, these are "never" events--not "sometimes OK" events.

The article highlights AB2146 (Feuer), an important bill supported by many consumer groups like Health Access California, AARP, CALPIRG, Consumers Union, as well as business and labor organizations. It would have California follow the federal government in not paying for these adverse events, as part of a shift to change the financial incentives in this category.

I would also add AB2967 (Lieber), which would add more transparency to the cost and quality of the care being provided in California. This information is valuable in its own right, and will have a impact in getting hospitals to prevent these errors, which will improve health outcomes, and save money too. Information shouldn't be the only tool, but it should be part of more aggressive oversight.

Read the article. It's worth your time.

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posted by Anthony Wright | Permalink | 1:32 AM


Follow along...

Sunday, June 29, 2008
Our report revealing the full magnitude of the health care budget cuts got lots of good response and press attention (such as from the Contra Costa Times, Ventura County Star, New America Media, and others) earlier this week.

For those following the budget, we have one-sheet on the proposed health cuts in the 2008-09 Health Care Budget on our home page.

The Budget Conference Committee is expected to come back on Monday, and perhaps close out in this week. Our website also has an often-updated Budget Cuts Scorecard where you can follow along to see--item by item--what the Assembly has done, what the Senate has done, and what the Conference Committee had done on a specific cut.

The scorecard answers the relevant question: where is the Legislature on the proposals that would deny coverage to one million Californians?

Our report details four cuts that lead one million Californians to be denied:
* One of the biggest and most direct cuts, to directly close eligibility for 430,000 low-income working parents, has been rejected by both the Senate and the Assembly.
* Two of the smaller cuts have been accepted by both the Senate and Assembly: the increase in premiums for Healthy Families, and the suspension of key reforms to streamline eligibility for children. Together, that potentially would prevent as many as 160,000 children (and some parents) from getting coverage.
* The Assembly rejected the other big cut, to impose paperwork requirements through quarterly status reports, which would by 2010 deny coverage to 470,000 children. The Senate, however, is looking at imposing the additional paperwork every six months, which would have from a third to half the impact, but it would still be significant. We'll see what they decide.

In short, the Legislature has indicated that, in the best case scenario, the budget will contain health cuts to leave roughly 150,000 more Californians without coverage. The Conference Committee will determine if that number could go to 300,000 or more... and if the "Big 4" negotiations between the Democrats and Republicans don't yield the necessary revenues to prevent these cuts, the number of uninsured Californians could grow by over one million.

Let's also not forget two other major categories of cuts: the provider rates, which were cut 10% and the Legislature is considering making some restorations; and the proposed elimination of dental and other key benefits to Medi-Cal patients, the impacts of which are detailed in this fact sheet, entitled "Vital Medi-Cal Benefits on the Chopping Block ".

Decisions made in the next weeks will determine the fate of care and coverage for hundreds of thousands, if not millions. The stakes are high.

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posted by Anthony Wright | Permalink | 1:37 PM


Where does our money go?

Friday, June 27, 2008
The most exciting thing this week (other than Health Access' report release) was the release of the California Medical Association's annual "Knox-Keene Health Plan Expenditures Report,'' which replaces my old dog-eared copy from a couple years ago.

The report gathers data reported by health plans to the Department of Managed Health Care to show which ones spend the most on medical services for their enrollees (and which ones spend the most on administration and profit). This is called the "Medical Loss Ratio,'' you know, because plans ''lose'' money when they spend it on health care for you. The percentage of premium dollars spent on patient care is an important (though not the only) measure of a plan’s value.

Sadly, there is not similar data publicly available for PPOs, which are regulated -- more loosely -- by the Department of Insurance. Not having the data on the Department of Insurance side creates a huge hole for advocates, because 40 percent of insured Californians now buy the less robust insurance products regulated by the Department of Insurance. These plans are required to spend 70% of revenues on patient care and are among the worst offenders on the market. Low-value products are marketed to consumers for their low premiums. Patients do not have the actuarial expertise, or information to assess whether a particular low-premium product will actually provide them value – meaning it would pay for physician visits, drugs and other health costs when they need it. Products that have low medical-loss ratios often do not have maternity coverage, do not cover prescription drugs, have high deductibles, high co-insurance, and lack caps on how much consumers need to spend out-of-pocket for their illnesses. Such flimsy coverage causes consumers to defer care, or leaves them saddled with medical debt. Low-value health plans have dedicated as little as 51 cents of every premium dollar toward on what patients need. Meanwhile insurers spend 49 cents of every dollar consumers pay against consumers -- fighting bills for patient services, scouring health records in order to retroactively rescind policies, and other administrative costs—or to the profit of the insurer.

CMA is the sponsor of SB 1440 (Kuehl), which Health Access also supports. The bill would require health plans spend 85 percent of revenues on patient care (also called Medical Loss Ratios -- 'cause to insurers, they ''lose'' money when they have to spend it on you.) That is different from the current law, which only caps administrative costs at 15 percent (which means profits layered on top of that eat into the amount spent on patient care.) A nice feature of the latest version of this bill is that it will require plans to report the Medical Loss Ratio by product, rather than averaging them across the insurer's entire book of business, allowing the really awful products to be lumped in and hide behind better ones.

Okay, on to the report.

For-profit plans that spent the least on patient care in 2007:

  1. Great-West Healthcare of California: 69.4% patient care; 11.5% admin; 11.3% profit
  2. Blue Cross: 79% patient care; 11.1% admin; 6.1% profit
  3. Aetna: 81.4% patient care; 8.7% admin; 6.3% profit
  4. Molina Helathcare of California: 84.2% patient care; 15.5% admin; 0.2% profit

Non-profit plans that spent the most on patient care (not including public health plans)

  1. Scripps Clinic Health Plan Services: 95.3% patient care: 4.5% admin; 0.1% income
  2. Partnership Health Plan: 94% patient care; 6.1% admin; -0.4% income
  3. Western Health Advantage: 90.8% patient care; 8.7% admin; 0.6% income
  4. Kaiser Foundation Health Plan: 90.6% patient care; 3.6% admin; 5.8% income

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posted by Hanh Kim Quach | Permalink | 4:24 PM


Patients, not paperwork!

Great editorial in the LA Times today: should we spend on healthcare, or on paperwork? That's the proposal in the Governor's budget, and while the Assembly rejected it, the Senate is still considering a modified version of the proposal. Read the whole thing, but here's the final paragraph:
The semiannual applications are projected to save California $25.6?million while taking medical coverage away from tens of thousands of children. Meanwhile, the costs of doubling the paperwork would erase much of the savings. The health of poor children is a vital social interest; more paperwork is not.

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posted by Anthony Wright | Permalink | 10:18 AM


Clicking around...

It's been exhausting, with all the last-minute legislative activity, the release of our budget report, and everything else.

For those seeking to get a broader perspective, here's some good compilations of the world in health policy blogs, by both the Kaiser Family Foundation's Blog Watch, and the new Health Wonk Review, hosted by the Disease Management Care Blog.

Both highlight our post on gender discrimination in the California individual insurance market, and many insightful posts from around the web.


posted by Anthony Wright | Permalink | 1:33 AM


Bills before break...

Thursday, June 26, 2008
Thursday, June 25th, 2008

* Health legislation heard in final policy committees before July break
* Bills pass to require 85% of premium to go to patient care; regulate recissions; foster a public insurer; discourage "never events," encourage hospital community benefits.

Click Here for What's New on the Health Access WeBlog: Continued Real-Time Budget Conference Committee Reports; The Perils of "Junk" Insurance; Gender Discrimination in the Individual Insurance Market; The Mortgage Metaphor for SB1522; Improving Medicare with a Phone Call.

With tomorrow's deadline for legislation to have cleared policy committees in the second house, lawmakers heard a battery of bills this past week. Key pieces of legislation of interest to health advocates were also on the agenda. Many of the bills advocates have been tracking passed.

Following is a list of the bills heard this week and the outcome. Additionally, advocates may visit the Health Access website, at http://www.health-access.org/advocating/2008_bills.html for a complete list of bills.

The following bills passed in Assembly Health Committee, chaired by Assemblyman Mervyn Dymally, on Tuesday:

* 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
* 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. Would also require plans to report how much they spend on health care versus administration on each single product they offer. Support
* SB 973 (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.
* 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
* AB 1351 (Corbett): DISTRICT HOSPITAL OVERSIGHT: Would require Attorney General oversight into transactions involving district hospitals. Support

The following bills passed in Senate Health Committee, chaired by Senator Sheila Kuehl, on Wednesday:
* 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
* AB 2549 (Hayashi) RECISSION TIME LIMIT: Would impose an 18-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved. This bill was amended from previous versions, which limited the time frame for rescission to the first six months. Watch, seeking shorter time limit.
* AB 2569 (De Leon) RESCISSION AND BROKER ACCOUNTABILITY: Ensures that family members whose coverage depends on that of the rescinded person may be offered another individual policy. Also requires brokers who take applications to attest, under penalty of perjury, that the information is complete and accurate to the best of their knowledge. Support.
* 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 general acute hospitals caring for less affluent populations. Support
* AB 2942 (Ma) COMMUNITY BENEFITS: Would standardize what non-profit hospitals report as “community benefits” to justify their non-profit status. Support

The Legislature will now take a break from committees while budget negotiations are expected to continue throughout July. Both houses will resume committees on August 4. These bills will need to pass fiscal committees by August 15th and the final floor votes by August 31. If they pass through the Legislature, the Governor will have the month of September to decide to sign or veto the bills.

Health Access will continue to track the progress of this legislation in the coming months. For information, please contact the author of this report Hanh Kim Quach at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 1:28 AM


One million more uninsured, just to begin with...

Wednesday, June 25, 2008
Earlier this week, Governor Schwarzenegger called the number of uninsured in California a "moral crisis"--and he was right, both about that and the need for concerted action on health reform.

Unfortunately, the Governor's cuts-only budget goes in completely the opposite direction, making our health care system even more broken, and leaving more people uninsured. Today, we are releasing a report that reveals the full magnitude of the cuts the Governor proposes--with over one million more Californians uninsured. While the Legislature has adopted some of these cuts and rejeced others, all of these proposals are on the table until a budget solution is agreed to. There's early press from Aurelio Rojas at the Sacramento Bee and Jordan Rau of the Los Angeles Times.

Thursday, June 26th, 2008

New Analysis Reveals Full Impact of Governor’s Health Cuts:
One Million More Californians Would Lose Health Coverage

* Permanent Policy Changes, Not One-Time Cuts, Would Hinder Reform
* Magnitude of Cuts Would Have Ripple Effects Through System
* Health Consumers and Providers Urge Alternative to Cuts-Only Budget

Over one million more Californians would lose health coverage, with significant impacts throughout the state’s health system, if the Governor’s budget and health cuts were passed, according to a new analysis today.

The study, by the health care consumer advocacy group Health Access Foundation, uses information from the Schwarzenegger Administration, but shows a much greater magnitude than earlier estimates, which only looked at the impact of the cuts for less than a year, and not at full implementation.

The report is available on the front page of the Health Access California website, and directly at:

The study shows that these health care budget cuts are of a magnitude that will impact every Californian, as they place huge burdens on the health system we all rely on. These are permanent, not just one-time cuts, to leave more than one million more Californians uninsured, and over three and a half million having to pay more and get less.

Previous summaries of the Governor’s budget proposals, including the May Revision, show the impact of the cuts in only the first year – with tens of thousands losing coverage or being barred from enrollment. But the impact is much greater, in three ways:
  • The Governor’s budget is not proposing one-time budget savings, but lasting policy changes and coverage reductions for the health care system.
  • A snapshot of the savings in the budget year does not reveal the full impact in the following years, once the reductions have been enacted and all the administrative changes have occurred to continue the reductions.
  • Finally, the cumulative impact of all the proposed cuts, when added up together, suggests that the magnitude of the cuts—with more than a million more uninsured—will have impacts not just on specific programs but on the entire health care system on which we all rely.
The permanent policy changes reflected in the budget will be in place long after the 2008-09 budget year comes and goes. Of note, these policy changes are contrary to health reform proposals the governor previously put forward.

The cuts include:
* A roll-back of eligibility for basic Medi-Cal coverage for low-income working parents to well below the poverty level. (429,000);
* Additional paperwork burdens for children and adults, requiring reports every three months in order to avoid disenrollment (471,500);
* Suspension of already-passed legislation to streamline child enrollment (97,000)
* Increased premiums for children’s health coverage, leading to decreased enrollment (60,000).

The cuts represent a reversal for the Administration, reducing programs that just a few months ago were being considered for massive expansions to provide coverage to millions more people. Rather than shrinking the number of uninsured, the Schwarzenegger budget would increase the number of uninsured substantially.

The report includes appendices that include:
* a county-by-county breakdown indicated the increase in the uninsured by county by 2010, the last year of the Schwarzenegger Administration;
* a chart comparing the policy changes in the Governor’s budget that would restrict coverage, to the health reform proposal supported by the Governor earlier this year to expand coverage; and
* a further detailing of the populations that under the proposed cuts would be forced to pay more or get less benefits, totaling 3.5 million Californians.

Allowing one million more California children and parents to go uninsured creates ripple effects throughout the entire health care system. It includes:

  • an increased burden on “safety net” providers, from emergency rooms to hospitals to community clinics—many of which are dealing with direct cuts of their own;
  • a cost-shift, from both the uninsured and reduced Medi-Cal provider payments, to private purchasers of health care—which likely means increased premiums; and
  • worse health and economic impacts for California communities, from the destabilizing impact of more children uncovered and getting sicker, to more families facing medical debt and bankruptcy for being uninsured.

As a result, all Californians—not just the million more uninsured—will be impacted these cuts. The report makes clear the stark choice the budget debate this summer presents for California policymakers, between allowing these devastating cuts to move forward and to make these structural policy changes to our health care system, or to find the revenues needed to prevent these cuts.

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posted by Anthony Wright | Permalink | 6:57 PM


Improving Medicare...

According to our collegues at Families USA, we have some good progress on improving Medicare in the U.S. Congress:

On Tuesday, the U.S. House overwhelmingly passed the Medicare Improvements for Patients and Providers Act, H.R. 6331, by a vote of 355-59. They report that the U.S. Senate expects to vote on the House-passed bill as early as Thursday, June 26. An earlier version of this bill was blocked by a Republican filibuster after the President threatened to veto the bill.

The bill also makes needed changes to private Medicare Advantage plans and re-directs funding to Medicare’s doctors and health care providers. This bill makes several important improvements that will help seniors and people with disabilities get the health care they need, including:
* Broader protections for low-income beneficiaries
* Expanded coverage for preventive services
* Reduced cost-sharing for mental health services
* Stronger consumer protections

Families USA is asking health care advocates to call their U.S. Senators, and tell them to support the House-passed version of the Medicare bill -- the Medicare Improvements for Patients and Providers Act (H.R. 6331). You can call 1-800-828-0498 and ask to be connected to your Senator Boxer or Feinstein.

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posted by Anthony Wright | Permalink | 3:28 PM


Mortgage metaphor...

Tuesday, June 24, 2008
How confusing and complicated is the individual insurance market? It makes the much-maligned mortgage industry look clear and simple in comparison.

I was reading a recent study in the Journal of Insurance Regulation (Winter 2007) conducted by Michael Wroblewski during his time at Consumers Union, and the comparison came up. From the article:

“The question remains how consumers choose individual health insurance when they are required to assemble the information on the relevant attributes themselves, because they do not have employers or unions acting as intermediaries for this purpose. And, unlike other financial decisions consumers make, such as mortgage products in which the market provides consistent information for standard products (e.g. 30-year mortgages), standardized information for individual health insurance products does not exist; hence, comparative cost, coverage and benefit data is much more difficult to come by.”

Our individual insurance market is like trying to figure out to compare mortgages where different companies had different terms and lengths, and its impossible to compare, with one company selling 27- and 32-year mortgages, another selling 31.5- and 26-year mortgages.

Contrary to those who mis-characterize the bill, SB1522 doesn’t prohibit the equivalent of a 28.5-year mortgage, if some insurer wanted to provide that “creative” product; it just requires that the insurance company offers a standard product—the equivalent of the 30-year mortgage—as a benchmark.

My hope with SB1522 is that we at least get to the place where people have a standard loan that they can compare between plans, that they are appropriately alerted when purchasing “subprime” insurance, and that we set a minimum standard to prevent the “junk” products that are the insurance version of predatory lending.

Obviously, with everything going on in the mortgage and housing crisis, there’s renewed attention whether those disclosures and consumer protections are enough. Yet it would be a major step to even get those basic protections in the individual insurance market.

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posted by Anthony Wright | Permalink | 11:00 PM


Join us...

Monday, June 23, 2008
* Fight health care budget cuts, win health consumer protections, prepare for health reform
* Get timely updates on health policy & politics, and help with your advocacy efforts
* Advance the cause and build the movement for quality, affordable, health care for all

If you have been a reader of this blog, we hope you have found these updates, reporting, and analysis helpful in your work. You also know that there are big decisions being made in next few weeks and months that will have dramatic impact on California patients, insured and uninsured.
  • There are draconian health care cuts proposed, that would deny care for hundreds of thousands of Californians, and undermine the health care system we all rely on. We need to fight for an alternative to a cuts-only budget, for one that includes the revenues needed to prevent such severe cuts.
  • At the same time, there is the possibility of advancing consumer protection legislation to cap out-of-pocket costs and set better standards for insurance sold to individuals; to place new oversight over insurers about their rescission practices; to have better transparency about the cost and quality of the health care provided by doctors and hospitals; and more.
  • Both these fights are critical for laying the foundation for major health reform in 2009, and we need to prepare now for a new window of opportunity, with a new President and Congress at the federal level, and new legislative leadership and gubernatorial interest at the state level. We can't give up on winning broard health reform, from an expansion of public programs for children to a full-blown single-payer system, and everything in between.
ORGANIZATIONS CAN JOIN THE HEALTH ACCESS COALITION: To best advance these goals, we urge your organization to become a member of Health Access California, the statewide health care consumer advocacy coalition. When you do, you will join the dozens of other member organizations representing seniors, people with disabilities, children, immigrants, communities of color, health care professionals, people of faith, working families, women, low-income families, and communities throughout California.

Join online at our website, at:
To join by printing out a form to fill out and mail-in, go to:

We invite organizations that support the goal of quality, affordable health care for all to join the Health Access coalition. With your organization’s contribution, commitment, and membership, we can work to achieve meaningful change for the insured and the uninsured.

INDIVIDUALS CAN CONTRIBUTE: If you are an interested individual who wants to contribute, we welcome that as well. You can also contribute at the Health Access Foundation website, at:

BIG DECISIONS COMING UP: In the next few weeks, with your support and strength, we have the opportunity to fight these budget cuts, place greater oversight over insurers and providers, and advance efforts at the state and national level to expand coverage to all Californians. Sacramento policymakers will be making decisions on the budget and bills shortly; a list of pending bills (one of the many resources Health Access provides) is available on our website at:

In the next few months, we will work to ensure that health care continues to be a major issue in the fall elections, so that there is a mandate for comprehensive health care reform and coverage expansion in 2009, a campaign for which we are actively planning and organizing.

HELP YOUR ORGANIZATION ADVOCATE: More than any specific policy goal, our main focus at Health Access California is to provide your organization with information, materials, relationships, and resources to assist you to advocate effectively on the health care issues that matter most to your constituency. In addition to providing these up-to-the-minute e-mail updates and alerts on health policy developments, we also produce fact sheets, talking points, and analyses of legislation and ballot propositions. We develop policy proposals and organize public campaigns in support of policy solutions to help you engage your constituents around health care issues.

For a sample of the resources we provide, please visit our main website at:

As a coalition organization, Health Access works to assist its member organizations to build their capacity, so they can better advocate on health care issues. More than a source of information, Health Access works side-by-side with its member organizations. Our diverse staff, with expertise in consumer advocacy, government, journalism, labor, electoral campaigns, lobbying, community organizations, and media relations, are available as resources, to give presentations or assistance on a range of subjects. We give our members issues and substance around which they can organize, plan media events, and build their base locally. Realizing that our member groups have multiple priorities and issues, we work to provide them with resources that allow them to get meaningfully involved in health care advocacy without draining their internal resources.

JOIN HEALTH ACCESS: We ask that your organization join with many other California organizations in becoming a member of Health Access California for 2008 with a contribution of $250 (less for small groups at the discretion of the Executive Director; $1000 or more for large membership organizations and unions). The resources raised from membership help us provide the advocacy work in the Capitol and the information that you and other advocates use for your own work.

Your organization can join online, at:
To join by printing out a form to fill out and mail-in, go to: http://www.health-access.org/docs/2006%20Official%20HAC%20Membership%20Form.pdf

We hope that these E-mail updates and our research, organizing, coalition-building, public education, and advocacy will continue to be beneficial to you as a member of Health Access California. Your organization's membership -- both the contribution and the commitment -- gives us the resources to effectively assist your organization, and to win policy victories on behalf of health care consumers.

To check if your organization's membership is current for this year, or if you have any questions, comments, or suggestions about how we can be of better service to your organization, please feel free to contact me at 916-442-2308 or awright@health-access.org.

INDIVIDUALS CONTRIBUTIONS HELP: If you want to contribute as an individual, we would welcome that as well. You can also contribute at the Health Access Foundation website, at:

We look forward to working with you in the weeks and months ahead. Now back to our blogging...


posted by Anthony Wright | Permalink | 10:56 AM


It's called discrimination...

Sunday, June 22, 2008
The scrutiny on the inefficient, iniquitous individual insurance market continues, with David Lazarus' column in the Los Angeles Times.

We've explored before how women get discriminated against in the individual insurance market. They have to pay significant surcharges for maternity coverage. A recent NY Times story spotlighted how a C-section can be classified as a pre-existing condition that leads to higher premiums or a denial of coverage.

But now the California insurance marketplace had come full circle: Lazarus reports that three insurers: Aetna, Blue Cross, and now Blue Shield are charging men and women differently, and others are now looking to go there as well.

Where does it stop? As Lazarus says:

But parsing rates according to gender is a relatively new phenomenon. If women are more expensive than men to insure, and middle-aged women are significantly more expensive than middle-aged men, what about, say, older women with red hair? After all, they have fairer skin and thus are more susceptible to skin cancer.

How about if, statistically speaking, blacks are more expensive to insure than whites? Or Christians more expensive to cover than kosher-observing Jews?

How far will insurers go in determining risks?

This may be a standard insurance practice, but I think the public realizes that this is unacceptable social policy to have such discrimination, against women or any other group.

We should pass bills like AB1962(De La Torre) to require maternity as a basic benefit; institute guaranteed issue in the individual insurance market so that those with "pre-existing conditions" can get coverage; and fundamentally reform the health system to expand group coverage and shrink the individual market--where women and others are subject to discrimination, in multiple ways.

One last point: I keep reading that McCain is interested in appealling to women voters, but how can he explain to them his health plan, which would shift millions into the individual market, where they are likely to be discriminated against?

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posted by Anthony Wright | Permalink | 4:57 PM


Buyer beware, indeed...

Our efforts to reform the individual insurance market got more attention this week, by John Howard in the Capitol Weekly and Aurelio Rojas in the Sacramento Bee, which both profiled SB1522, by Senator Darrell Steinberg, and sponsored by Health Access California.

SB1522 passsed the Assembly Health Committee this week, and is now pending in the Assembly Appropriations Committee.

The Bee has the story of the Mary McCurnin and Ron Bednar of Rancho Cordova, who unwittingly bought a plan that the insurer Mid-West National Life Insurance Company called "definied benefit" coverage.

McCurnin and Bednar said they paid a monthly premium of $600 for what they thought was comprehensive coverage. But in 2002, after she was diagnosed with breast cancer and he had open-heart surgery, they learned otherwise.

Their plan covered only 10 percent of his hospitalization, and the company rescinded her coverage because she didn't disclose on her application that she was given a prescription for an anti-depressant years ago that she never filled.

With more than $250,000 in medical bills, the couple filed for bankruptcy protection and now face the loss of their home.

"Health insurance companies will do everything they can not to cover you," McCurnin said. "Having good (individual) health insurance is a myth."

The wife of the couple was rescinded under that now-infamous practice; the husband got "coverage," but found it covered only 10% of his costs because the benefit was capped. Examples like this inform consumer advocates' deep skepticism about the individual insurance market, and any attempt to expand it, as President Bush and now Senator McCain seek to do.

With little bargaining power, the individual consumer trying to get coverage will be at the mercy of the big insurance companies. SB1522 (Steinberg) tries to set some minimum standards in terms of benefits (doctors, hospitals, preventative care), and to place a cap on out-of-pocket costs. Other bills this year deal with rescission, or making sure than premium dollars go to patient care. All are consumer protections that attempt to make the situation a little more fair in an inherently unfair situation.

Even if all passsed, more reform will be needed. Both stories put this bill in the context of reconstructing health reform.

As the Weekly describes it, "Although the governor's health-care reform plan died this year in the Capitol's political crossfire, critical pieces have been resurrected and are quietly moving through the Legislature. One of the most important--already approved in the Senate and opposed by HMOs--would force health insurers to give consumers uniform, clear and accurate descriptions of their policies to aid comparative shopping."

And in the Bee, Senator Steinberg himself not only makes the clear case for the bill on its merits, and but ends the article making the case that the bill as a foundation for future, and more comprehensive, reform.
"As we move forward to more comprehensive reform in the future, creating confidence that people know what they are buying will be a key element," he said.

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posted by Anthony Wright | Permalink | 3:17 PM


Lots of Key Bills Pass 2nd House Health Committee...

Wednesday, June 18, 2008
Thursday, June 19th, 2008

* SB1522 to ban junk insurance passes Assembly Health Committee
* AB1945 would impose new rules on insurers who cancel insurance policies
* AB2967 to collect cost and quality data from medical providers passes

Click Here for What's New on the Health Access WeBlog: Continued Real-Time Budget Conference Committee Reports; A Predictable LAO Analysis on Single-Payer; Following the Bills in Health Committee; Also: Thursday June 19th Events: San Francisco Lunchtime Rally Against AHIP & Insurance Companies; Los Angeles TCE Panel Discussion on Health Reform

Key bills of interest to health advocates were heard in the last two days, in, respectively, the Assembly Health Committee, chaired by Assemblymember Mervyn Dymally, and Senate Health Committee, chaired by Senator Sheila Kuehl.

Hundreds of bills that passed the house where they were introduced must now clear the second house; and the first step of that is to pass policy committees by June 27. A number of bills that would benefit health care consumers were in Assembly and Senate Health committees this week, including a number of key bills that would lay the foundation for comprehensive health reform in the next couple of years. An updated list of bills is available on the Health Access website, at:

INSURANCE STANDARDS: Among those bills was SB1522 (Steinberg), sponsored by Health Access California, that would weed out junk insurance from the individual insurance market by ensuring that every plan covered doctor, hospital and preventive services. It would also place a cap out-of-pocket costs. The bill would organize the market into five tiers so that consumers could make apples-to-apples comparisons between plans and require that pricing of those plans was consistent with the level of benefits the plans offered.

In an interesting admission, the Association of California Life and Health Insurance Companies noted that "more transparency would be good." This bill passed out of Assembly Health Committee with little debate on a party line vote. It heads next to the Assembly Appropriations Committee.

On Wednesday, the Senate Health Committee heard more bills being tracked by health advocates including:


AB1945 (De La Torre) would create an INDEPENDENT REVIEW process when an insurer wishes to rescind a consumer’s health insurance policy. The Department of Managed Health Care and Department of Insurance would also have the final say on whether a policy could be rescinded. Lastly, the bill would standardize health plan questionnaires for consumers applying for coverage in the individual market.

The issue of rescissions has received much attention in the past couple of years as the LA Times and other papers have written a number of stories about patients who have had their policies unilaterally cancelled while in the middle of expensive chemotherapy or other medical treatments. Rescissions (or reviews to rescind coverage) have been triggered when a patient begins an expensive course of treatment, and then insurers have allegedly scoured applications looking for a rational to deny their care--any hint that the consumer omitted information about their health status--whether related to the current treatment or not.

Earlier this year, the Department of Managed Health Care had 1,200 policies that were illegally cancelled reinstated. Kaiser, who supported the bill, was one of the insurers that agreed to a settlement with the state to reinstate coverage for rescinded patients. HealthNet--and annoucned earlier today, Pacificare--also reached agreements with the DMHC.

A number of health plans did not oppose, but had concerns about two issues. First, they preferred not to have a uniform questionnaire, but rather a "menu'' of approved questions from which they could pick and choose so they could control the length and scope of the application. Secondly, health plans did not want all rescissions to automatically go to independent review, but rather something that the consumer could opt out of. While some consumer groups, including Health Access California, supported the bill, some organizations raised concerns about the impact on consumers' rights to bring a court proceeding against health plans. The bill heads next to the Senate Judiciary Committee, where some of these questions will be addressed. The bill passed on a bipartisan vote.


Another bill heard Wednesday that would help lay the foundation for comprehensive reform in the coming years is aimed at collecting data so that skyrocketing health care costs could be better controlled. Medical errors cost millions annually and result in thousands of unneccessary deaths.

AB 2967 (Lieber) would provide greater TRANSPARENCY AND DISCLOSURE for health care purchasers. The bill would require public reporting of cost and quality by doctors, hospitals HMOs and others in the health care industry. In order to funnel health care dollars more appropriately into treatments that work, the state needs to first gather data. Recognizing that there are many factors that contribute to a patient's health, the data would be adjusted to take into account income, geography, cultural and linguistic issues and other factors.

Collecting data, said author Assemblywoman Sally Lieber, would be "better than driving in the dark with no headlights, which is what we're doing now.''

In an unusual coalition, consumer, labor and business groups all joined together to support this. The California Association of Health Plans were also in Support if amended. Some of the questions that arose came from representation on the baord that collects the information. As constituted in the bill, providers make of half of the board, while consumers, labor and employers make up the other half.

Strong opposition came from the physicians and hospitals, however, who said they did not want "non-scientific people'' collecting data and "releasing it to the public.'' Providers did not trust that data would properly take into account the fact that some patients are poor and have many health issues. Assemblywoman Sally Lieber, however, countered that information to be collected will take into account poverty, health status and cultural issues, which will then be factored in reporting, which can be measured and adjusted. Studies about health disparities that contain this information are regularly published and the data that would be collected through this bill would help the significant work in place now to reduce the health disparities seen in race and income.

Sen. Sheila Kuehl acknowledged the fear that providers had, but said "I like the idea of data collection and knowing to be able to compare.'' The bill passed.

OTHER KEY BILLS: Other bills heard in Assembly or Senate Health Committee this week included the following, listed by bill number (author name) VOTE OUTCOME in Commitee. SHORT DESCRIPTION. Description of Bill. Position of Health Access California:

* SB 1168 (Runner): PASSED Assembly Health. DEPENDENT COVERAGE. 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.
* SB 1633 (Kuehl): PASSED Assembly Health. DENTAL DEBT PROTECTIONS 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.
* SB 1525 (Kuehl): PASSED Assembly Health. MEDICAL NECESSITY. Requires health plans to explain how they determine medical necessity. Also requires health plans to report their rates of denial of care or modifications to care because of medical necessity. Support.
* AB 1203 (Salas) PASSED Senate Health. 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
* AB 1887 (Beall) PASSED Senate Health. MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses. Support.
* AB 1962 (De La Torre) PASSED Senate Health. MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services. Support.
* AB 2220 (Jones) PASSED Senate Health. BINDING ARBITRATION: Requires providers and health plans to resolve contracting and payment disputes through binding arbitration. More on this legislation must be resolved in the Senate Judiciary Committee. Watch.
* AB 2400 (Price) PASSED Senate Health. HOSPITAL CLOSURES: Would require public notice before closing a hospital. Support
* SB 1096 (Calderon): FAILED Assembly Health. PRESCRIPTION INFORMATION. Would allow pharmacies to send mailers to consumers about the drugs they have been prescribed without the patient’s authorization. Oppose.

A final wave of legislation will be heard next week before the June 27th policy committee deadline. Health Access will keep advocates updated on the progress of consumer-related health bills.

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

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posted by Anthony Wright | Permalink | 9:50 PM


LA panel: looking forward to 2009...

For those health reformers not in the Bay Area, there's also a star-studded panel tomorrow (Thursday) night in Los Angeles. Sponsored by The California Endowment, it reflects on a special issue of The American Prospect that includes my recent summary of lessons learned from the California "year of health reform," as we attempt to seize a new opportunity in the next year. I'm away and not on the panel, but some of my fellow contributors to that issue are there. Here's the info...:
The American Prospect: What Path to Universal Health Care?
Thursday, June 19 — 7 p.m.

The California Endowment's Center for Healthy Communities
1000 N. Alameda St., Los Angeles, CA 90012

Will any of the candidates' solutions actually fix our system? This is the central question of a new special issue of The American Prospect and of this Center Scene Public Program. Experts and contributors to the magazine discuss the politics of health reform and what it will take to achieve a system that is truly universal, efficient, affordable and has prevention at its core.

Panelists include:
* Fabian Núñez, member and speaker emeritus, California State Assembly
* Neal Halfon, M.D., director, UCLA Center for Healthier Children, Families and Communities
* Ezra Klein, associate editor, The American Prospect

Matt Miller, senior fellow, Center for American Progress and
host, Left, Right & Center on 89.9 KCRW
Miles Rapoport, president of D?mos, will make opening remarks.

Click here to R.S.V.P. Light refreshments will be served. Admission and parking are free. For more information, please e-mail rsvpchc@calendow.org

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posted by Anthony Wright | Permalink | 8:21 PM


The insurance companies come to town...

America's Health Insurance Plans (AHIP) is having its conference this weekend, starting tomorrow, Thursday, at the Moscone Center in San Francisco.

Healthcare activists both in-state and nationally are hosting a rally for a "Health Insurance DAY OF ACTION." It is:

Thursday, June 19
12pm – 1:30pm (Pacific Time)
4th and Howard Streets, San Francisco (map)

More information is available at:

My only question is: what were they thinking? To come to the state where their notoriety has only increased with the rescission issue, where a single-payer bill is moving in the Legislature, where policymakers of both parties want to place new rules over their behavior... it just seems masochistic.

It's a good opportunity to put the spotlight on the problems with insurance companies practices in general, and to voice support for single-payer health care (including SB840 and HR676) in specific. Especially if you are in the Bay Area, it's worth your lunch hour and afternoon.

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posted by Anthony Wright | Permalink | 3:55 PM


Let's do it, then.

Tuesday, June 17, 2008
Anne Eowan, lobbyist for the Association of California Life and Health Insurance Companies, made a marvelous suggestion in Assembly Health Committee.

She was opposing Health Access' sponsored bill, SB1522 (Steinberg), which would do lots of things -- including weed out junk insurance and organize the individual insurance market into five tiers so that consumers would know what they were buying if they bought a five-star plan, versus a one-star plan.

In opposing it, however, Eowan suggested that "more transparency would be good'' and welcomed efforts to have the California Health Benefits Review Board take measurements of the existing individual insurance market.

Luckily, we already have similar language drawn up on that. AB2289 (Chan) -- remember that from 2004? It was vetoed.

Then, though, Eowan's organization, along with her merry band of health insurers, took varying degrees of opposition, opining that having to explain how many enrollees they had in their various plans, what the deductibles, copays, out-of-pocket maximums were, etc. for various plans were, was far too onerous, expensive, burdensome, time consuming, etc.

Nice to see she's had a change of heart.

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posted by Hanh Kim Quach | Permalink | 10:22 PM


Coming up today...

Assembly Health Committee, chaired by Assemblyman Mervyn Dymally, meets later today: SB1522(Steinberg) is up. Hanh will have a report later...


posted by Anthony Wright | Permalink | 1:00 PM


More indecision

Monday, June 16, 2008
The Budget Conference Committee resumed deliberations on 439 pages of budget items today and health issues taken up remain undecided. They include:
  • 10% rate reduction for specific rural and uninsured clinic programs for migrants
  • Healthy Families premium increases

It will likely be a couple of days before health issues will be revisited, as the committee will have to cycle through the Big Book again.

Here's an updated version of our scorecard for those who are keeping track of budget actions.


posted by Hanh Kim Quach | Permalink | 1:49 PM


A predictable answer to the wrong question...

There's bee some buzz about the new analysis by the Legislative Analyst's Office (LAO) of the SB840(Kuehl), the universal, single-payer health care bill, and the companion financing bill, SB1014(Kuehl). SB840 has passed the Senate and is in Assembly Appropriations; SB1014, which contains the financing which requires a two-thirds vote, has stayed in the Senate.

The Sacramento Bee's Dan Weintraub describes the LAO's findings that SB840 and proposed financing would be a "financial train wreck," while Senator Sheila Kuehl disputes that conclusion, but finds affirmation that "a single payer health care system saves money and lowers the rate at which health care costs grow each year."

I haven't had the chance to see the LAO analysis yet, so I can't comment on the specifics. But I predicted a problematic report earlier this year in a blog post. The biggest problem is that it doesn't compare the risks of health reform with the risks of remaining with the status quo (not just risks--the certain problems with letting the health system unravel). The issues raised by the LAO does mean there is more work to do on the financing and policy elements of SB840, but it doesn't undermine the central argument for single-payer reform, that it provides the tools for covering more people and finding savings in the health system.

Why the report predictable? The LAO analysis of AB x1 1 earlier this year (detailed in this Health Access report here) would hinder any health reform, including single-payer. In fact, it says so, with a similar line at the bottom of the LAO single-payer report: "Any plan to reform the state’s health care system, by the nature of its complexity, will involve financial risk over the long term. Many of the fiscal risks discussed in this letter would be shared by a variety of health reform plans."

The LAO report would be less of a problem, frankly, if some single-payer supporters who were opposed to AB x1 1 didn't embrace the LAO analysis so vigorously earlier this year. But there were many SB840 supporters, including Health Access California, who also supported AB x1 1, and who saw and made the case that the LAO's January analysis was being inappropriately used to hinder not just AB x1 1 (a good but imperfect bill) but anything else as well.

There is a crucial role for such financial analysis (both AB x1 1 and SB840 had significant independent modeling and analysis), but the questions should include a comparison with the status quo, and how a proposal can be modified to be fixed. The LAO is basically quantifying a projection of rising health costs: an unknown figure that admittedly is likely to rise. It is also focused on the impact on the state, rather than all Californians, who will bear these costs in one way or another. And it's not like health care costs are going to stay the same if there is no reform.

There is an urgency to health reform. The delay is passing either SB840 or AB x1 1 or any other reform means it just gets harder to do the reform later, for every year the cost of health coverage goes up. That's why we need action ASAP, now and in the future.

We'll have more on the LAO analysis. There's lessons to learn here, from the politics and the policy...

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posted by Anthony Wright | Permalink | 12:33 PM


Live-blogging the conference committee...

Sunday, June 15, 2008
Saturday, June 14th, 2008

* Budget Conference Committee attempts to reconcile Assembly, Senate decisions
* Drug discount program, QSRs, and provider rates debated; Most items left open.
* These and other cuts dependent on final budget resolution and revenues

Click Here for What's New on the Health Access WeBlog: Healthy Blogging; Consumers Union's Cover America Tour; the LA Times on This Year's Health Reform; Hospitals Auctioning Medical Debt; C-Section as a Pre-Existing Condition; Speaker Bass on the Budget; Jones to be Health Chair; the Health Divide Between Obama and McCain; the Individual Market; High Deductible Plans; the Field Poll on Health Cuts; Health Access is Hiring; Budget Resources; the Biggest Threat to Health Reform: the Budget Cuts; New Families USA Report Grading California's Consumer Protections; Taking Consumer Representation Seriously; and Full Real-Time Budget Conference Committee Reports!

Budget season is in full swing as the bi-cameral Budget Conference Committee began meeting this past Thursday.

The conference committee is made up of six members -- three from the Assembly and three from the Senate. The Senate conferees are Senators Denise Ducheny (the chair), Bob Dutton, and Mike Machado. The Assembly conferees are Assemblymen John Laird (the vice-chair), Mark Leno and Roger Niello. Together, their task is to pore through a 439-page agenda contains all the differences between the Senate and Assembly version of the budget and reconcile them.

Health programs sit right in the middle of that agenda and came up Saturday afternoon. Health Access tracked discussions on the health budget on our blog in real time at:

For people tracking this issue, here's a scorecard of all the proposed cuts, including those accepted, rejected, and those where there is disargeement between the two houses:

Some of the most severe cuts, like direct cuts to Medi-Cal eligibility for working parents, were rejected by both the Assembly and Senate majorities and those are not "in conference." However, the legislators again repeated today that those cuts are still pending, unless the budget includes revenues to offset those cuts.

The conference committee focused on items where the Assembly and the Senate took different actions. That includes:
* the start of the California Discount Prescription Drug Program, where the Senate voted to defund the program and delay the start of it for a year, and the Assembly (along with the Governor) allowing the program to get underway, to start negotiating with drug companies.
* the question of imposing additional paperwork burdens for children on Medi-Cal, through quartely status reports. the Assembly voted against the proposal; the Senate put forward a modified proposal to have children's families renew their coverage every six months, rather than on an annual basis.
* the biggest dollar amounts considered were whether to restore the 10% provider rate cut made this February for doctors, hospitals and others who care for patients with Medi-Cal coverage.

Most items heard today, including these three areas, remained open while lawmakers directed staff to work out compromises or gather more information about the programs. Before leaving the items "open," lawmakers debated quarterly status reporting for children and adults, and the 10% rate cut for providers, as well as the frustration that many of these cuts mean losing federal matching dollars as well.

"We can talk about all we want to about restoring cuts, or we can defer the consideration of cuts, but until we can put focus as to where we are going to go with revenues, we are creating a false document,'' said Sen. Mike Machado, urging lawmakers to look realistically at the state's fiscal problems. "I think it's very difficult to talk about this if we're not going to talk about the revenue side. We're creating a budget in a vacuum.''

One cut that was made was to accept the Governor's proposed reduction to hospitals who do not contract with Medi-Cal.

The committee ended Saturday afternoon on an up note, with some federal funds identified that could be applied to California Children's Services, which pays for medical care for children with chronic illnesses and disabilities. The committee approved a compromise measure between the two houses on this issue.

Again, no decisions are final until a final budget is passed and signed into law.

Health Access will continue to track the Budget Conference Committee, which will resume Monday, June 16th at noon to continue discussion of health-related items, including to clinics and the Healthy Families program.

In the meantime, Health Access keeps a scorecard of items of interest to health advocates. For more information, contact Hanh Kim Quach, the author of this report, at hquach@health-access.org.

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posted by Anthony Wright | Permalink | 12:25 PM


More on Provider Rate Reductions

Saturday, June 14, 2008
Sen. Denise Ducheny corrected Assemblyman Niello's assertion that the budget debate has not included all the ways Medi-Cal could be reduced. The problem is, she said, cuts to benefits save so little.

Sen. Bob Dutton, R-Inland Empire, had a few interesting comments that I hope he'll remember in the future:

"I don't want to cut things that are going to get matching dollars from the federal government.'' In the Medi-Cal program, the federal government matches eligible expenses dollars for dollar. It means that for every dollar California cuts, we lose an additional dollar in federal investment. Duh. This logic should be applied anytime he looks at a Medi-Cal cut.

Dutton also made a logical argument for why provider rates ought not be cut: because it would discourage providers from taking more patients in certain areas and drive patients to the emergency room. Bingo.

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posted by Hanh Kim Quach | Permalink | 1:58 PM


Plain Wrong

Assemblyman Roger Niello suggests in conference committee during debate on 10% provider rate reduction that the state is not applying cuts to Medi-Cal in a way that attacks all "three legs'': Eligibility, provider rates and benefits.

That's just wrong.

The budget does all three.

  • 10% rate reduction for providers. (-$614 million)


  • Elimination of Adult Dental (-$73.8 million)
  • Other benefits, such as podiatristrists, eyeglasses and incontinence creams and washes (-$11.6 million)


  • Quarterly Status Reports. (-$43.3 million): a passive agressive way for the state to eliminate Medi-Cal recipients by blaming their disenrollment on the recipients' failure to report their income every three months.
  • Direct denial of low-income working adults (-$31.2 million): which would tell parents earning between $11,000 and $18,000 that they earn too much to qualify for Medi-Cal.
For updated information, visit our budget resource page.

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posted by Hanh Kim Quach | Permalink | 1:03 PM


Quarterly Status Reports

Budget Conference Committee members could not decide whether or not to completely abandon Gov. Arnold Schwarzenegger's proposal to require that children and parents on Medi-Cal report their income and whereabouts every three months, or modify reporting to every six months instead.

That budget item remains open.


posted by Hanh Kim Quach | Permalink | 12:43 PM


Drug Money

Assemblyman John Laird, chairman of the Assembly Budget Committee, put up a good fight for the yet-to-be implemented California Discount Prescription Drug Program, which was signed into law in 2006 but delayed because of budget constraints.

The Senate has proposed delaying this again this year for a $5.8 million savings (.006 percent of the state budget). I wanted to clarify something that Assm. Laird said. This program would allow approximately 5.4 million unisnured low- and moderate-income Californias (below 300% of poverty) to buy prescription drugs at a *fair* price (between 40 to 60 percent off). Right now, this population pays the sticker price for drugs -- or they go without.

Sen. Denise Ducheny, chair of the Senate Budget Committee, did not think as much was being lost if the program had not yet been implemented.

The item remains open.

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posted by Hanh Kim Quach | Permalink | 12:19 PM


Our big day is tomorrow!

Friday, June 13, 2008
The latest news is that the Budget Conference Committee will begin on health issues tomorrow morning -- that's right, Saturday -- around 10 a.m.

See you then....

UPDATE: They stopped tonight on page 170 -- California Integrated Waste Management Board. We begin on page 208. The committee plans to meet from 10-1 Saturday (men do not need to wear ties.) They will break on Sunday for Father's Day and resume Monday, tentatively, from noon to 3.

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posted by Hanh Kim Quach | Permalink | 6:09 PM


Conference Committee

For those of you following, the Legislative Budget Conference committee began yesterday and has been meeting all day today. They resume again at 4:30 p.m. with Department of Fish and Game. On the agenda, they are about 70 pages away from Department of Health Care Services issues. (So far they've gone through 133 pages in 1.5 days to give you an idea of the pace)

It's unclear if they will get to our issues tonight, or if they will address them tomorrow.

We'll keep you updated.

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posted by Hanh Kim Quach | Permalink | 4:07 PM


Taking consumer representation seriously...

Thursday, June 12, 2008
Good Health Wonk Review just published at the Health Affairs Blog, including our post on budget cuts being a big threat to health reform. Lots of good posts.

The Health Affairs Blog had a previous post of note, "Who Speaks for the Health Care Consumer?" Ron Cunningham quickly debunks the mis-used term of "consumer-directed health care," asking "When did consumers ever stand up and demand that they be allowed to pay more when they are sick?"

Taking the question seriously, he reports that "Unresolved questions about the meaning of consumer engagement in the health sphere surfaced Monday in a lively conversation among health services researchers at the AcademyHealth Annual Research Meeting in Washington." Here's a provocative paragraph:
Panelist Shoshanna Sofaer of the City University of New York bluntly described the term “consumer empowerment” as an oxymoron, because of the implication that if power could be bestowed on a consumer, it could equally well be taken away. In general, Sofaer said, as matters now stand, “consumers have no voice” in the workings of the health system. Her view was seconded by Ed Mendoza of the California Office of the Patient Advocate, who suggested that consumers have little or nothing in common with powerful “stakeholder” groups. Inviting consumer representatives or advocates to participate in a stakeholder collaborative could amount to little more than tokenism. True consumer activism is more likely to begin with a negative reaction to what incumbent stakeholders are doing, Mendoza said.

It's absolutely true that there's lots of task forces, commissions, and decision making bodies in the health care world and in state and federal government where there is a token consumer representation (although you'd be surprised at how many decision-making entities don't even make that effort.)

Placing a random "consumer" or two on a board may introduce some good questions and thoughts to a discussion, but is of limited use: they are often outnumbered, but often don't come to the table to with the information, political savvy, or political power to make a difference.

Sofaer is right: consumer empowerment needs to be done by the consumers, not the government. As a consumer advocacy coalition, we don't believe that we are "empowered" by government officials, but by the organizations and individual members and constitituencies.

So Health Access California seeks to provide real consumer representation on board and commissions and the like. First of all, we work to build political power to represent consumers, as a stakeholder of equal or greater standing than the traditional "stakeholders" in the process. We work to build the biggest and broadest coalition of organizations that represent consumers to advocate for policy changes that would help their community. Health Access and other organizations not only then come with power and standing, but with accountability, that they are actually representating a constituency, albeit a very broad one.

(And for the record, we are organized for the positive goal of quality, affordable health care for all; we do often have a "negative reaction" to industry practices, but that's because of the industry practices... we'd rather be focused on our positive agenda.)

And then there's expertise. For example, Health Access is lucky to have Elizabeth Abbott direct our administrative advocacy, working to represent us at various agencies, and on various board and commissions. She often is the only (or one of a few) consumer advocates on a panel--but she has the backing of Health Access and our collective knowledge and resources, as well as her own experience running Medicaid and Medicare for CMS at their Regional Administrator until recently. This gives her the ability to ask the right questions, the savvy to sniff out when something sound wrong, and the ability to make a stand when necessary, and to ensure that people listen.

So consumer representation and engagement can be mere tokenism, but it doesn't have to be be, if the representatives come with their own expertise, accountability, and organizational resources and power.

Finally, there's just the numbers: why is it acceptable to have lots of boards and commissions with the goal of benefitting consumers, and consumers only have a seat or two, or are outnumbdered 10-1?

There's much more work to do to have our health system be truly "consumer directed," in the original and true meaning of that term.

One more thing: I sometimes dislike when decision-makers just call us "the advocates," because that description robs us of our central role, as consumer representatives: we aren't just advocating for advocating's sake: we are representating consumers, who are, in our estimation, the point of this whole health care enterprise in the first place.

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posted by Anthony Wright | Permalink | 11:46 PM


Evidence for Reform

A national report released today confirms what many health advocates already knew: California's individual health insurance market is a big mess.

The individual market is where consumers to go buy health insurance if you don't get it at work (where you have a group going in to buy coverage together and spreading out the risks) or through public programs.

California's feeble -- or lack -- of protections leaves consumers extremely exposed. Here's how we fared:
  • Requiring insurers to sell coverage to all applicants (also called guaranteed issue): No Credit.
  • Requiring affordable coverage alternatives for uninsureables -- people with pre-existing conditions: Partial Credit. (California has the Managed Risk Medical Insurance Program, which allows this population to buy coverage at above-market rates. Without this program, these consumers would be denied coverage. MRMIP, however, is unable to accommodate all who need coverage. They do not advertise, yet have 8,101 enrollees and 339 applicants on a waiting list.)
  • Prohibiting higher premiums based on health status: No Credit.
  • Requiring advanced review of proposed premium rates: No Credit.
  • Requiring insurers to spend at least 75% of premiums on health care: No Credit. (Actually, HMOs in California are required to spend at least 85% of premiums on health care. PPOs, which are regulated by a different department, are required to spend 70% of premiums on health care, though some insurance products spend as little as 51% on health care)
  • Limiting how long coverage can exclude pre-existing conditions: Partial Credit.
  • Limiting look-back period: Partial Credit
  • Using objective standard to define pre-existing conditions: Full Credit (the first!)
  • Requiring medical underwriting to be completed during application: Full Credit (We're not completely convinced this is the case -- otherwise, why the need for some insurers to rescind insurance later?)
  • Reviewing insurers' requests to revoke coverage: No Credit (The Department of Managed Health Care Services has restored coverage to more than 1,000 patients and is in the process of reviewing more than 5,000 cases where patients have had their insurance revoked since 2004. )
  • Accepting appeals when coverage is revoked: Full Credit
  • Reviewing denials for all state-licened carriers: Full Credit
  • Making external reviewer decisions binding: Full Credit
  • Offering free external reviews regardless of claim size: Full Credit
Pretty sad. But there's hope! Fortunately, we're actually trying to do something about our abysmal performance.
  • SB 1522 (Steinberg) INSURANCE MARKET STANDARDS & PREVENTING "JUNK" INSURANCE. The bill would set a minimum benefit standard for coverage, and weed out "junk" insurance that still leaves people exposed to bankruptcy. It would require 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.’’ 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.
  • SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT. It would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care.
  • AB 1945 (De La Torre) INDEPENDENT REVIEW OF RESCISSIONS. It would require health plans to seek approval by an independent review panel under the Department of Managed Health Care or Department of Insurance for each individual rescission. It would also standard the process and questions used in any underwriting. Also up in the Assembly is AB 2549 (Hayashi) that would impose a six-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved.

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posted by Hanh Kim Quach | Permalink | 11:49 AM


Digging a bigger hole for reform...

Wednesday, June 11, 2008
As the Budget Conference Committee in the California Legislature is about to begin its deliberations, a couple of reminders.

1) The cuts being discussed are ugly. The proposed cuts by the Governor would deny coverage to over a million Californians, and reduce access to care and coverage to millions more, and defund and undermine the health system on which we all rely.

For six and a half million children, parents, seniors, and people with disabilities, their Medi-Cal coverage will be harder to get, harder to stay on, and for those who keep it, they will have reduced ability to get the benefits and access to the providers they need.

2) The decisions around the budget will have a decisive impact on health reform, at the state level, and even at the national level. These proposed health cuts would go in the exact opposite direction of the policy reforms our broken health care system needs. If adopted, the Governor's proposed cuts take us further from the goal of health reform: it digs a bigger hole, that will need to be filled before embarking on additional expansions.

Medicaid and SCHIP (Medi-Cal and Healthy Families in California) are the groundwork for health reform, on which additional expansions are built--but that only works their funding is strong and sustainable.

Regarding of the plan, from single-payer to a Massachusetts-style proposal to any public program expansion to anything else, any health reform and coverage expansion presupposes that we will need significant subsidies for lower-income families, who simply won't be able to afford coverage by themselves. Yet by significantly cutting public programs that exist now--which are incomplete in policy and practice already--we have less to work with.

If these cuts are made, reformers will have to raise all those additional resources elsewhere--a major task indeed. In the effort for universal health care:
* For every dollar cut from the health care budget by California and other states, that's a dollar that we will have to raise later.
* For every child or parent that loses coverage, that's a child or parent that we are going to have to re-find and enroll later.
* For every policy change to place more administrative barriers to getting care and coverage, that's just more we have to do later.

In other words, the greatest threat to health reform in 2009 may not be the insurance industry or even voter distrust (although they are significant obstacles as well), but the budget crisis and the state Governors and legislators who are making these health care budget cuts around the nation, and are undermining the foundation on which we need to build.

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posted by Anthony Wright | Permalink | 1:48 AM


Scoring at home...

The Budget Conference Committee will start their marathon sessions with a meeting tomorrow, Thursday, to reconcile the differences between the Assembly and the Senate versions. You can follow along with our handy, newly-updated Health Care Budget Cuts Scorecard, featured on our website's front page. which shows the Governor's proposed cuts, and their status. We also have recent fact sheets on the cuts in general, and the Medi-Cal benefits cuts in specific.

Follow along! There's a column so fill in to see what the Conference Committee might do...

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posted by Anthony Wright | Permalink | 1:29 AM


We are hiring, to make a difference...

If you read this blog, you know the big health care issues and the major stakes of the next few years. Health Access is currently hiring smart, dedicated, and skilled people to work with us to fight health care budget cuts, work for health consumer protections, and organize for comprehensive health reform at the state and federal levels.

We are currently taking resume for a Northern California organizer in our Oakland office, as well as an online organizer and a lead organizer/project coordinator on our health reform efforts, where both positions are flexible about whether they are located in our Los Angeles, Oakland, or Sacramento offices.

More detailed job descriptions are available on our website, at:

If you are interested in joining are talented, diverse, and passionate staff, we are looking for cover letters and resume to be sent to: jobs@health-access.org.


posted by Anthony Wright | Permalink | 12:52 AM


Field Poll: strong opposition to the health cuts...

Tuesday, June 10, 2008
The coverage of today's Field Poll is broadly about the budget, but has lots of specific information on health care.

On the broad take, it's clear that the voters' top two priorities in the budget are education ("the public schools") and health care, with 80% and 77% of the public opposing to making cuts in these areas. The budget reflects the will of the voters: around half of the budget is education, and a third is health and human services.

The terrifically high support for health care could actually be an underestimate, given the question (about making cuts to "health care programs for low-income Californians and the disabled.") It's true that Medi-Cal, the main health program, serves 6.5 million low-income children, parents, seniors, and people with disabilities. It's also true that Medi-Cal is an essential funding base for the entire health care system on which we all rely.

The poll in fact did ask about specific health areas: here are the proportions reporting being very or somewhat concerned about each of the five health program areas measured.
• hospital emergency rooms and trauma centers (86%)
• health care programs for low income Californians and the disabled, like Medi-Cal (80%)
• staffing for nursing homes (76%)
• immunizations and prenatal care (72%)
• public health and bio-terrorism preparedness (60%)

The public is clear about rejecting these health care cuts. The polls also tests a range of taxes to prevent those cuts, with some getting majority support, and some not. It's up to our elected leaders to figure out exactly the mix of revenues to prevent these cuts. But that's the job of our leaders now.

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posted by Anthony Wright | Permalink | 11:52 AM


An Unhealthy Trend

75 million adults -- that's 42% of working age adults in the US -- had no insurance or really bad insurance (the kind that makes you pay up the nose anytime you sneeze) in 2007.

That's up from 35% of working age adults that were uninsured or underinsured in 2003, the first time Health Affairs did this analysis. A new analysis -- out today!-- updates the study from five years ago.

Among the findings:

  • 25 million people who were technically "insured'' actually have really crappy insurance (that amounts to one-fifth of the entire "insured'' population)
  • The number of adults earning between $40k and $60k who were underinsured nearly tripled from 5% to 13%.
  • The number of adults earning more than $100k and were underinsured (meaning that they spent more than 10% of their income on out-of-pocket medical expenses) increased from 1% to 7%.

The series of studies is important because until recently, most analyses only tracked the number of people without coverage and how lack of coverage impacts a person's ability to stay healthy. Just as important now, though, is this tracking the number of people with inadequate insurance. High deductibles, high co-pays, high co-insurance and high out-of-pocket costs cause patients to behave in similar ways to a person who is uninsured -- they forgo care because of the expense.

Insurance companies like to argue that these low-quality, low-premium plans are at least a backstop to keep people from going into bankruptcy. But as our previous study has shown, people don't have much in the way of assets -- and a $5,000 deductible would wipe out the savings of 40% of Americans. Health Affairs (obviously a nerd's must-read publication) also recently published a study that showed uninsured families earning more than 300% of the poverty level had less than $4,000 in liquid assets. (Here's our blog post on that study).
From our perspective, being underinsured means you're paying premiums to be functionally uninsured. All in all, we don't really buy the insurance company logic on this and think they should be labeled and limited (and the most egregious ones banned) -- as SB 1522 would do.

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posted by Hanh Kim Quach | Permalink | 11:32 AM


Dressing up the Individual (Market)

Monday, June 09, 2008
As we continue to struggle with how to get more people coverage, I'd suggest a look at this Kaiser Family Foundation report from February. The study looks at people who can't get public coverage and aren't offered insurance through their jobs.

Among the findings:
  • At 400% of poverty, the outer limit of an income that could qualify for subsidies in California (under last year's health reform discussions), only 25% of family purchased coverage on the individual market.
  • At 1000% of poverty, fewer than half (49%) of families purchased coverage.

Self-employed families, who receive tax credits on the premiums took up coverage at ever-so-slightly higher rates:

  • At 400% of poverty, about 30% purchased coverage
  • At 1000% of poverty, 58% took up coverage

The study, however, did not take into consideration the regulatory atmosphere -- whether individuals *wanted* to buy coverage, but were denied because of pre-existing conditions, or priced out because of their health histories -- all important factors as we go forward.

So the upshot is this: health coverage on the individual market isn't that attractive to lots of people and policymakers are going to have to find a way to make it more so, including subsidies that "may need to extend higher up the income scale than some policymakers may prefer.''

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posted by Hanh Kim Quach | Permalink | 11:46 AM


A great debate on the great divide...

Friday, June 06, 2008
There's few general-interest political reporters who get health policy and health issues like Ron Brownstein of the National Journal (and formerly from the Los Angeles Times). Now with the primaries over, he clearly and fairly lays out the choice between the plans of the presidential candidates, and it is stark.

His two recent articles in May, The Health Care Divide, and Going Solo, deserve to be read in full, but here are excerpts (the emphasis is mine):

The Health Care Divide
by Ronald Brownstein, National Journal, Sat. May 17, 2008

Countless details separate John McCain's health care proposal from those of the Democratic presidential contenders. But the most significant difference is fundamental and philosophical.
The two sides are offering divergent visions about the basic role of health insurance in the nation's social safety net. The fork in the road could not be starker.

The plans unveiled by Barack Obama and Hillary Rodham Clinton encourage the sharing of risk between the healthy and the sick, even at the cost of requiring the former to subsidize the latter. McCain's proposal would maximize individual choice in obtaining coverage, even at the cost of reducing risk-sharing. This contrast, which reflects the broader divide between the Democratic emphasis on community and the Republican focus on personal freedom, is the wellspring from which all of the major differences in the candidates' plans flow.

Confused press coverage and McCain's shift to other issues have obscured the magnitude of his proposal. But he may be pushing for greater changes than the Democrats in both the way Americans pay for health insurance and how they buy it--changes that have potentially profound implications for the pooling of risk...

America subsidizes employer-provided coverage this way partly because it is administratively efficient, but mostly because it promotes the pooling of risk. By putting young, healthy workers into the same risk pool as colleagues who are older or sicker, employer-based coverage supports cost-sharing...

McCain's plan could threaten these arrangements, although how much is uncertain. He would eliminate the tax "exclusion," so that health premiums paid by employers would count as taxable income for workers. But he would replace the current exclusion with a refundable tax credit of $2,500 for individuals and $5,000 for families...

But almost all analysts think that without the economic incentive that the exclusion provides, some employers would drop coverage. The great unknown is how many. Even employers who want to maintain coverage might find it increasingly difficult to do so...

These dynamics could prompt a modest shift from group coverage to individually based insurance--or a massive exodus...

There's been a lot of heat about the debate at the federal and state levels around the idea of an "individual mandate." What Brownstein points to is a far more central debate: group vs. individual coverage. Since people want coverage, the issue was not so much the individual mandate, but the individual market.

When Health Access and other groups evaluated a health reform proposal here in California, one of the key barometers we looked at was whether it increased or decreased the number of Californians subject to the individual insurance market, the least efficient, most expensive way to get coverage, where the consumer is alone, at the mercy of the big insurers.

Schwarzenegger's original health reform plan expanded group coverage, but also expanded the individual market, but with some important improvements (guaranteed issue, medical loss rations, etc.) While consumer advocates supported many of those insurance reforms (like the insurance standards in this year's SB1522), we still preferred the benefits of group coverage.

The negotiated plan, AB x1 1, got support in part because the modelling showed that it shrank the individual market, while also attempting to fix it for those who are left.

McCain's plan does the worst of both worlds--it shifts millions into the individual market, as he deregulates the market as the same time!

Going Solo
by Ronald Brownstein, National Journal, Sat. May 24, 2008

Today, most Americans receive health insurance through large organizations (either their employer or the government). Only a small number of them (about one in 11) buy it on their own in the individual insurance market.

Almost all experts agree that the health care proposal that presumptive GOP nominee John McCain recently announced would shift that balance--perhaps substantially--toward individually purchased coverage. McCain wants to replace the tax benefit for employer-provided coverage with a personal tax credit of $2,500 for individuals and $5,000 for families. That trade would cause some companies to drop coverage, driving an unpredictable number of their workers from employer-based insurance to individually based plans...

That raises an obvious question: Could the individual market handle the load? A wide variety of experts, including some in the insurance industry, say that the answer, at least for today, is no.

For starters, the administrative costs of individual policies are at least triple those of employer-based policies. That means a worker shifting from a group policy to an individual one receives significantly less coverage for the same price, notes Kenneth Thorpe, an Emory University health policy professor. And although group policies share risk between the young and old, the healthy and sick, the cost of individually based policies varies enormously, depending on the person's health. Most important,
people with prior health problems often cannot get affordable coverage--if they can get any at all. "If you are a 60-year-old woman with multiple chronic diseases, forget it," Thorpe says. "There is nowhere for you to go in the individual market."

America's Health Insurance Plans, the industry's trade association, insists that the individual market works better than Thorpe and similar critics believe. But, tellingly, even AHIP is not arguing for more reliance on individually based insurance. "We haven't advocated that," says Karen Ignagni, the group's president. AHIP has endorsed a McCain-like tax credit for the uninsured, but it opposes eliminating the tax break for employer-based coverage.

McCain would respond to the problems in the individual market by massively deregulating the insurance industry, a step that he argues would promote productive competition. Each state currently sets minimum standards for the health insurance plans sold within its borders. McCain would override that state regulation by allowing health insurers to sell in every state any policy approved in any state. That would mean states could no longer require insurers to pay for specific medical procedures (such as mammograms) or establish coverage requirements (such as maximum deductibles) if any other state set a looser standard. The state that regulates least would set the rules.

...many experts argue that McCain would be courting disaster by deregulating the insurance industry just as his plan drove more people into the already turbulent individual market. That could produce massive premium increases and diminished (or no) coverage for people in poor health. Again, it is revealing that even AHIP has not endorsed nationwide insurance sales.

While McCain would deregulate the industry, Democratic contenders Barack Obama and Hillary Rodham Clinton would restructure it by imposing new national standards. Each Democrat would establish government-organized purchasing exchanges for individuals and small businesses, and would require insurers participating in them to sell to all applicants at comparable prices, regardless of their health.
The Democratic plans would face their own political challenges, but none may be as daunting as McCain's task of convincing Americans that the health care system will work better for average families if there is less regulation of the insurance industry, not more.

With the primaries over, I hope the medica coverage really focused on this clear distinction between the two candidates. It's never been as clear, or as important.

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posted by Anthony Wright | Permalink | 10:49 AM


Jones to be chair of Health Committee...

Thursday, June 05, 2008
Speaker Bass has announced that Assemblyman Dave Jones (D-Sacramento) will be the new chair of Assembly Health Committee. Here's health-specific excerpts from the report by Shane Goldmacher at the Sacramento Bee Capitol Alert:

Jones, a Sacramento Democrat, is currently chairman of the Assembly Judiciary Committee. The new chairmanship is considered higher on the Capitol pecking order, as many influential bills pass through the health panel, particularly as Gov. Arnold Schwarzenegger has said reforming the state's health system remains a top priority.

The current chairman, Assemblyman Mervyn Dymally, D-Compton, is termed out this year...

None of the changes are effective immediately. The new chairs will take over the committees in December.

Here's a recap of... the committee chair and leadership moves Bass has made since her selection as speaker:
Majority leader: Alberto Torrico
Assistant speaker pro tem: Lori Saldaña
Appropriations: Kevin De Leon
Budget: Noreen Evans
Rules: Ted Lieu
Health: Dave Jones

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posted by Anthony Wright | Permalink | 5:52 PM


Bass on the budget...

Speaker Karen Bass made some budget announcements today, mostly pulling together the budget as a whole, and what the Assembly Budget Subcommittees have done in terms of rejecting cuts, and indicating the need for revenues to prevent those cuts to education, health care and other vital services.

Some excerpts from the press release about the need for revenues to prevent cuts:
The Assembly Democrats’ plan will require some cuts and some new revenues and relies on the Legislative Analysts Office’s revenue and property tax assumptions.

How these goals will be achieved:

* Assembly Democrats have said all along that we would not accept a cuts-only budget. We were encouraged that the Governor agreed with us.

* Assembly Democrats have also said that everything has to be on the table, and
we’ve proposed several ways to increase revenues.

Speaker Bass continued: “The four legislative leaders have already begun meeting to talk about how we get to where we need to be to balance this budget with revenues. And I believe we need to start with closing loopholes and restoring the tax giveaways of past budgets, particularly for corporations and the richest of the rich Californians. That’s where the discussion will start, and I look forward to
more of the productive discussions I’ve had during the past few weeks.”

“Our plan will be our starting point in the Budget Conference Committee, which will begin meeting mid-to-late next week. We will miss the June 15th deadline because of the complexity of the proposals and size of the deficit, but we are on target to vote before the fiscal year with a proposal that is not just a ‘drill,’” Speaker Bass concluded

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posted by Anthony Wright | Permalink | 5:45 PM


Pretty soon, the insureable will be a pretty exclusive club

Wednesday, June 04, 2008
The NYT had an interesting story on Sunday about women, of childbearing age, who are denied coverage on the individual market because they had previously had a Caesarean section. The rationale is that these women would be likely to have another expensive C-section should they get pregnant again.

If that were truly the case, most of the women I know who have had children would not be able to get coverage on the individual market, which seems horribly unfair -- as the story, and my friends point out -- many women don't go into labor wanting to have a C-section.
"Insurers are adding insult to injury. Not only are women feeling pressure
to have Caesareans that they do not want and may not need, but they may also be
denied coverage for the surgery.''

So women: If you haven't already been excluded from coverage for a rash, prescription, infection or allergy, having a baby will do it to you.

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posted by Hanh Kim Quach | Permalink | 1:54 PM


When medical debt attacks...

If you want to know more about the financial consequences of being uninsured, read yesterday's Wall Street Journal article by Sara Rubenstein.
In a move that consumer groups say could increase pressure on people with unpaid medical bills, some hospitals are trying out a new tactic to recoup patients' debts: They're auctioning the debt online.

Hospitals have long relied on outside collection agencies to go after debtors. Under traditional arrangements, these agencies receive a percentage of any money they get from a debtor; the more they collect, the more they earn.

Now, some of the same collection agencies, as well as other firms that purchase debt outright, have begun participating as bidders in online auctions, in which they buy the debt or provide guaranteed payments to hospitals for access to the unpaid accounts. Some experts say this gives them more reason to aggressively pursue patients in arrears. Auctions can drive up the amount paid for debt, meaning a collector must recoup more money from patients to cover its initial investment and turn a profit. And the winning bidders often get to keep all the money they collect on the auctioned debt.
Health Access California has talked to lots of Californians with medical debt, as we worked to pass AB774(Chan), to prevent hospitals from overcharging the uninsured. Invariably, the experience of these patients in dealing with the bill was worse after the bill was referred to collections, and much worse after the debt was sold. That's why AB774 included a moratorium on patients being sent to collections. There are other existing consumer protections against aggressive collections practices, but is it enough?

Winning bidders may "have to work harder" to make a profit from auctioned debt, says Michael Klozotsky, an analyst at Kaulkin Ginsberg Co., a collections-industry strategic-advice company. "Working harder means sometimes using strategies that are more aggressive.

"Many of the auctions of hospital debt have been done through Web site ARxChange.com1 -- shorthand for "accounts receivable exchange" -- owned by TriCap Technology Group. Another site is medipent.com2, run by Medipent LLC. The auction-site owners, both small companies based in New York, say their systems create safeguards that protect patients from potential abuse. Collection firms are vetted for their tactics and approach to patient needs and concerns before they are allowed to participate in auctions, the site owners say. The site owners also try to ensure that collectors comply with hospital rules -- whether they must record phone calls, for instance, or get the hospital's permission before initiating a lawsuit against a patient. Hospitals have final say over who bids on their accounts, and, on ARxChange.com, don't necessarily award the contract to the highest bidder.

Consumer advocates say patients are less likely to successfully dispute bills or negotiate them downward if they are dealing with a third-party collector rather than a hospital directly. Collectors also are further removed from hospitals' financial-assistance policies."The hospital is an institution in the community, has a reputation, in many cases has a nonprofit mission to uphold," says Anthony Wright, executive director of the consumer-advocacy coalition Health Access California. "Once it goes to collections, that starts a process that can get a lot more antagonistic, a lot more aggressive, and a lot more damaging to a family's credit history and financial future."

The federal Fair Debt Collection Practices Act and some state laws govern how debt collectors can treat consumers. For instance, debt collectors aren't allowed to harass consumers or make false statements, including implying they will sue if they don't intend to do so. Consumer groups say calling the medical provider or your insurer could help clarify any confusion about what you owe. The hospital also could provide information about financial assistance or charity-care.

A hospital bill is typically the biggest bill a person gets in their entire life. The first goal is to prevent these situations from happening in the first place: to make sure people are covered, or have other financial options that can help pay the bill. But in any case, patients with medical debt should have basic consumer protections. We don't want people to not go to the hospital for fear of the bill, or those who come to collect it.

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posted by Anthony Wright | Permalink | 10:59 AM


This year's health reforms...

Tuesday, June 03, 2008
Health reform is alive and well, reports Jordan Rau at the Los Angeles Times.

More than a dozen health bills are advancing through the Legislature, many over the objection of insurers. Some of the proposals were transplanted from the plan that passed the Assembly last year, only to be rejected in the state Senate in January. Other measures are newly devised by the Democrats who control the Legislature.

The bills would require
insurers to spend at least 85% of their earnings on patient care; block insurers from canceling policies of patients who need extensive care; and force them to cover more procedures, such as maternity services. Over the
objections of the major doctor and hospital lobbies, the Assembly approved a
measure backed by Schwarzenegger that would require medical providers to publicly reveal their costs and medical performance.

In a sign that a desire for piecemeal healthcare changes is strong this election year, some of the Democrats' bills even have picked up votes among Republicans who did not support Schwarzenegger's package.

Many of these are good bills, and would be considered big deals in any other year, if it wasn't in comparison to the huge, comprehensive effort of AB x1 1. But it is important to recognize that they aren't just small pieces: some of the legislative proposals form a foundation for future reforms:

Daniel Zingale, a senior advisor to Schwarzenegger, said the governor favors many of the ideas, if not the exact language, in the bills and plans to add others into the mix in a few weeks. "This year, the first floor of healthcare reform will be built, and it will make current coverage more secure, control costs, promote prevention and end the worst anti-consumer practices by HMOs," Zingale said.

Many of the bills would affect the insurance market for individuals who buy coverage themselves rather than through employers -- now more than 2 million Californians. It is a more lucrative niche for insurers than selling policies through employers because insurers have more leeway to set the terms of individual policies and face fewer regulations about what medical procedures must be covered and which customers must be accepted.

The Senate passed a proposal by the incoming president pro tem, Darrell Steinberg(D-Sacramento), that would make it easier for individual customers to compare competing plans. The bill also would limit maximum out-of-pocket costs for those individuals and force insurers to offer a whole range of policies if they want to do business in the state.

That bill, SB1522(Steinberg), sponsored by Health Access California, is an example of a bill that if implemented, creates a much sounder floor from which to build reform.

Most of note, the article indicates that this agenda to placing greater oversight over the insurance industry is getting bi-partisan support.
Opposition from insurers, however, is not dissuading Republicans -- a traditional ally of the industry -- from supporting some new restrictions. On Thursday, 12 of 32 Assembly Republicans joined Democrats to require insurers to obtain approval from state regulators before canceling coverage for people who have become ill and submitted medical bills. That bill, by Assemblyman Hector De La Torre (D-South Gate) is one of three measures the Assembly has passed to address that practice, which has prompted state investigations of -- and in some cases led to fines for -- many of the state's biggest insurers.

Some GOP lawmakers also are agreeing to expand the type of procedures insurers must cover. Twelve of 15 Republicans joined their Democratic colleagues in the Senate and voted to require insurers to pay for surgery to fix
cleft palates, a common birth defect that occurs in one of every 790 babies. A panel of experts said this would add only $146,000 in annual costs to California's $79-billion insurance industry, but insurers are opposing it because they don't want lawmakers limiting the policies they offer.

On the Senate floor in mid-May, five of 15 Republicans ignored industry opposition by voting to compel insurers to reveal how often they rule that procedures are not medically necessary.The
bill, by Kuehl, also would force insurers to disclose the medical qualifications of the employees who make those decisions.

That same day, four Republican senators voted to pass another Kuehl
bill that would require insurers to offer customers the option of adding, for an additional charge, coverage to include the purchase of wheelchairs, oxygen tanks and other durable medical equipment.

Sen. Sam Aanestad (R-Grass Valley), who voted for the measure, said insurance policies have become too complicated to understand."I've got grown kids who have advanced college degrees, and they're not sure if something's covered or not," he said.

Amen to Dr. Aanestad's comment. If there's a theme to the reforms this year, it's that people are concerned that there coverage will not be there for them when they need it. In some cases, it's because the insurance company rescinds coverage; but in many others, it's because you don't realize what is covered, and not covered, until it is too late.

We can begin to fix that with these bills, as well as with fighting the budget cuts that undermine that security for the millions with public coverage programs.

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posted by Anthony Wright | Permalink | 11:26 AM



Monday, June 02, 2008
Just a reminder about Election Day tomorrow. The primary contests tomorrow will largely determine who the next state Legislature will be, and how receptive and active they will be on health care and other issues.

It doesn't have the pizzazz of the February elections with the presidential candidates, but there's key races around the state, for state and local offices, that will make a difference...


posted by Anthony Wright | Permalink | 5:41 PM


We knew her when...

Sunday, June 01, 2008
The effort to win national health care reform is heating up: lots of planning meeting and activities to ensure that there is a mandate for a new President and Congress to take this issue on, and to be ready to roll in 2009.

Consumers Union (a Health Access California board member) is spearheading a Cover America Tour: an RV that will criss-cross the country for four months, collecting stories about the issues that people have with the broken health care system.

The effort has a website and blog of interest, which includes a video of the launch of the Cover America Tour from Consumers Union's Yonkers headquarters, being cheered by staffers from the labs that test all those products that are evaluated in Consumer Reports. It should be an interest and informative trip, that I urge folks to follow along on the web.

The video prominently features the energetic Meg Bohne (pictured above, crouching), a Health Access alumnus, who has told me she give us partial credit (or blame) for her current assignment. On the website page that describes the whole enterprise, Meg Bohne cites her experience as a "a seasoned community activist, advocate and organizer, Meg has come to specialize in on-the-road campaigns in vehicles that have spanned a bus, an ambulance and, now, an RV." At left is the ambulance she drove up and down the state of California for Health Access, in the cause of lower prescription drug prices.

We wish Meg and the whole crew at Consumers Union luck in their trip and their effort. We look forward to hearing the stories, the personal health care experiences, and the adventures on the road!

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posted by Anthony Wright | Permalink | 2:02 AM


Healthy blogging...

Those interested in health policy should be subscribed to the news summary that the Kaiser Family Foundation puts out on a daily basis. Now, those summaries will often include a health policy blog roundup, which will be another way to keep up-to-date. Here's several gold nuggets they found from panning the blogosphere about McCain's health plan:

Joe Paduda of Managed Care Matters examines presumptive Republican presidential nominee Sen. John McCain's (Ariz.) health care plan and whether it could increase the number of uninsured residents by destabilizing the employer-based health care system. Robert Laszewski of Health Care Policy and Marketplace Review builds off of Paduda's post to argue that McCain's market-based plan reforms might work well for some voters, as long as advisers present certain changes carefully. Bob Vineyard of Insure Blog reacts to a Slate article and discusses McCain's proposal to allow individuals to purchase insurance across state lines. Peter Harbage from the Wonk Room Blog discusses a new Center for American Progress Action Fund paper about McCain's health care plan and administrative costs.

Really good stuff there.

Don't forget the biweekly Health Wonk Review, which this week is hosted by Hank Stern at InsureBlog. We are listed in there with over a dozen interesting posts from around the web.

Finally, for those who prefer to read offline, our state-based colleagues at the Connecticut Health Policy Project have a blog of interest, CT Health Notes Blog, and have a recommended booklist for your summer reading.

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posted by Anthony Wright | Permalink | 1:10 AM


The budget stage is set.

Friday, May 30th, 2008


* Assembly and Senate budget committees vote to reject severe cuts to Medi-Cal, including major denials of coverage to working parents & others, elimination of dental & other benefits. Votes would also restore some of the provider rate reductions.
* Significant cuts agreed to by at least one committee include: Cuts to public and private hospitals, counties, health plans; increases in Healthy Families premiums; additional reporting for children; increased premiums for seniors
* Clear choice in budget debate moving forward: Hundreds of thousands of Californians denied coverage & care, or an alternative to a cuts-only budget that includes revenues.

Click Here for
What's New on the Health Access WeBlog: Floor Reports on Health Bills Passing This Week; Ongoing Updates from Budget Committees; What Makes Coverage Coverage?; Health Reform in Obama's First 100 Days?; and more...

After a busy week on the floor, Senate and Assembly budget committees topped off the week with simultaneous hearings and votes on outstanding health budget items. A number of items that were left open in previous months while committees vetted the issues were either modified, approved or rejected Friday morning (listing below).

Health Access has posted a Health Care Budget Cuts Scorecard, which details the Governor's proposed cuts, and for each cut, the budget savings, the number of people impacted, and the actions by the Assembly and Senate today. The scorecard is here, at:


The Senate Budget Committee, chaired by Senator Denise Ducheny, and the Assembly Budget Subcommittee on Health and Human Services, chaired by Assemblywoman Patty Berg, both voted to approve or reject the many health care cuts proposed by Governor Schwarzenegger in the May Revision of the budget. That budget sought to bridge a $17.2 billion shortfall in a $100 billion general fund budget without raising taxes.

While no action is final until a final budget is approved and signed into law, both the Assembly and Senate committees rejected many of the Medi-Cal cuts to eligibility and benefits as too severe, and both proposed restoring some of the provider rate cuts made earlier in the year.

At the same time, both committees did vote to approve other cuts proposed by the Governor, and other cuts. Cuts approved by at least one committee included cuts to hospitals, cuts to counties, cuts to Healthy Families health plans; caps in benefits; increases in Healthy Families premiums; additional reporting requirements for children; and increased premiums for seniors.

Health Access is posting summaries on its blog, at www.health-access.org/blogger.html.


In the Senate, the budget committee’s proposal will head to the floor for a vote. In the Assembly, the full Assembly budget committee will still need to approve each sub-committee’s proposal before being perfunctorily approved by both houses with the intent that the conference committee -- made up three budget committee members from each house – will reconcile differences between each house’s working proposals. The Legislature is supposed to finish working on its budget June 15th, but that has only happened five times in the past 40 years.
The fiscal year begins July 1 – a mere 30 days from now -- and there is no expectation that California will have a budget on time.


Below is a listing of major decisions made by the Assembly Budget Subcommittee on Health and the full Senate Budget Committee. For a full list of actions taken this year, click here.

* Direct denial of coverage to very low income working parents: Would have denied coverage to parents earning wages between $11,000 and $18,000 a year (for a family of three). A parent would need to work fewer than 100 hours a month in order to qualify. REJECTED by both houses.
* Quarterly Status Reports for children and adults: Would have required Medi-Cal recipients to report any changes in their life every three months. Currently, children only have to report annually, and adults every six months. MODIFIED by Senate to require reports every six months for both children and adults. REJECTED by the Assembly.
* Medi-Cal rate reimbursement: Approved earlier this year, will reduce reimbursements to Medi-Cal doctors by 10%. California already ranks near the bottom (43rd) on reimbursements for providers in this program. Both houses sought to restore this already-made cut: REDUCED to 5% reduction by Senate. REVERSED by Assembly.
* Reduced benefits for legal immigrants: Legal immigrants who currently receive comprehensive Medi-Cal benefits would lose all but four services: emergency, pregnancy, some long-term and cancer care. REJECTED by both houses.
* Monthly reporting for immigrants: Would require undocumented immigrants to establish their eligibility for limited emergency Medi-Cal services every month. REJECTED by both houses.
* Elimination of dental benefits for adults on Medi-Cal: Would have eliminated the ability for adults on Medi-Cal to receive cleanings, crowns, filling or other oral surgery unless a physician treated them. REJECTED by both houses.
* Eliminate vital services for Medi-Cal recipients: Adults would no longer be able to see an optometrist, fill eyeglass prescriptions, obtain hearing aids, get speech therapy, treat sores caused by incontinence, see a podiatrist, chiropractor, acupuncturist or psychologist. REJECTED by both houses.
* Require very low-income seniors to pay more for their health care: Would have required seniors who earn $1,100 a month to either pay $100 premium for coverage to see their doctor, or spend half their monthly income on healthcare. MODIFIED by both houses to continue to pay premium for enrollees who do not pay $500 a month for health services.
* Premium increase for some Healthy Families subscribers: Would have increased Healthy Families premiums between 27% and 77% for subscribers between 151 to 250 percent of the poverty level. MODIFIED by both houses to increase premiums by half the amount proposed.
* Co-payment increase for Healthy Families subscribers: Families between 151 to 250% of the poverty level would pay $7.50 (rather than $4) for “non-preventive’’ services, such as prescriptions, some emergency room visits, some doctors visits, eye exams and glasses, therapy and dental work. REJECTED by both houses.
* Capping Healthy Families dental benefit: Would limit dental coverage to $1,000 per enrollee. MODIFIED. Both houses increased the cap to $1,500.
* Shifting money away from public hospitals: Takes federal money used for public hospitals to pay for unrelated programs. REJECTED by the Senate. REJECTED by the Assembly.

No action, including the rejection of cuts in both houses, is final unless the final budget is approved and signed into law by the Governor. However, the actions to reject many of these cuts sets the stage for the budget debate this summer: whether to deny care and coverage to millions of Californians, or whether the state raises the revenue to prevent these cuts. That's the clear choice.

Health Access will continue to track budget actions on the floors and in conference committee during the budget season. For more information, contact the author of this report, Hanh Kim Quach at hquach@health-access.org

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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.