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Report from DC...

Thursday, January 29, 2009
 
Many of us at Health Access made in through the sleet and cold in DC this week to attend the Families USA conference. On Thursday, the most interesting remarks were by Republican Senator Chuck Grassley, and Democratic Congressman Henry Waxman of California. We'll post a fuller report later, but other bloggers have their impressions, from Sarah Arnquist at The Health Care Blog, and Jonathan Cohn at The New Republic's The Treatment.

My initial take is that many, from House Energy and Commerce Chairman Waxman to House Majority Leader Steny Hoyer to Senator Debbie Stabenow, to many other top staff and organization leaders, repeated a similar mantra: "This is our moment," "This is the year," etc. But it was repeated so much it was as if people don't quite believe it. And we all recognize the major obstacles and difficulties, the contours of the rocky shoals on which previous reform efforts have been marooned.

Another clear case that hass been made, in different ways by different people, is that the economic crisis is not an excuse to not do health reform; in contrast, we cannot have a sustainable economic recovery without health reform.

More to come...

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posted by Anthony Wright | Permalink | 10:38 PM


 
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SCHIP passes the Senate

 
SCHIP passed the U.S. Senate tonight on a bipartisan vote of 66-32! California Senators Boxer and Feinstein voted for the measure, as did all Democratic Senators and 9 Republican Senators.

A few weeks ago, the U.S. House of Representatives passed a similar bill, 289 to 139, with virtually all Democrats and 40 Republicans in support. Good news!

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posted by Anthony Wright | Permalink | 10:23 PM


 
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Health help in the balance...

 
Last night, the U.S. House of Representatives passed an economic recovery bill, with virtually all Democrats in support, and all Republicans in opposition. The vote of the California delegation was entirely down party lines.

The bill has lots of important health provisions, as outlined by Robert Pear in the New York Times. This includes an increase in Medicaid matching funds, funding for health information technology, and for those who are becoming unemployed and uninsured due to recession, subsidies for COBRA coverage and a temporary expansion of Medicaid.

The Senate is working on their own version of the economic recovery, with many of the same elements, but some important differences.

Given California’s particularly high 9.3% (!) unemployment rate, our state has a particular interest in two differences:
* The House version offers full federal funding for a temporary expansion in Medicaid for those who are on unemployment or who meet certain income requirements. The Senate does not include this provision at all.
* The House formula for federal Medicaid matching funds partially takes into account the state’s economic climate (such as a high unemployment rate). The Senate version has much less targeting, and the difference for California could be over a billion dollars.

California advocates have a big interest in seeing the House health care provisions prevail, either as the Senate continues to amend and adjust their proposal, or in conference committee.

Also yesterday, SCHIP was up for debate in the U.S. Senate, and all the hostile amendments from Republicans have been defeated, so far. There’s talk that a final vote could happen today.

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posted by Anthony Wright | Permalink | 7:12 AM


 
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Children in the Senate...

Wednesday, January 28, 2009
 
The U.S. Senate continue to debate SCHIP as we speak, as there are various votes so far to reject amendments proposed to weaken the bill.

Back in California, the Senate Health Committee is expected to hear SB1 (Steinberg), the measure to cover all kids, on February 11. The hearing will include an informational hearing on the state of kids’ health more generally. Rm. 4203, 1:30pm. Health advocates should be sure to get your letters of support to the committee a week in advance: Senate Health Committee, State Capitol, Sacramento, CA. 95814.

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posted by Beth Capell | Permalink | 6:14 AM


 
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Notes and news about nonprofit hospitals...

Tuesday, January 27, 2009
 
In California, about 10% of hospitals are for-profit while over two-thirds are non-profit entities.

Non-profit hospitals, like other non-profits, pay no property tax and no corporate income and they even get a special deal on unemployment insurance taxes. For-profit, private hospitals pay property taxes, corporate income taxes, unemployment insurance taxes, the Employment Training Tax and other taxes just like any other business. Yet, in the words of Bill Leonard, a conservative Republican member of the Board of Equalization, “when I drive past a hospital, I can’t tell the difference” between a non-profit hospital and a for-profit hospital.

Last week the Board of Equalization met and considered a proposal by Board Member Betty Yee to obtain information from non-profit hospitals regarding what in tax lingo is called the “welfare exemption”, meaning their non-profit tax status. Ms. Yee has been working on this for some time: last year she proposed requiring non-profit hospitals to spend 5% of revenue on charity care in return for their non-profit tax status. That proposal was not favorably received by the Board. Last week, Ms. Yee had a better day.

The California Hospital Association challenged the authority of the Board to collect the desired information and CHA also said that some of the information was duplicative and some information was impossible to provide.

The attorney for the Board and all five members of the Board of Equalization, including the representative of State Controller John Chiang, were unequivocal in asserting their right to collect the information they deemed necessary in order to determine whether any entity, including a hospital, could be a non-profit in the eyes of the State of California.

The Board decided to embark on a stakeholder process to refine the proposal to collect the information.

The information desired by Ms. Yee (available online at www.boe.ca.gov) includes such basic information as how much charity care hospitals provide as well as whether liens on primary residences are levied on consumers.

In addition, Ms. Yee wanted to know whether non-profit hospitals had revenues in excess of expenditures (otherwise known as profits) of more than 10% and if so, what the hospitals spent the money on. There is existing case law in California (the Rideout case) that allows hospitals to have excess profits and still be non-profit so long as they put the money back into the hospital, rather than taking it out in profits.

We know that when Senators Baucus (D-Montana) and Grassley (R-Iowa) investigated hospitals, a bipartisan effort that has spanned the change in control of the US Senate, they were dismayed to discover excessive CEO compensation, overcharging of the uninsured, and various other bad behavior by hospitals benefitting from not paying taxes.

Given the bipartisan support in Congress for efforts that have resulted in the IRS revising the reporting for non-profit hospitals, perhaps we should not have been surprised that the California Board of Equalization voted unanimously on a bipartisan vote to support the concept of collecting the information by May 2009. But I certainly was. Bill Leonard said plainly that if a non-profit hospital is acting like a for-profit, it should lose its non-profit tax status.

For those of you who are wondering what in the blazes the Board of Equalization is, you should know that you have the opportunity to elect its members every four years. Among those who currently serve on the Board of Equalization is Judy Chu, former Chair of Assembly Appropriations, as well as Betty Yee, State Controller John Chiang, Bill Leonard, and Michelle Steel (verify). The Board of Equalization is a key tax agency responsible for determining the equity of taxes across counties as well as whether entities are worthy of non-profit tax status. Its hearing room was as crowded as any legislative hearing for that reason.

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posted by Beth Capell | Permalink | 8:23 PM


 
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Capping our prospects and our future...

 
There's an important article by Steve Harmon at the Contra Costa Times, that explores the implications of a spending cap. It's being pushed by legislative Republicans in budget negotiations: the question is whether legislative Democrats agree to such a long-term restriction to get the revenues needed to fix the immediate budget problem.

Jean Ross of the California Budget Project has blogged about the implications for health and other vital services. Such a cap would inevitably force cuts in health and human services, especially for our growing and aging population. In health care, where costs go up higher than inflation, would be particularly hard hit.

But more than that, such a cap would prevent us from ever addressing needs that we know we have: do we want to remain nearly last in the nation in Medicaid reimbursements to our medical providers? do we want to continue to have 6+ million uninsured?

Let's hope that to get out this immediate and urgent budget problem, we don't exacerbate the problems in health care and many other sectors of California life.

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posted by Anthony Wright | Permalink | 8:32 AM


 
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It's about time...

 
HEALTH ACCESS UPDATE
Tuesday, January 27, 2009


THE RIGHT TO TIMELY ACCESS TO CARE: New Regulations Pending!
* CA Department of Managed Health Care Prepares to Finalize Important New Regulation on Timely Access to Health Care
* Public Comments Solicited on Newest Version of Regulation that Establishes Time Limits for Consumers to Receive Primary and Specialty Care in California
* ACTION ALERT: Letters Needed To Support Key Consumer Protections

New on the Health Access WeBlog: The Senate Stimulus; New Assembly Committees; The Reinvestment and Recovery Act in the House; Jump-Starting the Economy and Health Reform; Healthy Families Cuts Implemented; Health Wonk Review; President Obama’s First Health Care Actions; Bush’s Record; Do Bi-Partisan Efforts Help or Hurt Reform?; Federal Decisions Will Dramatically Impact Help to California.


Consumer and health advocacy groups may be close to witnessing the final regulation by the Department of Managed Health Care (DMHC) to write the “rules of the road” on timely access to health care. One of the most common complaints from consumers is that they cannot get in to see their doctor on a timely basis. These regulations will put in place requirements and establish expectations for concrete, time-elapsed standards based on type of service needed and degree of medical urgency. These rules stipulate that consumers should be able to:
* See a primary care physician for urgent care in less than 48 hours,
* Consult with a specialist within 96 hours of an urgent referral,
* Obtain a non-urgent appointment for primary care within ten business days, or
* Receive advice from a health care professional 24/7 regarding whether a symptom indicates an emergency or the consumer can safely wait until regular business hours on the next workday.
* Have interpreter services coordinated with scheduled appointments.

Research shows that Californians often obtain medical care from emergency rooms, the most expensive place to get medical care, because they cannot get in to see their doctor on a timely basis. It is also true that because consumers do not have clinical training, it is difficult for them to judge whether they are facing a true emergency and they need immediate care or whether they can safely wait.

A Long Road

This seemingly basic health care right to timely access to care has been a long time in coming. Health Access first sponsored legislation in this area in 1997, when we sponsored AB497 by then-Assemblymber member Scott Wildman. In 2002, AB2179 was carried by Assemblymember Rebecca Cohn (D-Saratoga), passed the legislature, and was signed by Governor Davis.

In 2002, many in the advocacy community thought California would soon usher in “a new era” where consumers and patients would have a clearly-defined right to timely access to health care for all those who were enrolled in managed care plans (HMOs). Those in favor of the statute anticipated a drop in health care costs (because of a decrease in people seeking care in emergency rooms) and an increase in quality of health care because it would be dispensed in a much more timely fashion resulting in better health care outcomes for patients.

Regulations Matter

However, some would say the battle over issue of timely access to care was just beginning. The statute laid the groundwork in the law (like an architect’s design for the building). However, many realized that the regulations written by the responsible state agency represented the actual detailed instructions about how the law would operate and resemble the general contractor’s plan for the building. This is where the phrase “the devil is in the details” comes from. The requirement to write detailed rules about how the law is supposed to work, what planning, measurement, reporting and auditing offered all stakeholders another opportunity to discuss (and disagree!) on the principles underlying the law and the key provisions of how it should operate. In many cases, legislation prescribes specific standards. However, Health Access took a different approach in AB2179: the legislation directed DMHC to develop the standards for timely access. It is no coincidence that almost seven years have elapsed since the legislation was signed into law.

Not surprisingly, HMOs and providers have fought over these years not only to delay the regulations but to make them meaningless. Health Access opposed earlier versions of the regulations that were no better than the inadequate procedures in place since 1975 when the Knox-Keene Act was created.

We now are at a major juncture in the road and consumer advocates eagerly await the finalization of this important regulation. After numerous consumer advisory panels, stakeholders’ meetings, public hearings, informal comments, formal written comments to the Department of Managed Health Care, withdrawal and reissuance of previous versions of this regulation, we now may be close to this regulation being enacted.

Support Needed for Specific Standards

Health Access and other members of our health care coalition generally agree that the language of the regulation, while not perfect, provides reasonable protections and specific time-elapsed standards for consumers to obtain timely access to health care. It also outlines reporting responsibilities of the plans, appeals actions available to consumers, and oversight duties to be performed by DMHC.

In our role as advocates, we have offered pages and pages of specific comments over the years: DMHC has not adopted every comment we have ever offered but the regulations provide basic consumer protections along with mechanisms for monitoring HMO compliance with those protections.

The Department has formally issued this regulation and they are soliciting comments on it from the public through February 23, 2009.
Action Needed Now
Consumer advocates need to act now to support these regulations. We need to make our voice heard so that consumers can get the care they need when they need it.
Key Points to Make:
* Consumers need care in a timely manner.
* Specific time-elapsed standards are reasonable minimums, getting urgent care within 48 hours and non-urgent care within 10 days are standards consumers should be able to expect.
* Being able to get triage and advice 24/7 from a qualified professional is an important consumer protection.
* Interpreter services should be coordinated with the appointment.
* Providing timely access will mean consumers get care from their doctor, rather than being forced to go to an emergency room to get care quickly.

Comments should be addressed to Department of Managed Health Care, Office of Legal Services, Attn: Regulations Coordinator, 980 9th Street , Sacramento , CA 95814 or you may comment on DMHC’s website at www.dmhc.ca.gov. Your comments should reference Timely Access to Non-Emergency Health Care Services, Control No. 2008-1579 and must be received by DMHC no later than 5:00 pm on Monday, February 23, 2009. Health Access can make available draft comment letters including model language for you or your organization to use if requested.

Please feel free to contact Elizabeth Abbott at Health Access if you have questions or need further information. She may be reached at (916) 497-0923, ext. 201 or at eabbott@health-access.org.

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posted by Anthony Wright | Permalink | 12:27 AM


 
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Max Healthroom....

Monday, January 26, 2009
 
Two of the leading health care bloggers, Jonathan Cohn and Ezra Klein, of The New Republic and The American Prospect, respectively, discuss the upcoming health care reform debate over on bloggingheads.tv:



It's a good, politically savvy, policy substantive discussion about where we are...

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posted by Anthony Wright | Permalink | 4:00 PM


 
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The sailing SCHIP....

 
Having just confirmed Treasury Secretary Tim Geithner, the U.S. Senate has started to debate SCHIP (the State Child Health Insurance Program), for those watching C-SPAN right now.

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posted by Anthony Wright | Permalink | 3:25 PM


 
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Contrary purposes...

Sunday, January 25, 2009
 
Mike Zapler at the San Jose Mercury News makes an important observation about the contradictory conversations in Washington, DC, and Sacramento.

In Washington, DC, there is an emerging consensus for the need for increased government spending, to both stimulate the economy in the short term and make critical investments in the long term. In Sacramento, the state requirement for a balanced budget has forced over $16 billion in cuts, and threatens many more.

The contradictions are even starker than described.

In Washington, DC, the assumption is that government spending, rather than tax changes, gives the most "bang for the buck," and that explains the where the focus is. (See Appendix 1 of the Administration's top economists, showing the much more significant multiplier effect of government spending, versus tax changes)

In Sacramento, we've reduced government spending, and negotiations continue to cut more. Part of these negotiations are discussing a "spending cap," which will handcuff the state in the future to make any of these needed investments for the economy. And both these cuts and caps impede our ability to claim our state's maximum share of these federal stimulus dollars.

Many of these dollars--like the increased Medicaid matching funds--are tied to state spending. So every time we cut, we are leaving federal dollars behind--and with the increased match, we would leave even more behind.

Instead, we should be doing everything in our power--including raising taxes and revenues--to take advantage of that increased federal match, and cover more people, especially at a time when they need it. That's the spirit of these funds, to address the increased needs in this economic recession.

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posted by Anthony Wright | Permalink | 1:36 AM


 
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Stimulating debate...

Saturday, January 24, 2009
 
Similar to my post over at TNR's The Treatment, here's California Representative Pete Stark about the health provisions, their virtues, and how they relate to health reform (Thanks to Josh Richman's Political Blotter blog of the Contra Costa Times for the clip):



The Senate Finance Committee, chaired by Senator Max Baucus, has put out their own version of economic recovery and reinvestment. On the health portions, there's lots of similarities with the house: Health IT investment, COBRA subsidies, some Medicaid funding, and a temporary increase in Medicaid matching funds--partially based on the state's economic climate. There are differences, including that the Senate version does not seem to include the House's version of a Medicaid expansion for unemployed adults.

More to come...

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posted by Anthony Wright | Permalink | 11:02 PM


 
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Introducing your Assembly committees...

 
Assembly Speaker Karen Bass has announced the rosters of Assembly Committees. Here's the members of the health-related committees:

Assembly Health Committee
Assemblymember Dave Jones (D), Chair
Assemblymember Nathan Fletcher (R), Vice Chair
Assemblymember Anthony Adams (R)
Assemblymember Tom Ammiano (D)
Assemblymember Marty Block (D)
Assemblymember Wilmer Carter (D)
Assemblymember Hector De La Torre (D)
Assemblymember Bill Emmerson (R)
Assemblymember Ted Gaines (R)
Assemblymember Isadore Hall (D)
Assemblymember Mary Hayashi (D)
Assemblymember Ed Hernandez (D)
Assemblymember Bonnie Lowenthal (D)
Assemblymember Pedro Nava (D)
Assemblymember V. Manuel Pérez (D)
Assemblymember Mary Salas (D)
Assemblymember Audra Strickland (R)

Assembly Budget Subcommittee #1 - Health and Human Services
Assemblymember Jerry Hill (D), Chair
Assemblymember Jim Beall Jr. (D)
Assemblymember Hector De La Torre (D)
Assemblymember Bill Emmerson (R)
Assemblymember Ed Hernandez (D)
Assemblymember Brian Nestande (R)

With the announcement of the Senate Committees last week, the cast of characters has been largely set for the next two years, in the various debates about health policy.

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posted by Anthony Wright | Permalink | 8:37 PM


 
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Even earlier...

Friday, January 23, 2009
 
One other point: As much as the economic recovery package in the House would help the state budget crisis, the health system, and our economy, there are many elements that can also be viewed as a first round for comprehensive health reform.

The most exciting proposal that acts as a "down payment" on health reform is the provision that will allow states to expand Medicaid, temporarily, for unemployed adults. Many people think our public coverage programs cover the poor, but the truth is that they only cover some of the poor. Medicaid largely covers low-income children and parents, and the "aged, blind, and disabled." But there are many adults who don't have a child at home, who are not eligible for any public program-even if they are under the poverty level, which is $10,400/year for an individual, $14,000 for a couple. Sometimes called "medically indigent adults," they are left to whatever their county decides to provide in terms of a safety-net service.

The stimulus would authorize such a Medicaid expansion only temporarily. But many of the reform plans now circulating in Washington, spanning the ideological spectrum, envision childless low-income adults getting coverage through Medicaid anyway. So by enrolling them in Medicaid now, the stimulus would basically jump-start the reform process--making the long-term job of getting everybody covered that much easier.

That's a snippet from a post of mine at the The Treatment, the new blog by Jonathan Cohn and other writers at The New Republic magazine. I'll be contributing there when I can, if nothing else to merit the kind introduction Jonathan has given me. Regardless of my posts, it's worth reading, especially this year with so many opportunities at the federal level...

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posted by Anthony Wright | Permalink | 1:07 AM


 
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Totalling the federal help for health...

Thursday, January 22, 2009
 
A new Center for Budget and Policy Priorities analysis of the economic recovery package being considered by the U.S. House of Representatives indicates that $88 billion would be provided for states through increased Medicaid matching funds.

Their state-by-state breakdown indicates that California could get $11,069,212,000 over 9 quarters--although given that the formula is based on the economic climate in each state, the figure is not certain. Another caveat is that this is the current House version, but presumably there will be changes as this is considered over the next few weeks. We need to continue to press for:
* an even higher amount of overall funding for state and Medicaid, and
* a formula, like the one in the House, that considers the economic situation of the state (California has been particularly hard hit, and has a high unemployment rate, and the help should recognize that fact).

As proposed, this will significantly help Medi-Cal and health care in California. What it won't do is solve the overall budget crisis. The overall deficit for 2008-09, and 2009-10, is projected at $42 billion. The House economic recovery package is estimated to provide $3,612,818,000 in 2008-09, and $4,911,064 in 2009-10. (The remaining $2,545,330 comes in the 2010-11 budget year.) That's $8.5 billion that can be attributed to our $42 billion problem--a help, but it still leaves California in dire straits.

In other words, the Medicaid matching fund increase is a necessary but not sufficient part of the budget solution. Even with such significant aid, it still leaves tough choices--including the need to raise taxes and revenues, to prevent devastating cuts.

The aid does clarify some of the tough choices. It makes it even clearer that cuts to Medi-Cal and other health services are counterproductive, both in hurting our economy, and losing these federal dollars. It was insane to cut Medi-Cal when we were getting a one-to-one match for federal dollars. Under this bill, we would be getting even more--and each cut would have over twice the impact to our health system and our economy.

We will continue to need to raise revenues to sustain these programs, and to draw down these new and ongoing federal dollars. But this help would be more than enough to prevent current health cuts, restore previous health cuts, and do some targeted expansions, for children and adults, so that these safety-net programs serve their intended purpose in a downturn, and meet the increased needs of Californians.

But before we get to that discussion, California advocates, and legislators, need to continue to make the case for California getting all the help it needs.

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posted by Anthony Wright | Permalink | 9:27 PM


 
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Chipping away at children's coverage...

 
Many of us have watched the budget proposals by the Legislature and the Governor over the last several months that have included a series of benefit caps, restrictions on specific services, and increases in consumers’ share of cost to close a breathtaking budget gap in California’s finances. Health Access has been among those who have urged a balanced approach to the budget impasse by softening unavoidable service cuts with new revenues, without additional cuts in services. As the national and state economies falter, it is anticipated that more and more Californians will become reliant on the safety net including public programs until they can land a new job, replace their health insurance, or stabilize their mortgage financing.

While the budget negotiations continue and more cuts looming, we now have a Real Life Example of the cuts already made, as we look at the actual new rules for the Healthy Families Program. Healthy Families is California’s children’s health insurance program, which is funded by state and federal dollars for low-income children whose families who have too much income to qualify for the Medi-Cal program. These are not proposals or negotiating positions, but these are new rules for almost one million children that are effective February 1, 2009. These new rules were published on Christmas Eve as emergency regulations, open for public comment for only five working days. (No doubt most of us were otherwise engaged in the week between Christmas and New Year’s!) The final changes include:

· Dental benefits per child are capped at $1500 per calendar year (with some exceptions). Research substantiates the importance of dental care for children in their general health, ability to learn, and positive impact on other health outcomes.
· An increase in monthly premiums (based on family income cut-offs) from $6 or $9 to $12 or $17. Although those sound like minimal increases, remember these are monthly dollar amounts per child for families with incomes as low as $21,000 per year. These costs are estimated to cause tens of thousands of families to delay enrollment or not continue their children on Healthy Families.

This is billed as a cost-saving measure, but in an ironic twist, the state estimates the changes to premiums will result in savings of state dollars to be a relatively paltry $2.2 million in the current year. However, this additional cost sharing by consumers will also result in a loss of federal dollars to the state of $3.8 million this year. The changes to dental benefits will not result in savings in state dollars during the current fiscal year, but will result in the loss of federal matching funds to the California’s Healthy Families program of $3.3 million next year. It seems these cuts impose more problems for patients than savings for the state.

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posted by Elizabeth C Abbott | Permalink | 6:34 PM


 
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Music to our ears...

 
For those who have been paying attention, it's clear that President Obama is making health care reform a year-one issue. Now others are noticing: here's a report from Politico from Carrier Baroff Brown suggesting a White House meeting and launch of a health reform effort right after the economic stimulus is done, perhaps in March

What should reform look like? The Disease Management Care Blog, by Jaan Sidorov, is hosting this week's edition of Health Wonk Review, which has opinions on all sorts of health-policy-related matters, including ones from Beth Capell and yours truly on this blog. She makes connections not just between these issues, but with video clips of rock and roll standards. It's good reading and listening...

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posted by Anthony Wright | Permalink | 10:34 AM


 
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The beginning of change...

Tuesday, January 20, 2009
 
The New York Times' Robert Pear reports that President Obama (!) is started by undoing some of the worst of the Bush Administration's actions on health coverage. This includes the "global gag rule" and the last-minute "provider conscience" regulation, both seeking to advance the President's position on abortion. Undoing those may take a regulatory review.

One thing that can be more easily undone is restrictions on the State Child Health Insurance Program (SCHIP), insisting on one-year waiting periods for children to get enrolled and otherwise inhibiting states from expanding coverage to children. California appropriately objected.

We also complained that the Bush Administration made these changes not through a public process of developing regulations, but through a simple letter describing how they would adminster the program. But that means it's a lot easier to overturn.

This will be the first in the real, tangible changes from having a new Administration.

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posted by Anthony Wright | Permalink | 6:07 PM


 
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Congratulations, Mr. President.

 
From President Obama's inauguration speech:

Homes have been lost, jobs shed, businesses shuttered. Our health care is too costly, our schools fail too many, and each day brings further evidence that the ways we use energy strengthen our adversaries and threaten our planet.

These are the indicators of crisis, subject to data and statistics. Less measurable, but no less profound, is a sapping of confidence across our land; a nagging fear that America's decline is inevitable, that the next generation must lower its sights.

Today I say to you that the challenges we face are real, they are serious and they are many. They will not be met easily or in a short span of time. But know this America: They will be met...


Now, there are some who question the scale of our ambitions, who suggest that our system cannot tolerate too many big plans. Their memories are short, for they have forgotten what this country has already done, what free men and women can achieve when imagination is joined to common purpose and necessity to courage.

What the cynics fail to understand is that the ground has shifted beneath them, that the stale political arguments that have consumed us for so long, no longer apply.

The question we ask today is not whether our government is too big or too small, but whether it works, whether it helps families find jobs at a decent wage, care they can afford, a retirement that is dignified.

Where the answer is yes, we intend to move forward. Where the answer is no, programs will end.

And those of us who manage the public's knowledge will be held to account, to spend wisely, reform bad habits, and do our business in the light of day, because only then can we restore the vital trust between a people and their government.

Nor is the question before us whether the market is a force for good or ill. Its power to generate wealth and expand freedom is unmatched.

But this crisis has reminded us that without a watchful eye, the market can spin out of control. The nation cannot prosper long when it favors only the prosperous.

The success of our economy has always depended not just on the size of our gross domestic product, but on the reach of our prosperity; on the ability to extend opportunity to every willing heart -- not out of charity, but because it is the surest route to our common good.

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posted by Anthony Wright | Permalink | 11:09 AM


 
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Good riddance...

Monday, January 19, 2009
 
Now that it is ending, an assessment on George W. Bush's presidency on health care is due, but it would be too depressing to write.

The writer would be have a tough decision about whether to focus on inaction--the lack of health reform, coverage expansion, or even a national HMO Patients Bill of Rights that he promised--or on what he did do--from the SCHIP vetoes, to the attacks on Medicaid through the waiver process, to the major subsidies to promote HSAs and high-deductible plans. The President claims Medicare Part D as a success, and while it has helped some seniors, other low-income seniors on Medicare actually pay more now, and there were too many bad policies and precedents to balance out, from the provisions with the purpose of privatizing Medicare, to the explicit bar on negotiating with the drug companies for a better price. It's certainly a open field of work for President-elect Obama.

There should be a special part of the report that would focus on what he actually wanted to do, bu didn't get around to. His broader plan to move people away from group coverage and into the an even-more-deregulated individual market was astonishingly adopted by Senator McCain as a whole, and served a ripe target for the Obama campaign. Hopefully some of those ideas ended with the McCain campaign, and now with the Bush presidency.

We'll see.

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posted by Anthony Wright | Permalink | 10:51 PM


 
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What does bi-partisan mean?

 
Bob Laszewski at the Health Policy and Marketplace Review has argued that the SCHIP vote does not bode well for health reform, because ranking Republican Senator Charles Grassley did not vote in committee for the bill. His case, which he has made before, is that health reform needs a broad, bipartisan supermajority to be successful.

It's a worthy admonition, to think about how any health reform needs to be successful after passage--and having enough political investment in its success.

Maggie Mahar at HealthBeat pushes back, saying that health reform is do closely tied to core values that the debate is inevitably going to be partisan.

Both are right: health reformers need to be aggressive in their outreach to all constituencies--even those that have historically opposed reform--and work for support from both sides of their aisle. But they should be mindful to keep the traditional health reform base united--and not let anybody hold health reform hostage, giving anybody veto power over the effort.

The SCHIP debate was instructive: the votes indeed *have* been bipartisan, with a significant number of Republican votes in the House of Representatives, and in the Senate Finance Committee, with Republican Sen. Olympia Snowe voting in support.

Laszewski thinks Grassley didn't support the new SCHIP bill because of the change getting rid of the five-year waiting period for legal immigrant children. Regardless of "the merits" of the change, such a move was "a mistake." I'll refrain from the many humanitarian, public health, and economic reasons to support this provision of a much larger bill. If the Democrats didn't make this change, it would have meant defections from the Latino caucus, and maybe from representatives of states--like California--that already provide coverage to those kids and don't understand the arbitrary exclusion.

An attempt to get a few Republican votes, by leaving that provision (and many children) behind, would have been much more damaging to health reform--by undercutting the policy goal to cover all children, to undermine good policy, and to start to fracture the natural base of health reform. That would be a "mistake."

Our attempt at health reform in California illustrates the problem. We had a bipartisan health reform negotiated by our Republican Governor Arnold Schwarzenegger and our Democratic Speaker Fabian Nunez.

Schwarzenegger wanted his health reform to have support from Republican legislators, and so he waited for them to engage in negotiations, from January throught August. Schwarzenegger let Republican legislators--who have shown that they won't raise taxes to fund basic services, much less an expansion of health care--play out the clock. By the time Schwarzenegger decided on a ballot strategy to go around the Republican leaders, there were left with only several weeks to meet the required deadlines.

Schwarzenegger also placed a premium on representing allies in the restaurant industry, even though they have been rabid opposed to previous efforts. On their behalf, he opposed efforts to ensure that the employer's contribution to health coverage was shared down through the workforce. That omission did not gain additional business support, but it was significant in losing some potential labor support--support that could have made the difference in getting the bill through the Senate. Especially with opposition that ranged from BlueCross to the tobacco industry, the reform needed all the support it could get.

In the effort to pass health reform, the goal is to get enough support for passage: a majority, and sometimes more. We should actively work to get support from unusual suspects, and both sides of the aisle. But that outreach should be seen as part of the effort to get enough support for passage, not as an additional obstacle to passage.

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posted by Anthony Wright | Permalink | 12:05 AM


 
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Help for health care from the feds?

Friday, January 16, 2009
 
HEALTH ACCESS UPDATE
Friday, January 16th, 2008


FEDERAL DECISIONS TO SET LEVEL OF HELP FOR HEALTH CARE IN CALIFORNIA
* First Draft of Economic Recovery Package Includes Significant Health Funding
* SCHIP Reauthorization Advances Through U.S. House & Senate Finance Committee
* Even With Fed Help, Tough Decisions on Cuts And/Or Revenues Still Needed at State Level


New on the
Health Access WeBlog: Schwarzenegger's State of the State; Another Health Policy Blog; More on Federal Help; SCHIP Passes the House; A National Budget Crisis; The New Senate Health Committee; Events Listing; Balance Billing Victory at the CA Supreme Court; The Governor Vetoes the Democratic Budget Package; New Language Access Regulations In Place; Dr. Sanjay Gupta as Surgeon General?; CIA or Budget Reform?; 1500 Posts!


Governor Arnold Schwarzenegger ditched much of the traditional State of the State on Thursday in order to focus solely on the impending budget crisis. He declared that the "state was incapacitated" and in a "state of emergency," because of the current gridlock on deciding on a budget on cuts and revenues.

Meanwhile, in Congress, financial assistance is being actively considered at the federal level, especially around health care issues. While such funding won't be close to matching the full $42 billion deficit, decisions made in the next few days and weeks will make a difference of billions of dollars to California.

ECONOMIC RECOVERY

The U.S. House Committee on Appropriations chaired by Dave Obey (D-WI) just released its version of the “American Recovery and Reinvestment” package. Representing the House Democrats in consultation with President-elect Obama's team, it includes, regard health care:

Increased Medicaid Matching Funds: It includes $87 billion nationally through the end of federal fiscal year 2010, “with additional relief tied to rates of unemployment.”

Health benefits for the unemployed: The proposal would spend $30 billion to pay 65% of the cost of COBRA for the newly unemployed, for the first 12 months of unemployment.

The proposal would also provide full funding for Medicaid coverage for unemployed workers up to 200%FPL (about $21,000 a year for an individual). And Medicaid eligibility is based on income at the time of application--what would matter is how much unemployment insurance someone is getting, not what they made last year.

Finally, for those over 55 who lose their job or who have worked for an employer for 10 years or more, they could keep their COBRA until they are Medicare eligible—although, after the first year those workers would be expected to pay the full cost of their coverage.

Cost containment: The House Democrats propose major investments in lowering costs and improving quality:
* Health information technology: $20 billion. Health IT is the infrastructure for better cost and quality data, for coordinating and managing care, for reducing medical errors and improving patient safety.
* Prevention: $3 billion to fight hospital infections, grants to public health departments, immunizations, etc.
* Health effectiveness research: $1 billion to compare the effectiveness of drugs, devices and other treatments, based on scientific evidence, not just drug company marketing.* Community health centers: $1.5 billion
* Training primary care providers: $600 million* Indian health services: $550 million

This proposal is the beginning of a (possibly short) debate about the size, scope, and content of an economic recovery package. California health advocates need to inform the state's Congressional delegation about the need and urgency for this assistance.

LEVEL AND FORMULA MAKES SIGNIFICANT DIFFERENCE TO CALIFORNIA

The Obey proposal includes an increase in Medi-Cal matching funds, as did previous versions of "economic stimulus" proposals. Right now, California spends 50 cents on Medicaid and gets another 50 cents match from the federal government--a lower number than many other states, but still a major influx of federal dollars to our health system and economy. The proposal is to temporarily increase that match.

A new study by the Institute of Health Policy Studies (IHPS), explores the different ways to determine that match, and how the decision about that formular could mean hundreds of millions of dollars for California: http://www.ihps.org/pubs/IHPS_FMAP_Enhancement_Issues_011209.pdf

In a letter, here's how IHPS broke down the potential difference:

Using the Congressional Budget Office’s estimate for last fall’s Senate bill of $29.2 billion inadditional federal Medicaid funding as the low end of the range of federal fiscal relief and the Governor’s request for $50 billion a year as the high end of the range, we estimate that:
* Using the equal FMAP percentage points per state approach, California's share of the Medicaid relief package would approximate $3.3 to 5.6 billion in FY 2009.
* Using the equal proportionate reduction in state cost approach analogous to the S-CHIP adjustment, California's share of the Medicaid relief package would approximate $3.8 to 6.5 billion in FY 2009.
* Using the targeted approach with more relief for states with weaker economies, California's share of the Medicaid relief package would approximate $4.0 to 6.8 billion in FY 2009.

An approach that uses the baseline of our lowest-in-the-nation Medicaid matching rate would disadvantage California; a targeted approach based on our economic condition would help California, given our weak unemployment rate.

California health advocates need to make the case with our delegation for
* the highest overall level of assistance for health programs, as well as
* a fair formula that ensures our dire economic situation is recognized.

SCHIP REAUTHORIZATION MOVES QUICKLY

As a separate piece of legislation, the reauthorization for the State Child Health Insurance Program (SCHIP) passed the U.S. House of Representatives Wednesday, 289-139. While it was a strong bipartisan vote, the split in the California delegation was stark, with support all Democrats and only Republican Mary Bono Mack. All other California Republicans voted against it. (Democratic Representative Hilda Solis, Labor secretary-designate, did not vote.)

This is a major boon for the 900,000 children on California's version of the program, Healthy Families, as well as many more children who are still eligible but not enrolled. By raising $32.3 billion with an increase in the federal tobacco tax, the bill extends SCHIP for 4.5 years, provides health coverage for 4.1 million additional children nationally.

The U.S. Senate Finance Committee passed a similar bill Thursday, on mostly a party-line vote, with Republican Senator Olympia Snowe from Maine voting with the Democrats in support. The hope is that a final package is available for President Obama's signature by his first week after his inauguration. Unlike President Bush, who twice vetoed similar child coverage proprosals despite overwhelming bipartisan support, President Obama is likely to make this his first legislative victory.

CALIFORNIA NEEDS KEY PROVISION: California has a strong interest in a key policy provision: Both versions would eliminate an arbitrary provision prohibiting federal matching funds for the first five years legal immigrant children are in the U.S. California, which covers these children, loses millions of dollars each year because of this current exclusion, and would benefit from the change. This important provision needs to stay in the bill: children cannot wait five years for coverage, and California needs the assistance.

THE STATE BUDGET CRISIS CONTINUES

If both the economic recovery package and SCHIP legislation passes shortly, with the formulas and provisions favorable to California, the state would still have a significant deficit to be remedied through cuts and/or taxes. On the other hand, the size of the problem is so great that it is hard to see how any solution is possible without significant federal assistance.

The Governor's current budget proposal offers $14.3 billion in tax increases and other new revenue, and $17.4 billion in spending cuts over the next 18 months, which includes both the first half of 2009, and the 2009-2010 budget year.

The budget includes many cuts that were previously rejected by the Legislature as too severe. It proposes to deny coverage to over a half-million Californians, and to deny specific benefits like dental, optometry, podiatry and psychology to millions more. The proposals would significantly impact not just state's health system, but also have an economic impact as well: California would lose hundreds of millions of dollars in federal matching funds, more than doubling the negative impact of these cuts not just in the health system, but the economy as a whole.

Advocates are actively working for both the state revenues and the federal assistance that can prevent these cuts and sustain these programs. Regarding just the health care cuts, the Governor's budget proposal would:

* Deny over a half-million low-income working parents Medi-Cal coverage, by lowering the eligibility from 100% to 72% of poverty level, cutting off eligbility for parents in families of three making more than $13,000. The cut would be $5.2 million in 2008-09; $176.4 million in 2009-10, and $342 million in 2011-12, ultimately impacting over 429,000 California parents. Over 100,000 additional Californians, largely legal immigrants, would lose most of their coverage under other proposed cuts.

* Eliminate dental, optometry, podiatry, psychology, and several other benefits for 2.5 million parents, seniors, and people with disabilities on Medi-Cal coverage. This cut would be $39.4 million in 2008-09 and $258.8 million in 2009-10.

* Impose significant additional costs on low-income aged, blind and disabled Californians--over 73,000 who make just over $890/month as individuals would have to pay potentially hundreds of dollars a month or forgo care and coverage. This cut would be $28.6 million in 2008-09, and $371.6 million in 2009-2010.

* Siphon funds away from counties, providers, and public hospitals on which we all rely. For public hospitals, the proposal would reduce rates by $54.2 million, at exactly the time the demand for their services is increasing. For counties, the proposal would also suspend cost-of-living increases, a cut of $24.7 million, that counties need to administer the Medi-Cal program. For providers, the proposal would also cut $85.5 million by delaying payment to Medi-Cal fee-for-service providers--effectively forcing these health providers to lose a month of reimbursements.

* Eliminate the First Five Commission, and thus significant funding for a variety of health coverage and other services for young children, such as "Healthy Kids" programs in various counties. This cut would be $275 million, but would require voter approval. A version of this proposal had been offered by Republican legislators, but this is the first time it has been adopted as part of the Governor's proposal.

There are also significant cuts to mental health, developmental services, in-home supportive services, CalWORKS, SSI/SSP, food assistance, and other human services. There are over a billion dollars in cuts to health and human services in the budget year, and that number significantly increases as the cuts are fully implemented in future years.

All experts warn that if at least some budget solutions (cuts and/or revenues) are not passed in the next few weeks, California will run out of money as early as February.

The budget will be the top priority of the new year 2009. More analysis about the budget will be available on the Health Access daily blog, at:
http://www.health-access.org/blogger.html

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posted by Anthony Wright | Permalink | 2:40 AM


 
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The formula matters...

 
In any economic recovery package, a main component is expected to be an increase in Medi-Cal matching funds. Right now, California spends 50 cents on Medicaid and gets another 50 cents match from the federal government. The proposal is to temporarily increase that match.

Here is a new study by the Institute of Health Policy Studies, which goes through the different ways to do that match, and how the decision about that formular could mean billions of dollars for California:
http://www.ihps.org/pubs/IHPS_FMAP_Enhancement_Issues_011209.pdf

Here's a letter that summarizes the findings:
IHPS%20FMAP%20Cover%20Letter.pdf

Using the Congressional Budget Office’s estimate for last fall’s Senate bill of $29.2 billion in
additional federal Medicaid funding as the low end of the range of federal fiscal relief and the Governor’s request for $50 billion a year as the high end of the range, we estimate that:
· Using the equal FMAP percentage points per state approach, California's share of the Medicaid relief package would approximate $3.3 to 5.6 billion in FY 2009.
· Using the equal proportionate reduction in state cost approach analogous to the S-CHIP adjustment, California's share of the Medicaid relief package would approximate $3.8 to 6.5 billion in FY 2009.
· Using the targeted approach with more relief for states with weaker economies, California's share of the Medicaid relief package would approximate $4.0 to 6.8 billion in FY 2009.


In other words, an approach that uses the baseline of our lowest-in-the-nation Medicaid matching rate would disadvantage California; a targeted approach based on our economic condition would help California, given our weak unemployment rate.

California health advocates need to argue for the highest overall level of assistance, as well as a fair formula that ensures our dire economic situation is recognized.

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posted by Anthony Wright | Permalink | 1:50 AM


 
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Bit by COBRA....

 
As people lose employment, we've discussed how important COBRA is to make sure people continue to get group coverage and group rates, and are not at risk of being denied for "pre-existing conditions."

But it's a tough option for many. A new Families USA report calculates that the cost of coverage in California under COBRA would typically be huge 29% of unemployment benefits for an individual, and a unfathomable 82% for a family.

Even The Onion couldn't make it more absurd, even though they tried.

It's gratifying that, as my colleague Beth Capell reports, that helping the newly unemployed with Medicaid expansions and COBRA subsidies is a top priority in the proposed economic recovery package.

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posted by Anthony Wright | Permalink | 12:34 AM


 
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State of the Schwarzenegger

Thursday, January 15, 2009
 
Earlier this week, there was lots of rumors about Governor Arnold Schwarzenegger's State of the State. There was considerable buzz that the Governor would mention new efforts around health care, beyond the continued focus on the ongoing budget saga. It was unclear whether the Governor would seek to offer health proposals that seek to build bridges with the Democrats in the legislature, or more of the health cuts and vetoes that we have seen in the past year.

But the Governor today said he wasn't going to give a standard State of the State, while the budget and cash crunch loomed. He suggested he had big plans and proposed legislation, ready on his desk, on many issues, including health care... but that they will wait until after the budget deal. So no new news today on health policy.

On the budget, the Governor appropriately described the magnitude of the crisis and asked everybody to give, but he didn't recognize how much some have given while others have not.

The Governor needed to acknowledge the $16 billion in cuts already made to health, education and other vital services. In health care, cuts have been made to have a quarter-million children lose coverage, and yet we continue to have a Republican blockade on raising any taxes or revenues to prevent even worse cuts.

We need to remember that despite the Governor's recognition that we need to increase some revenues, his budget proposes to deny coverage to a half-million parents, and to deny specific benefits like dental, optometry, podiatry and psychology to millions more. The cuts the Governor proposes would not only harm the health system we all rely on, but also hinder efforts to stimulate our state's economy. California would lose hundreds of millions of dollars in federal matching funds, doubling--and in some cases tripling--the negative impact of these cuts not just in the health system, but the economy as a whole.

The speech seemed to reflect that a budget deal may be near--enough so that any other speech might risk blowing up negotiations. We hope any budget deal considers both the health and economic impacts of these cuts, and raises the taxes and revenues to prevent those cuts, and make sure we can meet the increased needs in California.

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posted by Anthony Wright | Permalink | 11:32 PM


 
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For your bookmark...

 
Jonathan Cohn, a longtime journalist with an expertise in health policy, and author of the book Sick, has provided very useful reporting at the blogs of The New Republic. Now that magazine has given him his own blog, The Treatment.

The new blog indicates the excitement level rising about health reform issues... this new blog serves a bit like a replacement of "The Stump," where people got obsessive coverage of the presidential campaign. As our modest blogging effort here in Sacramento suggests, there's certainly enough material to get as obsessive. It's a welcome addition to a community of health policy blogs.

His first day in newsworthy: SCHIP passes the Senate Finance Committee, including the ICHIA amendment that would allow California to get more federal matching funds!

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posted by Anthony Wright | Permalink | 6:08 PM


 
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A first look at Federal help...

 
The US House Committee on Appropriations chaired by Dave Obey (D-WI) just released its version of the “American Recovery and Reinvestment: Action and Action Now!”. It is a remarkable document in many respects, including what it envisions for health care. As President-elect Obama has said, the recovery plan should be a down payment on health reform—and this would be a hefty down payment.

Billions to stop Medi-Cal cuts: We were expecting something on improving the federal match for Medicaid—and it is there, $87 billion through the end of federal fiscal year 2010, “with additional relief tied to rates of unemployment”. Since California has a low Medicaid matching rate but a high unemployment rate, we can hope for significant help in preventing further cuts in Medi-Cal, California’s Medicaid program, and perhaps even the chance to eliminate the cuts we have already done.

Health benefits for the unemployed: We had heard there might be something to help the unemployed keep their health benefits---what is proposed is breathtaking.

First, the proposal would spend $30 billion to pay 65% of the cost of COBRA for the first 12 months of unemployment.

Second, the proposal would provide Medicaid coverage for unemployed workers up to 200%FPL (about $21,000 a year for an individual). And Medicaid eligibility is based on income at the time of application so what would matter is how much unemployment insurance someone is getting, not what they made last year. Third, for those over 55 who lose their job or who have worked for an employer for 10 years or more, they could keep their COBRA until they are Medicare eligible—of course, after the first year those workers would be expected to pay the full cost of their coverage.

Cost containment: The House Democrats propose major investments in lowering costs and improving quality:
· Health information technology: $20 billion. Health IT is the infrastructure for better cost and quality data, for coordinating and managing care, for reducing medical errors and improving patient safety.
· Prevention: $3 billion to fight hospital infections, grants to public health departments, immunizations, etc.
· Health effectiveness research: $1 billion to compare the effectiveness of drugs, devices and other treatments, based on scientific evidence, not just drug company marketing.
· Community health centers: $1.5 billion
· Training primary care providers: $600 million
· Indian health services: $550 million

Altogether it is between $150 billion and $200 billion into health care nationally, just when we really need it.

Of course this is not a law yet. The Congressional process is just starting. This is a proposal, not the final bill. The US Senate has not yet weighed in. But what a different world! Enough federal Medicaid money to avoid further Medi-Cal cuts in California and probably to reverse those already done. Health benefits for the unemployed, instead of letting people between jobs go without and put their lives at risk. An implicit recognition that keeping people in their 50s and 60s insured helps to save Medicare money. Real investment in cost containment and improving quality.

We are looking forward to implementing whatever becomes law in the new Obama Administration.

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posted by Beth Capell | Permalink | 2:05 PM


 
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Assembly chairs...

Wednesday, January 14, 2009
 
Assembly Speaker Karen Bass just announced chairs of committees, both policy committees (which we largely knew) and budget subcommittees (which we didn't). We are still awaiting the membership rosters, to see how hard it will be to pass legislation this year.

The biggest news is that first-term Assemblymember Jerry Hill (D-San Mateo), Chair will chair Budget Subcommittee #1 for Health and Human Services. He was a former San Mateo County Supervisor, which did some innovative work on expanding health coverage and providing health services, and so should come with real-world knowledge about the impacts of the health and human services cuts that he will be reviewing.

Here's the chairs and vice-chairs of other committees of interest to health consumer advocates:

Health:
Assm. Dave Jones, D-Sacramento, chair
Assm. Nathan Fletcher, R-San Diego, vice chair

Accountability and Administrative Review:
Assm. Hector De La Torre, D-South Gate, chair
Assm. Audra Strickland, R-Thousand Oaks, vice chair

Appropriations:
Assm. Kevin De León, D-Los Angeles, chair
Assm. Jim Nielsen, R-Gerber, vice chair

Budget:
Assm. Noreen Evans, D-Santa Rosa, chair
Assm. Roger Niello, R-Fair Oaks, vice chair


Revenue and Taxation:
Assm. Charles Calderon, D-Montebello, Chair
Assm. Chuck DeVore, R-Irvine, Vice Chair

Rules:
Assm. Ted Lieu, D-Torrance, Chair
Assm. Sam Blakeslee, R-San Luis Obispo, Vice Chair

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posted by Anthony Wright | Permalink | 6:25 PM


 
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Try, try, try again...

 
The reauthorization for the State Child Health Insurance Program (SCHIP) passed the U.S. House of Representatives today, 289-139. While it was a strong bipartisan vote, the split in the California delegation was stark, with support all Democrats and only Republican Mary Bono Mack. All other Republicans voted against it. (Democratic Representative Hilda Solis, Labor secretary-designate, did not vote.)

This is a major boon for the 900,000 children on California's version of the program, Healthy Families, as well as many more children who are still eligible but not enrolled. By raising $32.3 billion with an increase in the federal tobacco tax, the bill extends SCHIP for 4.5 years, provides health coverage for 4.1 million additional children nationally.

The U.S. Senate is expected to consider the bill in committee tomorrow, and the hope is that a final package is available for President Obama's signature by his first week after his inauguration. Unlike President Bush, who twice vetoed similar child coverage proprosals despite overwhelming bipartisan support, President Obama is likely to make this his first legislative victory.

California has a strong interest in a key policy provision: the House version would eliminate an arbitrary provision prohibiting federal matching funds for the first five years legal immigrant children are in the U.S. California, which covers these children, loses millions of dollars because of this current policy, and would benefit from the change. This important provision needs to stay in the bill: children cannot wait five years for coverage.

(Jonathan Cohn of The New Republic has an excellent write-up of the politics and policy of this provision.)

Even if SCHIP passes, and provides the 2-1 match from the federal government, then it will be up to state leaders to continue to fully fund the program to the point where we can cover all California's children. If not, then our funds will be directed to other states.

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posted by Anthony Wright | Permalink | 5:57 PM


 
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A national budget crisis...

 
California is not the only state in this mess. As Noam Levey of the Los Angeles Times writes in an article entitled, "Struggling states cut healthcare for poor before Obama can bolster coverage," other states are already making cuts to coverage.

California imposed additional reporting requirements to have over 250,000 children fall off coverage, and has active proposals by Governor Schwarzenegger to deny coverage to over 500,000 more California adults, largely low-income working parents.

If economic recovery funding comes, we need it not only to prevent these cuts, but to restore those that have already been made.

The expectation is that the new federal money from increased Medicaid funding may be bigger than the proposed cuts in Medi-Cal--but still small compared to the size of the overall budget deficit. But we have a good case to make that the money should be used as intended, to keep our health care programs and system whole, and to meet the increased and urgnet health care needs during this economic downturn.

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posted by Anthony Wright | Permalink | 10:22 AM


 
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Senate Committee Assignments...

Tuesday, January 13, 2009
 
Senate President Pro Tem Darrell Steinberg has announced the new committee assignments for the next session. Here's the committees of interest for health advocates:

HEALTH COMMITTEE:
Sen. Alquist (Chair - D)
Sen. Strickland (Vice Chair - R)
Sen. Cedillo (D)
Sen. Negrete McLeod (D)
Sen. Wolk (D)
Sen. Pavley (D)
Sen. DeSaulnier (D)
Sen. Leno (D)
Sen. Cox (R)
Sen. Maldonado (R)
Sen. Aanestad (R)

There are 11 members of Senate Health Committee: There are 7 Democratic Senators, and any legislation need 6 votes to pass out of the committee.


APPROPRIATIONS COMMITTEE:
Sen. Kehoe (Chair -D)
Sen. Cox (Vice Chair -R)
Sen. Yee (D)
Sen. DeSaulnier (D)
Sen. Corbett (D)
Sen. Leno (D)
Sen. Oropeza (D)
Sen. Hancock (D)
Sen. Wolk (D)
Sen. Runner (R)
Sen. Wyland (R)
Sen. Walters (R)
Sen. Denham (R)


BUDGET & FISCAL REVIEW
(All Senators will be members of the full Budget Committee. However, there will be only three voting members on each of five Subcommittees.)

SUBCOMMITTEE #3 ON HEALTH & HUMAN SERVICES, LABOR & VETERANS' AFFAIRS
Sen. Leno (Chair - D)
Sen. Alquist (D)
Hollingsworth (R)

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posted by Anthony Wright | Permalink | 4:33 PM


 
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Quick links...

Monday, January 12, 2009
 
The new Health Wonk Review is being hosted at The Health Care Blog this week.

The California Budget Project has joined the blogosphere.

Paul Krugman of The New York Times goes over the relative economic impacts of taxes/tax cuts and government spending/budget cuts. It is public investment--like in health care--that we get the bang for the buck.

The Robert Wood Johnson Foundation has new research on the need to provide assistance for child health insurance at higher income levels than when SCHIP started over 10 years ago, given the rise in premiums and the declining value of incomes.

With all the discussion around health plans by Baucus, or even Conyers, it's important to note that Rep. Pete Stark has his AmeriCare health reform proposal in the mix as well.

More about the unacceptable status quo (getting worse since 1994!) from the Center for American Progress.

More to come...

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posted by Anthony Wright | Permalink | 5:32 PM


 
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Events this week...

Sunday, January 11, 2009
 
Health Access is pleased to co-sponsor the Working Families Summit, for this Tuesday, January 13th, from 9am-4:30pm.

Organized by the California Center for Research on Women & Families, the agenda at the Sacramento Convention Center has panels and plenaries on the budget, the safety-net, health care, and the broad range of issues impacting California's families. We will be presenting, and it's a conference where we can't just show up and wing it... a lot of work was required of all presenters to make the day a meaty policy discussion.

You can register here.

--

We are also pleased to co-sponsor a screening of Unnatural Causes: Is Inequality Making Us Sick? at the State Capitol in Sacramento, in the late afternoon of Wednesday, January 14th.

The California Endowment is hosting the screening, which will feature Larry Adelman, the series Executive Producer. The documentary series was shown last year on PBS, and is now available on DVD.

--

The big event is Governor Schwarzenegger's State of the State on Thursday, January 15th. There's lots of speculation of what he will say on the budget crisis, his rationale for vetoing the latest budget package, and even what he might say on health reform. Stay tuned.

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posted by Anthony Wright | Permalink | 12:07 AM


 
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What the "balance billing" court ruling means....

Friday, January 09, 2009
 
As my colleague Anthony Wright said, and which has been trumpeted in front-page headlines around the state today, the ruling in the Prospect case is a big win for consumers---and it is particularly sweet since it was a unanimous and conclusive decision in a case that might well have led to murky law, as did the appellate case that it overturned.

Here is what the California Supreme Court said:

For HMO members, it is always clear in advance who has to provide emergency services — any emergency room doctor to whom the member goes in an emergency — and who has to pay for those services — the HMO. The conflict arises when there is no advance agreement between the emergency room doctors and the HMO regarding the amount of the required payment… The resolution of such disputes can create difficult problems.

But the question of how to resolve disputes between the doctors and the HMO over the amount due for emergency care is not before us in this case. The issue here is narrow, although quite important for emergency room doctors, HMO’s, and their members: When the HMO submits a payment lower than the amount billed, can the emergency room doctors directly bill the patient for the difference between the bill submitted and the payment received — i.e., engage in the practice called “balance billing”?

Interpreting the applicable statutory scheme as a whole — primarily the Knox-Keene Health Care Service Plan Act of 1975, Health and Safety Code section 1340 et seq. (Knox-Keene Act) — we conclude that billing disputes over emergency medical care must be resolved solely between the emergency room doctors, who are entitled to a reasonable payment for their services, and the HMO, which is obligated to make that payment. A patient who is a member of an HMO may not be injected into the dispute. Emergency room doctors may not bill the patient for the disputed amount.

Often legal decisions are a tangle of precedents and legal Latin (literally) that take a bit of thinking to untangle. Not so in this ruling. Justice Ming Chin, writing a 7-0 decision, chose to use very plain English, and his colleagues concurred.

How did the Supreme Court arrive at this decision? How did they find the law so plain when others have struggled to sort out what the law is on balance billing? Well, they did what courts do: they looked at the statutes that have been enacted in sequential order and said here is what the statutory scheme is:

The only reasonable interpretation of a statutory scheme that (1) intends to transfer the financial risk of health care from patients to providers; (2) requires emergency care patients to agree to pay for the services or to supply insurance information; (3) requires HMO’s to pay doctors for emergency services rendered to their subscribers; (4) prohibits balance billing when the HMO, and not the patient, is contractually required to pay; (5) requires adoption of mechanisms to resolve billing disputes between emergency room doctors and HMO’s; and (6) permits emergency room doctors to sue HMO’s directly to resolve billing disputes, is that emergency room doctors may not bill patients directly for amounts in dispute. Emergency room doctors must resolve their differences with HMO’s and not inject patients into the dispute. Interpreting the statutory scheme as a whole, we conclude that the doctors may not bill a patient for emergency services that the HMO is obligated to pay. Balance billing is not permitted.
Among the key statutes, the Court cites is one of our victories in HMO Reform: the California law that states that the HMO must pay for emergency care if a consumer reasonably believed they had an emergency. While we have been most pleased with this because it is a more consumer-friendly standard than the “prudent layperson” standard used in other states, the law has also been clear that HMOs must pay providers for emergency care they provided so long as the consumer “reasonably” thought they had an emergency.

One of the things that we have learned as we have struggled with legislative and regulatory solutions to the balance billing question over the last five years is that HMOs have obeyed the law--- that is, the HMOs actually do pay emergency room providers and in a reasonably timely way. What the ER docs and hospitals are upset about is that they want to get paid more. So the ER docs and some hospitals have gone after the patient to get the money---or to get the patient to complain to the HMO so the HMO will pay more. This is what Health Access opposes because it puts consumers with insurance in the middle of a business dispute between two institutional players that play this game every day while the average consumer goes to the emergency room once in a blue moon and has no idea what hit them when they start getting collection notices.

You may be thinking, but wait, that nice emergency doctor, they deserve to get paid. That’s right. The emergency doctor (and the hospital with the emergency room) do deserve to get paid and to get paid timely and to get paid a fair amount. But as the Court pointed out, there are mechanisms for that in the law. And more importantly, ER docs bill HMOs every day—and HMOs pay ER docs. There are literally hundreds of thousands of claims made, and paid, every year in California.

When was the last time you went to the emergency room? Thank goodness, it has been several years since I helped a loved one through an ER visit. And he never did figure out all the bills and the paperwork. Consumers should not have their credit ruined just because they did the right thing and got medical care when they needed it most urgently.

There were lots of other arguments and issues that could easily have tangled up the Court, making for a murky decision---implied contracts, delegation of the HMO role, legislative efforts, and the regulation on balance billing which is also being litigated. The Court was distracted by none of this.

So it is a sweet victory, and sweeter because it is unanimous and conclusive. There is other pending litigation in this area. We shall see what the Court and the various parties do as a result of this ruling. This ruling technically applies only to doctors and not to hospitals, but it is difficult to see the Court reaching any other conclusion with respect to hospitals. And it only applies to emergency care.

Going to the emergency room is never a happy experience. But the only thing you should be worrying about if you have insurance is getting better—not the fear that your credit will be ruined. That is what we thought the law should say. And now the Supreme Court has said that is what the law says.

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posted by Beth Capell | Permalink | 10:11 AM


 
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Victory at the Supreme Court!

Thursday, January 08, 2009
 
Big consumer victory today. The California Supreme Court ruled 7-0 to protect patients from unfair bills during disputes between insurers and providers.

This unanimous ruling by California Supreme Court in Prospect Medical Group vs. Northridge Medical Center, is clear and unequivocal.

The case states directly, that when there's a billing dispute between an emergency room doctors and an HMO, "a patient who is a member of an HMO may not be injected into the dispute. Emergency room doctors may not bill the patient for the disputed amount."

After years of contentious fights through legislation and regulations, this is big news. As Health Access California has always contended, insured consumers should not have their credit and financial future ruined by unfair double billing. This ruling will prevent patients from being held hostage in a billing war between doctors and health plans. We appreciate the court's decisive ruling to protect premium-paying patients from being unfairly billed and sent to collections and worse.

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posted by Anthony Wright | Permalink | 6:43 PM


 
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The veto message...

 
In his perplexing letter announcing his vetoes of the Democratically-passed mid-year $18 billion budget package, Governor Schwarzenegger writes:
The measures you sent me punish people with increased taxes, but do not make the serious cuts in spending necessary to balance our budget; do nothing to help keep California families working during this recession; and do nothing to help Californians facing foreclosure in this mortgage crisis. It is unfair and unacceptable to place an even greater burden on hard-working taxpayers without doing all we can to cut spending, create jobs and keep people in their homes.

I would say this letter is surprisingly tone-deaf, but this is admittedly after the Governor had his last budget package of severe cuts announced while he was away on an Idaho ski vacation.

The rhetoric of "punishing" people with increased taxes seems wrong for someone who recognizes that they need to be part of any solution, which his own budget suggest. Taxes aren't a punishment--they are, as the quote says, the price we pay for civilization. They are never loved, but most people recognize we have to pay for the services (education, health, public safety, etc) that we get.

Moreover, the phrasing seems oblivious to the real punishment being felt by those impacted by the cuts he is proposing, especially in health and human services.

Finally, preventing these cuts to health and human services will do more for the economy and "keeping California families working" than anything he has proposed as so-called "economic stimulus." The funding for these programs goes right into the community and economy, gets spent immediately, and largely goes to either low-income beneficiaries and/or service workers--both of which are likely to immediate spend that money again, providing a multiplier effect. In health care (and some other programs), this multiplier effect is increased further because of federal matching funds.

It seems frustrating that with the awful choices and trade-offs that have to be made this year, we still are seeing this type of rhetoric and distractions in the conversation.

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posted by Anthony Wright | Permalink | 12:01 AM


 
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The right to communcate...

Wednesday, January 07, 2009
 
Bobby Caina Calvan of the Sacramento Bee had the write-up about the new regulations on language access finally getting the force of law.
Millions of Californians with limited English proficiency now have the right to an interpreter from their commercial health and dental plans – made possible by a first-in-the-nation law aimed at dismantling the language barriers that get in the way of good medicine.

The new regulation – implemented New Year's Day after five years of hearings, delays and wrangling among insurance companies, regulators and consumer advocates – is widely hailed as a milestone in reducing mistakes because of miscommunication.

We were happy to be part of the broad coalition in support of the original law, SB852(Escutia), and the ongoing regulatory process at the Department of Managed Health Care.

Health Access has also been pleased to work to pilot and implement video medical interpretation at various public hospitals, providing an example of how providers can meet these requirements in a cost effective and efficient manner.

Now we need to make sure that patients know their rights--that they don't have to mime their way through a doctors appointment, or bring their child to translate inappropriate information.

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posted by Anthony Wright | Permalink | 11:44 PM


 
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The Best Health Reform Team on Television?

Tuesday, January 06, 2009
 
There's been lots of commentary on Dr. Sanjay Gupta of CNN as the possible next Surgeon General of the United States.

The conversation is that he has a background in health policy, and has negotiated a role in the health reform effort. If he takes the position role, he clearly will be a visible spokesperson for reform.

One of the things I remember about past health care ballot measure fights is the need of a credible, trusted, known spokesperson.

I remember on Prop 54, the Ward Connerly initiative to ban the collection of racial data, it was helpful to have former Surgeon General C. Everett Koop make the case that the Proposition would hinder public health efforts. In a 30 second ad, it mattered it was Koop... a known quantity for even those that don't pay attention to this stuff that much, saying that the proposition would hurt your health care. Prop 54 failed.

For various reforms since, we have used many great name-brand organizations and many noted doctors, nurses, community leaders, and elected officials, in both TV ads and the ballot pamphlet. There's a reason those endorsements matter: for initiatives, when people are not inclined to know or study all the details, they tend to rely on the advise of those they trust: and that works best when it is a person, rather than an institution or credential. And while some issues might have that person (Al Gore on the environment?), there's not a lot of those people for the health and economic issues related to health reform.

But at the end of the day, President-elect Obama will be the primary person: reform's chances will be tied to the popularity and trust of his name. The "Clinton health plan" started to sink as Clinton's ratings went down due to unrelated policy and political matters--even while the provisions of the plan polled the same.

But given how foundational health care is to people's lives, it won't hurt to have a key surrogate that had credibility on health issues--not just on public health, but on health reform as well.

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posted by Anthony Wright | Permalink | 11:42 PM


 
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Easier than fixing our budget mess...

Monday, January 05, 2009
 
Former California Congressman (and former White House Chief of Staff) Leon Panetta has been tapped to head the Central Intelligence Agency.

He was making news recently as co-chair (and perhaps most visible spokesperson) of California Forward, a bipartisan, foundation-funded effort to remake state government, especially our budget process. They have a range of broad proposals, including multi-year budgeting and increased oversight and evaluation of programs.

Certainly, there are some reforms here that could help build the trust with the public needed to have a functioning government. My critique is that even if all these changes are made, they fundamentally won't prevent the gridlock that we've seen.

The core issue is the lack of accountability brought about by the 2/3 rule to pass a budget or taxes, allowing a tyranny of the minority: a relative handful of legislators (as few as 14 Senators) can block the entire budget, and yet are insulated from consequences. The majority can then hide behind the obstruction of the minority, and thus everybody escapes accountability. California Forward has the right theme, but it seems their desire for buy-in from both parties prevents them from confronting this core issue (as well as others, like ballot-box budgeting that gives the Legislature little discretion to begin with.)

John Myers of KQED interviewed Panetta a few weeks ago, before he moved on. California Forward will certainly move forward without him... we'll see how its proposals evolve, as the budget discussion continues.

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posted by Anthony Wright | Permalink | 1:35 PM


 
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Back in business...

 
We have just passed 1500 posts since putting up our updates starting May 2002, and since we posted on a daily basis over two years ago.

For 2009, we resolve to continue to provide timely updates about what is going on with health policy that would impact California consumers: the bills, the budget, the ballot box propositions, and beyond.

We resolve to provide reports, commentary, and action items on the push for health reform, not just at the state but at the federal levels. We expect (and will encourage) a lot of activity in both Sacramento and Washington, DC.

We resolve that we will have a broader range of voices from the Health Access California community. We resolve to make other improvements and changes to this website soon. If you have other suggestions for the new year, please let us know...

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posted by Anthony Wright | Permalink | 12:32 AM


 
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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.