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Nothing like a deadline...

Friday, February 27, 2009
 
Lots of bills were filed today, as it was the last day to submit legislation. Health Access will be reviewing all the bills, looking for those of particularly interest to health consumers.

One note from today: the single payer bill has a new author and number. In the current decade, it was first introduced by Senator Sheila Kuehl in 2003, as SB921(Kuehl). A subsequent version, SB840(Kuehl), passed the legisature--without financing--twice, and was vetoed twice by Governor Schwarzenegger. With term limits ending the legislative stint of Senator Kuehl, the new bill this year comes under the authorship of San Francisco Senator Mark Leno, as SB810(Leno).

As one of the last bill numbers, it serves as a bookend for SB1(Steinberg), the bill to ensure coverage for all children. Senator Alquist and Assemblyman Jones, chairs of the respective health committees also have comprehensive reform bills, although now they only include intent language. There's certainly the vehicles for a continued effort for health reform at the state level, even as the debate intensifies in Washington, DC.

There are many other bills with specific health reforms as well, and we'll have a list of some of the key ones soon.

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posted by Anthony Wright | Permalink | 5:22 PM


 
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An actual down payment...

Thursday, February 26, 2009
 
The big number out of President Obama's budget released today in $634 billion over the next ten years. This is detailed at http://www.whitehouse.gov/omb/ and covered in newspapers and blogs today.

Even with the effort to cut the deficit in half, President Obama has prioritized health reform enough to put this money aside to help finance health reform.

I say "help" because the Obama Administration is clear that this isn't enough, to provide affordable health coverage to all Americans.

One of the obstacles for health reform in California in 2007-08 was that because of our strained budget and balanced budget requirements, California's reform needed to be entirely self-financing. That put a lot of pressure to find funding sources, and to limit the help that consumers could get with affordability.

Having some money to start with helps. It's not everything, but it helps.

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posted by Anthony Wright | Permalink | 1:33 PM


 
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Health week... like shark week, but more sharp teeth...

Wednesday, February 25, 2009
 
As busy as it's been in Sacramento, the health care debate is taking off in Washington, DC.

On Monday, President Obama hosted a "fiscal responsibility summit," with the announced goal of cutting the deficit by half. But a major focus was health reform. (In fact, among those in attendance, looking at the C-SPAN coverage, was Health Access board member Dr. Ho Tran, director of the Asian and Pacific Islander American Health Forum.) The President's budget director, Peter Orzag, said: "entitlement reform is health reform; the path to fiscal responsibility is through health reform."

On Tuesday, the President delivered his address to Congress, where he was unequivocal: "let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year."

On Wednesday, the U.S. Senate Finance Committee, chaired by Senator Max Baucus is hosting a hearing on comprehensive health reform, officially starting the consideration of this major push in Congress. (And back in Sacramento, our Senate Health Committee, chaired by Senator Elaine Alquist, is also having a hearing on the prospects for health reform on Wednesday afternoon. The Assembly Health Committee, chaired by Assemblyman Dave Jones, is having a hearing on state health reform in a few weeks.)

On Thursday, President Obama is expected to release his budget proposal. There's expectation that he will include specific dollars for his health reform in the budget proposal--what was seen as a critical "put your money where your mouth is" marker about the priority of health reform. Some in-depth reporting is available from The New Republic's Jonathan Cohn and The American Prospect's Ezra Klein. All signs at the federal level are pretty positive right now.

We're off and running!

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posted by Anthony Wright | Permalink | 12:02 AM


 
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Timely coincidence...

Tuesday, February 24, 2009
 
Earlier today, Assemblyman Dave Jones chaired an informational hearing of the Assembly Health Committee had a hearing on emergency room access.

There was a lot of talk about minimizing "avoidable" emergency room use, to lessen the overcrowding in emergency rooms. There's probably a distinction between the use of the emergency room for non-emergency purposes, and emergency care that could have been avoided if the patient got care earlier.

Part of the solution was being heard just a day earlier at the Department of Managed Health Care, which considered regulations on timely access to care. Recent research suggests the increase in emergency room use is not from uninsured but insured patients. Part of the problem is that people, not being able to get appropriate triage or timely access to a primary care doctor or a specialist, end up needlessly in the emergency room.

It's nice that at least part of the solution to the problem is finally close to implementation, and to able to report that to the Assembly Health Committee.

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posted by Anthony Wright | Permalink | 11:39 PM


 
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"Cannot wait, must not wait, will not wait..."

 

From President Obama's Address to Congress this evening, emphasis added:



None of this will come without cost, nor will it be easy. But this is America. We don’t do what’s easy. We do what is necessary to move this country forward.

For that same reason, we must also address the crushing cost of health care.

This is a cost that now causes a bankruptcy in America every thirty seconds. By the end of the year, it could cause 1.5 million Americans to lose their homes. In the last eight years, premiums have grown four times faster than wages. And in each of these years, one million more Americans have lost their health insurance. It is one of the major reasons why small businesses close their doors and corporations ship jobs overseas. And it’s one of the largest and fastest-growing parts of our budget.

Given these facts, we can no longer afford to put health care reform on hold.

Already, we have done more to advance the cause of health care reform in the last thirty days than we have in the last decade. When it was days old, this Congress passed a law to provide and protect health insurance for eleven million American children whose parents work full-time. Our recovery plan will invest in electronic health records and new technology that will reduce errors, bring down costs, ensure privacy, and save lives. It will launch a new effort to conquer a disease that has touched the life of nearly every American by seeking a cure for cancer in our time. And it makes the largest investment ever in preventive care, because that is one of the best ways to keep our people healthy and our costs under control.
This budget builds on these reforms. It includes an historic commitment to comprehensive health care reform – a down-payment on the principle that we must have quality, affordable health care for every American. It’s a commitment that’s paid for in part by efficiencies in our system that are long overdue. And it’s a step we must take if we hope to bring down our deficit in the years to come.

Now, there will be many different opinions and ideas about how to achieve reform, and that is why I’m bringing together businesses and workers, doctors and health care providers, Democrats and Republicans to begin work on this issue next week.

I suffer no illusions that this will be an easy process. It will be hard. But I also know that nearly a century after Teddy Roosevelt first called for reform, the cost of our health care has weighed down our economy and the conscience of our nation long enough.
So let there be no doubt: health care reform cannot wait, it must not wait, and it will not wait another year.

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posted by Anthony Wright | Permalink | 11:28 PM


 
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Budget re-cap...

Sunday, February 22, 2009
 
HEALTH ACCESS UPDATE
Monday, February 23rd, 2009


GOVERNOR SIGNS BUDGET; ADDITIONAL SEVERE CUTS MAY BE TRIGGERED
* Additional Severe Cuts Depend on Federal Aid Meeting $10 Billion Threshold
* Elimination of Medi-Cal Benefits & Cuts to Public Hospitals, Human Services At Stake

* Voters to Consider Props 1D/1E for Additional Cuts to Mental Health & Children's Services
* Prop 1A Would Impose State Spending Cap That Would Force Cuts Into the Future


New on the
Health Access WeBlog: Lockyer on the Budget Trigger; Timely Access to Care Hearing & Comments Due Monday; National Health Reform Developments; Health Wonk Review; Many More Details on the Budget Deal, and the Implications for Health Care


SACRAMENTO--After long and intense negotiations, the California Legislature passed a 2009-2010 budget package on February 19, 2009 which the Governor signed the next day. The budget package made up of over 30 bills is primarily based on a framework developed by Governor Schwarzenegger and legislative leaders.

With the state facing a $41 billion deficit through June 2010, the current budget fills the gap through a series of spending cuts, tax increases, borrowing, and federal stimulus funds. The package also included several tax, budget and policy changes not related to closing the deficit.

More specifically, the budget includes: $14.9 billion in spending reductions (in addition to the $19 billion in cuts over the past three years); $12.5 billion in new and increased, but temporary, taxes (including a one cent increase in sales tax, adding a surcharge on state income taxes while reducing the allowed dependent tax credit, an increase in the vehicle-license fee); $7.8 billion in federal stimulus revenue ; an $5.4 billion in borrowed funds, including from the state lottery.

FURTHER HEALTH CUTS

In addition to the $19 billion in spending cuts over the past three years, the current budget cuts another $15 billion. Along with other areas, health care (here's the CHHS summary) is also subject to significant cuts in the current budget, including:

* $24.7 million in General Fund savings (and $24.7 million in lost federal funds) by suspending the 2009 Medi-Cal Administration cost of doing business increase for counties;

* $54.2 million in lost federal funds by reducing payment rates to public hospitals by 10 percent.; and

* $129.4 million in General Fund savings (and $129.4 million in lost federal funds) by eliminating dental and other Medi-Cal benefits for about 3 million adults, including audiology and speech therapy, acupuncture, chiropractic services, optometry, podiatry, and psychological services, and incontinence creams and washes.


THE ROLE OF FEDERAL ECONOMIC RECOVERY FUNDS:
The Potential to “Trigger-Off” Some Cuts & Taxes

Although the budget contains a number of spending cuts, it also contains a mechanism to restore some of those cuts using federal funds authorized by the American Recovery and Reinvestment Act of 2009 (ARRA) signed by President Obama on February 17, 2009. The mechanism requires that in order to restore cuts, the state must receive at least $10 billion in federal funds to offset General Fund costs. In other words, $10 billion of federal funds are needed to “trigger off” some of the cuts.

The precise amount of federal stimulus funds for California is still being determined, however, the Director of Finance and the Treasurer must determine by April 1, 2009 whether federal funds meet the $10 billion threshold to trigger off the spending cuts. Specifically with respect to health care cuts discussed above, if there is sufficient federal funding, Medi-Cal benefits would not be eliminated and public hospital payments would not be reduced. If there is insufficient federal funding, those cuts and others--including steep cuts in SSI/SSP, IHSS, and CalWORKS would be implemented July 1, 2009.

While some assumed that the federal funds in the economic recovery package would prevent the cuts, Schwarzenegger Administration officials have suggested that preliminary estimates are less than the $10 billion threshold, depending on which funds are counted, and for what period of time. This prospect is very disappointing to many health advocates, especially since the point of this economic package was to prevent cuts, particularly to health care, and not just to meet the increased health needs in a bad economic time, but also to help the economic recovery by having health care jobs in place. Treasurer Bill Lockyer released a statement Friday saying that any estimate is premature, and that he would making an independent decision.


THE ROLE OF CALIFORNIA VOTERS: May 19th Election to Decide
Additional Cuts, A Spending Cap to Force Future Cuts


In order to piece together a budget and secure the legislative votes to pass it, the current budget contains eight provisions that will be subject to vote on a May 19, 2009 ballot. Of the three provisions that will likely have the greatest impact on health care, two shift funding away from voter-approved health-related services and another imposes an overall state spending cap that will force cuts in the future if enacted.

* Proposition 1D would amend Proposition 10, which was passed in 1998 and increased the tobacco tax to be used exclusive for services for children up to five years old. This budget, subject to voter approval, would redirect Proposition 10 funds of up to $340 million in the first year and $268 annually for the following five years to be appropriated by the Legislature. As a result, local First Five Commissions would have to cut the programs they fund, such as county “Healthy Kids” coverage initiatives.
* Proposition 1E would amend Proposition 63, which in 2004 raised the income tax for the upper-tax bracket to earmark funding specifically for mental health services. This budget, subject to voter approval, would redirect Proposition 63 funds of up to $226.7 million in the first year and $234 annually for the following year from Proposition 63 mental health services to backfill the existing Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.

* Proposition 1A would pass a Constitutional amendment to institute a spending cap, to limit the amount of revenue that can be appropriated for the General Fund. It also would extend the temporary taxes to last from two to five years. Under the spending cap, any revenues above a forecasted amount must be put in a “Budget Stabilization Fund,” and can only be accessed under certain circumstances. In other words, the spending cap locks up money making the state less able to fund education, health care, and other core state services.

Even with all the cuts, this spending cap would have the most profound impact on health care. It would limit California ’s ability to invest in health, education and other vital services, and in fact is projected to force steep cuts every year into the future.

For health care, the impact of an artificial spending cap is to lock the state in to the current broken, resource-starved health system that we all rely on--preventing any action to address the needs of the over six million uninsured Californians, or to improve our system with the lowest per-patient Medicaid spending in the nation. As the limit does not take into account medical inflation or the costs of an aging population, health care programs and services would be particularly vulnerable under the cap. The cap would thus force cuts into existing programs and services, and prevent ever addressing unmet needs.

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posted by Anthony Wright | Permalink | 9:50 PM


 
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Saturday spam...

Saturday, February 21, 2009
 
After discussing the aftermath of the budget on Calitics radio (as well as more traditional media like Time), it's indeed time to refocus on the next debate: health reform.

There's a new Health Wonk Review up at InsureBlog. The theme is based around a delicacy in Hawaii, so I am surprised there isn't a discussion of the employer mandate in that state.

Suzy Khimm at The Treatment comments on a New York Times article by Cara Buckley, and the New Republic reporter makes an important, often overlooked point that I have been passionate about: we should not blame the young for being uninsured. It's not because they are young, but because they are typically low-income and not eligible for employer coverage. The article plays off a Community Catalyst report about expanding dependent coverage. Speaker Nunez had a bill on the subject several years backed, but it was vetoed by Governor Schwarzenegger.

There was another New York Times article by Robert Pear about some stakeholder convenings held by Senator Kennedy's office. I'll refrain from commenting on the policy substance in this post, but on the process: We at Health Access were part of a similar process in California reform, and given the similar breadth of organizations included, I think the article might overstate the level of agreement in those discussions. There are tough decisions to make, and those types of discussions, even private ones, are typically not the place where people show their cards.

Finally, getting stakeholder groups--even a critical mass of them--is only one, and perhaps not even the most important, hurdle. The need to finance any proposal and the political process, between the President, House, and Senate, will have its own demands of any health reform. As will the public at large. It's one thing to have some candid conversations in private, but there's some things that look good in private may look different in public.

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posted by Anthony Wright | Permalink | 2:39 PM


 
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Treasurer Lockyer speaks on the trigger...

Friday, February 20, 2009
 
Some more news on the infamous "trigger..."

To recap: the 2009-10 budget is bad, but it is far worse depending on a joint decision by the State Treasurer Bill Lockyer and Governor Schwarzenegger's Director of Finance Mike Genest. They need to detemine by April 1 whether California's general fund will receive from the federal stimulus package at least $10 billion by the end of the 2009-10 fiscal year.

If that determination is made, it will trigger the elimination of nearly $1 billion in health and human services reductions (including eliminating dental and other Medi-Cal benefits, cutting public hospitals, SSI/SSP, IHSS, and CalWORKS) and $1.8 billion in personal income tax increases, currently in the budget and scheduled to take effect on July 1, 2009.

After Director Genest preliminarily suggested that we would not meet the threshold, and thus trigger the cuts, State Treasurer Bill Lockyer weighed in this afternoon regarding the estimated California share of federal stimulus dollars contained in the "2009 Budget Act Package" released today by the Governor:

"Any speculation about whether budget cuts or tax increases will 'trigger off' as a result of the federal funds determination is premature. The Governor's enacted budget presentation today includes an estimate of $7.8 billion in federal assistance. I understand this figure is the Administration's preliminary estimate, and not by any means a final calculation. In arriving at any official determination of the actual funds available, I will make an informed and independent decision only after we have completed a full review and public hearing."

There's questions about what federal funds "count" to meet the threshold, and how the formulas work. There's a lot riding on that analysis and decision.

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posted by Anthony Wright | Permalink | 9:41 PM


 
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The May 19th ballot...

 
Secretary of State Debra Bowen has the announcement of the ballot initiatives slated for the May 19th ballot.

The cap on health, education, and other vital services will be Proposition 1A. The raids on the voter-approved funds for children's services and for mental health are Prop 1D and 1E, respectively.

Not only has the cap not been vetted in public hearings, the timeframe for the camapign is so short that it may be very hard to have substantive analyses of the full impact of such a major constitutional change--either in the ballot pamphlet, or even before the election a few short months away.

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posted by Anthony Wright | Permalink | 6:27 PM


 
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Last time? A timely access hearing on Monday...

 
With so much going on regarding the budget, it's important not to forget and highlight the upcoming hearing and DMHC comment deadline THIS MONDAY, FEBRUARY 23rd, on the crucial issue of timely access to care, an important plank in our ongoing work on HMO Patients Bill of Rights.

After six years since the law we passed, we have a chance to win clear standards for timely access to care!

ALERT: DMHC TO HOLD FINAL HEARING
ON NEW TIMELY ACCESS TO CARE STANDARDS
* CA Department of Managed Health Care Finalizes New Regs on Timely Access to Care
* Need Public Comments to Support Time Standards to Get Primary and Specialty Care
* ACTION ALERT: Letters & DMHC Hearing Testimony Needed on Monday, Feb 23rd



After years of advocacy by consumer and health advocate, California patients are close to a major victory in winning clear standards to ensure timely access to health care from their health plan.

One of the most common complaints from consumers is that they cannot get in to see their doctor on a timely basis. These HMO 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 insured 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. In many cases, care delayed is care denied, leading to worst health outcomes and more expensive treatments.

The History: Health Access first sponsored legislation in this area in 1997, when we sponsored AB497 by then-Assemblymember Scott Wildman. In 2002, AB2179, authored by Assemblymember Rebecca Cohn (D-Saratoga), passed the legislature, and was signed by Governor Davis.

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.

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. The proposed regulations are at the DMHC website:
http://wpso.dmhc.ca.gov/regulations/docs/regs/20/1231519617847.pdf

Support Needed for Specific Standards: Health Access beleives 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.

The Department has formally issued this regulation and they are soliciting comments on it from the public through February 23, 2009. For more information about the issue, go to recent posts on Timely Access issues on the Health Access WeBlog, at:
http://www.health-access.org/labels/TimelyAccess.htm

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.

LETTERS/COMMENTS REQUESTED: 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. The fax number is 916-322-3968. Contact Health Access for additional materials.

PUBLIC HEARING/ORGANIZATIONAL TESTIMONY REQUESTED: The Department will hold a public hearing THIS MONDAY, February 23rd, at 9:00am, in Sacramento, at 980 9th Street, 2nd Floor conference rooms.

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posted by Anthony Wright | Permalink | 6:12 PM


 
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When you assume...

 
Medi-Cal is potentially getting, at least by several estimates, $11.23 billion from the economic stimulus in increased funds. Yet the budget deal signed by the Governor today uses so much of that money for fixing the deficit and other purposes that steep additional Medi-Cal cuts may be taken.

The health cuts that are "triggered" depending on the amount of economic stimulus money are a 10% cut in public hospitals, and the elimination of several benefits (like dental coverage) for parents, seniors, and people with disabilities on Medi-Cal coverage. There's also very ugly cuts in SSI/SSP, IHSS, and CalWORKS.

Many--including some legislators, we think--assumed that the federal economic stimulus money will be enough to prevent these cuts.

But Administration officials are now saying--only after the budget has been signed--that their estimate is that the federal money is not enough to meet the threshold to prevent the cuts.

We know others have different estimates, and a final determination has to be made by April 1st, by Governor Schwarzenegger's Director of Finance Mike Genest, and Treasurer Bill Lockyer.

So just when you thought the budget battles and suspense over cuts was over--they are not.

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posted by Anthony Wright | Permalink | 3:00 PM


 
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Quick and dirty...

Thursday, February 19, 2009
 
After marathon legislative sessions that started the evening of Valentine's Day, a state budget proposal and various other legislative proposals was passed by the California legislature early this morning, to address a $42 billion deficit in the current and next budget year was.

But this budget deal is no victory. The budget will have significant negative impacts on health care, now and into the future.

Here's a general overview. While there were major changes to the overall package (constitutional amendments, even!), the health portions were not substantially changed from earlier in the week... although there was a late night change to take more of the federal economic recovery money for deficit filling, and thus increase the threshold by which many health and human services cuts were "triggered off." It was $9.1 billion, now California needs $10 billion for the general fund before a portion of additional taxes and cuts are nullified.

We'll do a more official run-down (and E-mail Update) after the Governor signs it... we are expected to see many line-item vetoes, so the damage is not done yet!

The overall framework includes, even after $19 billion in cuts in the past three years, an additional $15 billion in spending reductions, as well as $14.4 billion in new and increased (but temporary) taxes, and $12 billion in borrowing. The package also includes rollbacks of worker and environmental protections, some corporate tax giveaways, and pending a May 19th ballot vote, a spending cap and redirection of money raised by Propositions 10 and 63.

In particular, the spending cap would be devastating for health care. This artificial limit on health spending would not just prevent any restorations and reforms to our broken health system, but which would force cuts into existing services into the future. When Californians find out about the impact of a cap on health and other vital services, we believe they will reject it at the ballot box.

The specific cuts and impacts on health care fall into three categories.

* CUTS: Amidst very serious cuts to human services, there a $24.7 million health cut to counties from suspending the 2009 cost-of-doing-business increase for Medi-Cal administration, which means fewer county workers to enroll and process Medi-Cal applications for families. There were much more significant human services cuts as well.

While the package includes increased taxes to raise revenues during this significant downturn, they are temporary. There are corporate tax breaks, however, that are permanent. Such tax breaks reduces the ongoing general fund dollars that are available for health, education, and other core services, creating greater pressure in future years to further cut these areas. The over $1 billion in permanent tax cuts and corporate giveaways that will create budget pressure in future years to make further cuts, especially after the temporary revenue increases expire.

* MORE CUTS, DEPENDING ON THE AMOUNT OF FEDERAL HELP: These proposals would cut $183.6 million from health care, but this amount is included in a section that will “trigger off” depending how much money California gets from the federal economic recovery package. Director of Finance Mike Genest and Treasurer Bill Lockyer are to determine by April if we get over $10 billion in general fund money in the requisite period of time, which then will allow them to prevent these and other significant cuts. The potential cuts in health care include:

** a 10% cut to public hospital reimbursement rates (the Safety Net Care Pool), and
** eliminating specific Medi-Cal benefits for 3 million parents, seniors, and people with disabilities (here's a fact sheet on the financial and health impacts) including: dental, podiatry, optometry, psychology, acupuncture services, audiology services and speech therapy, chiropractic services, and incontinence creams and washes

* EVEN MORE CUTS, DEPENDING ON A MAY 19th BALLOT MEASURE: Several components of this plan would require voter approval, since they are either modifying initiatives that were previously approved by the voters, or changing the Constitution. These and other elements are proposed to be placed on the ballot on May 19th, 2009:

** Two different proposals would redirect some but not all funds from Prop 10 (tobacco tax for services for children 0-5) and Prop 63 (upper-income tax for mental health services). Proposition 10, the California Children and Families Act of 1998, is a major funder of children's programs throughout the state, including county-based "Healthy Kids" universal coverage programs. The budget transfers Prop. 10 reserve funds of $340 million in the current year to fill the general fund deficit, and then proposes to transfer $268 million annually for five fiscal years to the general fund. The budget proposes to shift money for children's health and other services, forcing the First Five Commissions to defund many of these programs.

** A spending cap would also be on the ballot for voters approval, which would limit California ’s ability to invest in health, education and other vital services, and in fact is projected to force steep cuts every year into the future. It would be tied to extensions of the temporary tax increases. If the cap is approved, the temporary taxes last for five years; if the cap is defeated, the taxes are in place for only two years.

For health care, the concern is that an artificial spending cap would lock us in to the current broken, resource-starved health system that we all rely on, which includes over six million uninsured Californians and the lowest per-patient Medicaid spending in the nation. As the limit does not take into account medical inflation or the costs of an aging population, health care would be particularly vulnerable under the cap. The cap would thus force cuts into existing programs and services, and prevent ever addressing unmet needs.

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posted by Anthony Wright | Permalink | 6:35 PM


 
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Next steps...

Wednesday, February 18, 2009
 
It seems like there might be a deal to get Senator Maldonado's vote. Preliminary reports indicate some changes in the tax mix (such as taking out the gas tax), and constitutional amendments on the ballot on matters such as an open primary.

We'll know more as the day progresses, but let's be clear. For health and human services, there is no victory here. There are significant $15 billion in cuts on top of $19 billion cuts in previous years. Yes, there are some revenues, but they are temporary. Other corporate tax giveaways are permanent, further squeezing the general fund. And there's a spending cap that could handcuff California for a generation, not just preventing the state from restoring these cuts, but even forcing additional cuts in the future.

If this deal passes, health advocates have a lot of work to do, immediately, especially with explaining to the public at large the full impacts of the cuts made, and the future impacts of that cap on health, education, and other vital services.

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posted by Anthony Wright | Permalink | 11:53 PM


 
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More than 140 characters?

 
Assembly & Senate sessions moved to 11pm. A sign of progress? Or just avoiding the 10pm Twitter blackout of @KQED_CapNotes, @capitolweekly, @ccleague, @sfbriancl, @LATimeslocal, @politico19, etc, and @aewright that are all following the budget debate closely?

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posted by Anthony Wright | Permalink | 10:02 PM


 
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Setting the stage for a Senate session..

 
After a Senate session that lasted all night. featured a leadership change in the Republican caucus, and a day of press conferences, national media appearances, and floor debate, the Senate *and* Assembly are scheduled to come back at 10pm tonight.

The rumors continue to fly about whether the 27th vote will come from Senator Cox or Senator Maldonado, and what they may ask for in return. For health advocates, we have to be concerned about what else the 27th vote may ask for.

In this hostage situation, the ransom for a budget has already been high: $15 billion in cuts, a spending cap that would force cuts into the future, corporate tax giveaways to further take resources from health and education, undoing voter-approved funds for children's services and mental health services, and changes to labor and environmental rules. A budget deal that includes all these elements is no victory. It's defeat.

The consequences for health and human services of no budget deal are significant, but so are the consequences of a deal. The difference is that the the budget deal is a negotiated terms of surrender, rather than allowing the carnage of continued war.

So we'll see what happens tonight.

On my personal Twitter account, I have been posting quick, short updates about the budget, at:
www.twitter.com/aewright

Thanks to references on Calitics, personal Facebook friends and Twitter followers, what started out as a few snide comments when staying up in the Capitol on Saturday night has turned into ongoing coverage with an emphasis on health issues (with my regular, personal asides on my two-year old son, television, the Tour de California, and turtles).

Twitter will be down at 10pm for a short bit when we go into session, so I'll post any quick updates here on this blog, as we have done for over nearly seven years. After the budget issue settles, we at Health Access will figure out if we should add Twitter to our communications arsenal, in our effort to help you best advocate for health care in California. If you have thoughts, share them with me, at awright@health-access.org.

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posted by Anthony Wright | Permalink | 8:17 PM


 
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The budget drama continues...

 
In an late-night session of the California Senate, the news was not about the budget. Instead, there was news that the Senate Republicans elected a new leader, Dennis Hollingsworth, to replace their current one, Dave Cogdill.

Soon after midnight, Senate President Steinberg put up the budget bills that includes the taxes, and placed the measure on call. The vote was along party lines, with four absentations, Democratic Senator Correa, and Republican Senators Ashburn, Cogdill, and Cox. The common wisdom is that Senator Cox's support (or that of Senator Maldonado, who voted No) would allow the others to case a vote knowing it will put the bill over the top.

After a uncomfortable silence with guards preventing anyone from leaving the chamber, the Senate President called a recess, but Senators are restricted to stay in the building.

We'll keep watching...

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posted by Anthony Wright | Permalink | 1:21 AM


 
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Back in health care world...

Tuesday, February 17, 2009
 
Even with the honoring of Capt. Sully, the pilot who managed to land a plan in a river despite having no engines working, the main event in the Capitol is clearly the budget. Every speaker at the honoring event invoked the budget. Back on health care policy issues, two things this afternoon:

There's an Assembly Health Committee, chaired by Assemblyman Dave Jones, on the "transparent reporting of quality data and outcomes." It's a huge, important topic, that's the key to health reform, in the effort for better patient safety, quality improvement, and cost containment. One of our board members, Betsy Imholz from Consumers Union, is testifying, with several of our allies (and opponents) in the transparency fight. It's also good to see the new Assembly Health Committee in action, with the new members getting grounded in some of these technical issues.

There's also a briefing and celebration of the signing of SCHIP, with a briefing entitled, "How Will California Seize Opportunities Provided By SCHIP Reauthorization and Other Federal Initiatives?" The briefing and reception is from 3-5pm, at the Sheraton Grand Sacramento Hotel at 1230 J Street here in Sacramento.

Lots going on, indeed.

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posted by Anthony Wright | Permalink | 2:50 PM


 
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Big health help in economic recovery package...

 
President Barack Obama today signed a $787 billion federal economic recovery package today, which includes significant health care provisions, including some help to the state Medi-Cal program, help to some unemployed looking to continue their health coverage, investments in health research and health information technology, and other efforts at cost containment.

The economic recovery package will provide significant and desperately needed help for California, our health care system, and for Californians directly. With our high unemployment rate, California will get particular and much needed help, for our state budget, and for individual Californians trying to keep their coverage.

As President Obama described the health portions of the package this way:

Because we know that spiraling health care costs are crushing families and businesses alike, we are taking the most meaningful steps in years towards modernizing our health care system. It's an investment that will take the long overdue step of computerizing America's medical records – to reduce the duplication and waste that costs billions of health care dollars and the medical errors that every year cost thousands of lives. Further, thanks to the action we have taken, seven million Americans who lost their health care along with their jobs will continue to get the coverage they need, and roughly 20 million more can breathe a little easier, knowing that their health care won't be cut due to a state budget shortfall. And an historic commitment to wellness initiatives will keep millions of Americans from setting foot in the doctor's office for purely preventable diseases.

Taken together with the enactment earlier this month of a long-delayed law to extend health care to millions more children of working families, we have done more in 30 days to advance the cause of health reform than this country has done in a decade.



Among other provisions, the compromise economic recovery package includes the following health-related items, and their impacts on California:

* Increase temporarily federal Medicaid matching funds by $87 billion, based on a formula that inlude 65% spread evenly, and 35% targeted to states, like California, with high increases in unemployment rates. California is roughly estimated to get $11.23 billion over the 27 months of the stimulus period, although that number is subject to change.

While increased federal Medicaid matching funds won't solve the California budget crisis, but it is an important part of any solution. We hope specific cuts, to Medi-Cal benefits and public hospitals, will be triggered off with these new funds.

* Subsidize COBRA health coverage, for those eligible who lose employer-based coverage, with over $24.7 billion to cover 60% of the cost of premiums for as long as nine months. This would not include those who are over certain income requirement, who left employment before September 2008, and who don't qualify for COBRA (for example, if the employer folded.) The final package also does *not* include a House provision allowing for some workers to stay on COBRA for a longer period through to Medicare eligibility.

The COBRA subsidies will help some newly unemployed Californians keep their coverage while they look for new work. Some unemployed Californians may not be eligible for COBRA, or may find it unaffordable even with the subsidies in this package. After all, it may be hard to pay 40% of premium after one loses a job and their income. This will help many Californians, but it's not enough to prevent an expected spike in the uninsured that will accompany the spike in unemployment.

* Provide $19 billion for health care information technology to implement electronic health records. There would be bonuses between $44,000 and $64,000 for physicians, and as much as $11 million for hospitals. Physicians and hospitals must implement EHRs by 2014 or face the loss of Medicare reimbursements.
* Increase funds to the National Institute of Health by $10 billion for biomedical research.
* Provide $1.1 billion for research to compare the effectiveness of medications and medical devices, an important first step in health reform and cost containment efforts.
* Establish a new Prevention and Wellness Fund with $1 billion.

We see this package as a down payment for health reform. Whether its preventing cuts to Medicaid which will be a foundation for additional expansions, or put in place the data and information technology tools to help control health care costs and improve quality, these are needed investments to our health care system.

President Obama is right that a sustainable economic recovery requires health care reform... we look forward to working with him this year on comprehensive change in health care!

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posted by Anthony Wright | Permalink | 2:07 PM


 
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Showdown in the Senate

 
HEALTH ACCESS UPDATE
Tuesday, February 17th, 2009


STATE SENATE STANDOFF ON BUDGET CONTINUES; MAJOR HEALTH IMPACTS
* Vote Scheduled for 10am; Steinberg Vows to Lockdown Senate Until Budget Agreement
* All Dems Voting for Package, But 3rd Republican Vote Required to Meet 2/3 Threshold
* Package Would Have Severe Health Care Impacts: Cut Counties , Redirect First Five Funds
* Cuts to Medi-Cal Benefit & Public Hospital Dependent on Amount of Federal Economic Aid
* State Budget Alert: State Spending Cap Could Force Cuts Forever Into the Future


New on the
Health Access WeBlog: More on the Budget and the Spending Cap; Responding to Sen. Cox on Children’s Coverage; Responding to Sen. Hollingsworth on Jobs; Julio Osegueda from McDonald’s as Obama’s Health Care Spokesperson?; Twittering the Budget Debate; Flap Over First Five Commission; St. Valentine’s Day Massacre; More Reasons to Oppose a Spending Cap; Comparative Goals for Comparative Effectiveness; Where This Budget Leaves Us; Capps Gets Key Roles on Committee, Continues California’s Strong Voice on Health; News on the Economic Recovery Act


After marathon legislative sessions that started the evening of Valentine's Day, stretched into the night and morning, and then through President's Day weekend, a state budget proposal to fix the $42 billion hole in the current and next year has yet to get the necessary Republican votes to pass.

THE POLITICAL SITUATION: At a 7:30pm session Monday evening, Senate President Darrell Steinberg laid out the consequences of not passing a budget on Wednesday: 20,000 state employees get laid off, 276 construction projects and even more transportation projects to get stopped, leading to tens of thousands of more private sector jobs losses.

Senator Steinberg laid out the political situation from his point of view. There's a 2/3 majority to vote for the current budget package in the Assembly, and all Democrats are voting for it in the Senate, but there aren't the needed votes from Republican Senators.In order to "spotlight" the problem, he's adjourning the session tonight, but will have the vote at 10am tomorrow, and will place it "on call until we get it done." He promised to keep everybody in the Chamber until a budget was passed: "Bring a toothbrush!" He added: "I will not allow anyone to go home, to resume their life, to have any kind of resumption of normal business" until a budget is passed.

With expectation that the full Democratic Caucus will vote for the budget package, with the assumption that Republican Senators Dave Cogdill of Fresno and Roy Ashburn of Bakersfield will join them, speculation for the third vote has centered around Senator Dave Cox of Sacramento or Senator Abel Maldonado of Santa Maria . Both argued against the package Monday night, although its unclear if they would support the package with some modifications.

THE PACKAGE: The budget package was negotiated between Governor Arnold Schwarzenegger and legislative leaders of both parties, the so-called "Big Five."

Even after $19 billion in cuts in the past three years, it includes an additional $15 billion in spending reductions, as well as $14.4 billion in new and increased (but temporary) taxes, and $12 billion in borrowing.

The package also includes rollbacks of worker and environmental protections, some corporate tax giveaways, and pending a May 19th ballot vote, a spending cap and redirection of money raised by Propositions 10 and 63.

An Assembly document summarizes the provisions of the over two dozen bills. The bills of interest to health advocates includes (with the Assembly and Senate versions identical):

* Mid-year adjustments in the 2008-09 budget: ABxxx 1 (Evans), SBxxx 1 (Ducheny)
* The 2009-10 budget bill, with reductions: ABxxx 2, (Evans), SBxxx 2 (Ducheny)
* The health trailer bill: ABxxx 5 (Evans), SBxxx 5 (Ducheny)
* The general government trailer bill: ABxxx 8 (Evans), SBxxx 8 (Ducheny)

* Changes to Prop 10 (tobacco tax for children's services): ABxxx 9 (Evans), SBxxx 9 (Ducheny)* Changes to Prop 63 (high income tax for mental health): ABxxx 10 (Evans), SBxxx 10 (Ducheny)
* Setting an election for May 19, 2009 to consider several items: ABxxx 11 (Evans)

* Temporary tax increases: SBxxx 3 (Ducheny)
* The constitutional amendment for a spending cap ACAxxx 2 (Bass)

THE HEALTH IMPACTS: If this budget is approved, it will have significant impacts on health care, now and into the future. The biggest impact would be the spending cap, which would force cuts into the future. And don't forget the over $1 billion in permanent tax cuts and giveaways that will create budget pressure in future years to make further cuts, especially after the temporary increases expire.

The specific cuts and impacts on health care fall into three categories.

* CUT NO MATTER WHAT: Amidst very serious cuts to human services, there a $24.7 million health cut to counties from suspending the 2009 cost-of-doing-business increase for Medi-Cal administration, which means fewer county workers to enroll and process Medi-Cal applications for families. There were much more significant human services cuts as well.

While the package includes increased taxes to raise revenues during this significant downturn, they are temporary. There are corporate tax breaks, however, that are permanent. Such tax breaks reduces the ongoing general fund dollars that are available for health, education, and other core services, creating greater pressure in future years to further cut these areas.

* CUTS DEPENDING ON THE AMOUNT OF FEDERAL HELP: The proposals would cut $183.6 million from health care, but this amount is included in a section that will “trigger off” depending how much money California gets from the federal economic recovery package. Director of Finance Mike Genest and Treasurer Bill Lockyer are to determine by April if we get over $9.1 billion in general fund money in the requisite period of time, which then will allow them to prevent these and other significant cuts. The potential cuts in health care include:

o a 10% cut to public hospital reimbursement rates (the Safety Net Care Pool), and

o eliminating specific Medi-Cal benefits for 3 million parents, seniors, and people with disabilities (Health Access has a fact sheet on the financial and health impacts if these benefits are cut) including:
§ Adult dental
§ Acupuncture services
§ Audiology Services and speech therapy services
§ Chiropractic services
§ Optometric and optician services, including services provided by a fabricating optical lab
§ Podiatric services
§ Psychology services
§ Incontinence creams and washes

* DEPENDING ON A VOTE OF THE PEOPLE: Several components of this plan would require voter approval, since they are either modifying initiatives that were previously approved by the voters, or changing the Constitution. These and other elements are proposed to be placed on the ballot on May 19th, 2009:

o Two different proposals would redirect some but not all funds from Prop 10 (tobacco tax for services for children 0-5) and Prop 63 (upper-income tax for mental health services).

Proposition 10, the California Children and Families Act of 1998, is a major funder of children's programs throughout the state, including county-based "Healthy Kids" programs, which are models of how to get to universal children's coverage. The budget transfers Prop. 10 reserve funds of $340 million in the current year to fill the general fund deficit, and then proposes to transfer $268 million annually for five fiscal years to the general fund. This would severely curtail those programs and services funded by Proposition 10 dollars.

o A spending cap would also be on the ballot for voters approval, which would limit California ’s ability to invest in health, education and other vital services, and in fact is projected to force steep cuts every year into the future. It would be tied to extensions of the temporary tax increases. If the cap is approved, the temporary taxes last for five years; if the cap is defeated, the taxes are in place for only two years.

For health care, the concern is that a artificial spending cap would lock us in to the current broken, resource-starved health system that we all rely on, which includes over six million uninsured Californians and the lowest per-patient Medicaid spending in the nation. As the limit does not take into account medical inflation or the costs of an aging population, health care would be particularly vulnerable under the cap, and the cap would thus force cuts into existing programs and services, and prevent ever addressing unmet needs.


The budget is still a fluid document, especially as legislative leaders and the Governor seek an additional vote for its passage. More analysis about the budget is being posted regularly, and is available on the Health Access daily blog, at: http://www.health-access.org/blogger.html

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posted by Anthony Wright | Permalink | 3:45 AM


 
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Correcting the record on children's coverage...

Monday, February 16, 2009
 
In the Senate discussion on the budget, Republican Senator Cox feigned outrage that later this week, there was supposed to be a Senate Health Committee hearing on SB1(Steinberg), the bill for universal children's coverage. He seems to suggest that it was sinister plot, that right after the budget was passed, those Democrats would go back to their spending.

He was wrong on the hearing--it had already been postponed. And wrong on the spending--even with a policy bill, actual money would need to be approved in the budget process, with the 2/3 vote that we are all painfully aware of.

Senator Cox went into details in his floor speech, talking about raising the eligibility level to 300% of the federal poverty level, about allowing other families to buy-in to the program, and about "presumptive eligibility"--like they were bad things. He had his aides distribute the "fact sheet" about SB1 as if it were a smoking gun--rather than a version of a bill that has been in circulation for years, and that Senator Steinberg has said multiple times since becoming President Pro Tem is a top priority for him.

It's stunning that any Republican legislators find it appropriate to demand corporate tax giveaways in the budget, yet somehow mock separate policy bills to ensure children have health coverage--not to mention a bill that would bring in California millions in new federal funds.

With President Obama's signature of the State Child Health Insurance Program and the economic recovery package that includes increased Medicaid matching funds, California has the opportunity to bring in hundreds of millions of dollars in new federal dollars.

It would be irresponsible if the Legislature did not start the policy conversation to consider how to take advantage of these new opportunities and new federal dollars, toward the worthy and nececssary goal of covering California's children. Earlier this decade, there was considerable outrage when it was found that the state was not taking advantage of federal funds--and that those funds were going to other states as a result. We ne

In his mulitple proposals about redirecting Proposition 10/First Five Commission dollars, Senator Cox has himself argued to prioritize dollars to children's coverage, so it is a puzzle why he would attack an already-delayed hearing of a measure to do just that.

For legislators that have complained about process, it seems we would want more hearings, not less. For legislators that want to support jobs, it seems we want to support a program that provides 2:1 and 3:1 federal matching dollars. And for legislators that have talked about prioritizing children's covearge, it seems we should hear a bill to do just that.

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posted by Anthony Wright | Permalink | 9:46 PM


 
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The real jobs impact on California

 
In the discussion this evening in the Senate, Republican Senator Hollingsworth seemed to scoff at the lost jobs that would result from all the construction projects that would be stopped this week without a budget. He made his own jobs case, arguing about the jobs impact of a sales tax increase, in explaining his "no" vote on the budget and revenues. This is "not in a vacuum."

Certainly not. These decisions are not in a vacuum. For every dollar that California does not raise in taxes, that's a dollar in cuts to health, education, and other vital services. But let's consider not the social but only the economic impact of such additional cuts--on top of the $19 billion in cuts already made, or the $15 billion of cuts in this deal.

In fact, cuts to health and other vital services would have more severe impact on jobs than equivalent changes in tax policy. Every dollar in health and other services goes to a Californian--not outsourced, not saved in an out-of-state bank--who will then spend it again in California. Especially when those services--like in education, health and human services--employ and/or serve low- and middle-income Californians, there's a bigger "multiplier effect", since those folks tend to spend those salaries and benefits immediately on the necessities of life, right back into the California economy.

Senator Cedillo was eloquent when he suggested that public sector worker shopping for groceries has the same economic impact as a private sector worker. Senator Steinberg made the point forcefully about the jobs impact of even additional cuts beyond the billions already in the package.

Health Access published a study last year that explored the economic impact of cuts, even in comparison to tax increases:
http://www.health-access.org/advocating/docs/EconomicImpactHC08-14-08Final.pdf

Here's a section of a federal report on the jobs impact of the economic recovery package, that includes Appendix 1, which evaluates the different economic "multiplier" and jobs impact between services and tax changes:
http://otrans.3cdn.net/45593e8ecbd339d074_l3m6bt1te.pdf

The basis of the Obama economic recovery package is that there's greater economic multiplier and jobs benefit in protecting services than in tax policy changes.

For Senator Hollingsworth, if there's a real issue with jobs, the real long-term threat to jobs is the spending cap, which would prevent California from ever making the investments to help our economy. Those who are really concerned about jobs should vote against the spending cap, not against the revenues in the budget. A spending cap would force cuts in health care and other vital services, well into the future. With health care inflation and an aging population, a cap would simply force additional cuts to the health system we all rely on, and that is a significant part of our economy.

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posted by Anthony Wright | Permalink | 9:31 PM


 
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Toothbrushes!

 
At a 7:30pm session today, Senate President Darrell Steinberg laid out the consequences of not passing a budget tomorrow, Wednesday: 20,000 state employees get laid off, 256 construction projects get stopped, leading to tens of thousands of more private sector jobs losses. The ripple effect will be even greater.

He laid out the political situation. There's 2/3 majority to vote for the current budget package in the Assembly, and all Democrats are voting for it in the Senate, but there aren't the needed votes from Republican Senators.

In order to "spotlight" the problem, he's adjourning the session tonight, but will have the vote at 10am tomorrow, and will place it "on call until we get it done." He promised to keep everybody in the Chamber until a budget was passed: "Bring a toothbrush!" He added: "No one goes back to their normal life" until there is a resolution.

I'll post in a second on some of the heated discussion afterwards...

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posted by Anthony Wright | Permalink | 9:14 PM


 
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Looking at language?

 
Perhaps the only good thing about the standoff over the budget is that version of the bills in consideration are now online. They are usefully compiled at Around The Capitol, at:
http://www.aroundthecapitol.com/billtrack/budget.html

Here are the bills of interest to health care advocates (the Assembly and Senate versions are usually identical):

* Mid-year adjustments in the 2008-09 budget: ABxxx 1 (Evans), SBxxx 1 (Ducheny)
* The 2009-10 budget bill, with reductions: ABxxx 2, (Evans), SBxxx 2 (Ducheny)
* The health trailer bill: ABxxx 5 (Evans), SBxxx 5 (Ducheny)
* The general government trailer bill: ABxxx 8 (Evans), SBxxx 8 (Ducheny)

* Changes to Prop 10 (tobacco tax for children's services): ABxxx 9 (Evans), SBxxx 9 (Ducheny)
* Changes to Prop 63 (upper income tax for mental health services): ABX3 10 (Evans), SBX3 10 (Ducheny)
* Setting an election for May 19, 2009 to consider several items: ABX3 11 (Evans)

* Temporary tax increases: SBX3 3 (Ducheny)

* The constitutional amendment for a spending cap ACAX3 2 (Bass)

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posted by Anthony Wright | Permalink | 3:56 PM


 
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Me and Julio down by the schoolyard...

 
The media loves Julio Osegueda, the famous "last question" at President Obama's Fort Myers town hall last week. In The New Republic's The Treatment today, I suggest we use his example and enthusiasm for the health reform effort:



So, yeah, he's a character. But all the interviewers, from MSNBC or CNN, miss the real story: he has worked hard for over four years at McDonald's but doesn't get health coverage.

We at Health Access California remember that in 2004, McDonald's was the biggest funder in opposition of Proposition 72, which would have required large companies to either provide health coverage to their workers, or pay into a purchasing pool that would do so. It hasn't been a surprise that chain & fast food restaurants have been spearheading the (so far unsuccessful) legal challenge to San Francisco's Health Security Ordinance.

So as a McDonald's employee, Julio is asking a question that strikes deep to the need for health reform. The good news for McDonald's is that while all health reforms in the discussion (from the Baucus plan to AB x1 1 to single-payer) require some employer contribution to health care, they generally offer a good bargain, with the costs less expensive and even subsidized from what health coverage would cost now. And in return, the employer would get a covered workforce that is healthier, more productive, and with less turnover. They should be as enthusiastic as Julio.

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posted by Anthony Wright | Permalink | 2:23 PM


 
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The waiting game...

Sunday, February 15, 2009
 
Lots of votes overnight, on cuts and caps and other things that will have a bit impact on health care in California. We'll go over the various bill in more details soon. But is it all moot? There has not been the needed 3 Republican votes in the Senate for the main budget package since last night, and there's be no visible movement overnight.

Some sources for info:
http://www.sacbee.com/static/weblogs/capitolalertlatest/
http://twitter.com/KQED_CapNotes

This is a moment to watch, since last-minute deals could have long-term consequences, in terms of direct program impacts, or even just lost revenue that will further the pressure for future cuts.

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posted by Anthony Wright | Permalink | 10:32 AM


 
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Limiting California...

 
Of the 26 bills that make up the budget deal, the one that I have a copy of actual language is the spending cap, ACA xxx1 (Niello/Adams).

It's short, but it will probably be unintelligable to the average citizen reading their voter pamphlet. The understanding is there will be a special election on Tuesday, May 19th to consider the spending cap and other elements of the budget proposal.

So it will matter how people view the cap. We've been clear here at Health Access about the impact to health care, and the California Budget Project has done impressive work attempting its quick analysis.

Here is Republican Senator Roy Ashburn on the Senate floor: "This will be... the strongest spending limit in a state constitution in any state in the United States."

The proposal will prevent use of the "rainy day fund" to support existing obligations if these demands exceed the prior year's spending, adjusted for inflation and population growth. The problem is--that could well be *every year*, because of the rise in health care costs or as the population ages and needs more senior and health services.

At first blush, it seems not just to prevent restorations or improvements, but actually seems to force cuts. In short order, we need to be very clear about the implications for California with such a proposal.

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posted by Anthony Wright | Permalink | 12:50 AM


 
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Gimme five: First 5, or 5am?

 
The budget deal also has two elements that depend on voter approval: redirecting funds from Prop 10 (tobacco tax for services for children 0-5) and Prop 63 (upper-income tax for mental health services).

Proposition 10, the California Children and Families Act of 1998, is a major funder of children's programs throughout the state, including county-based "Healthy Kids" programs, which are models of how to get to universal children's coverage.

The budget transfers Prop. 10 reserve funds of $340 million on a one-time basis in the current year, and then proposes to transfers $268 million annually for five fiscal years to the general fund. It would also place restrictions on what the remaining money can be used for--Senator Ducheny mentioned that the "media account," for example, would be eliminated.

We'll see in the coming days what the impact will be on Healthy Kids or other programs.

Senator Dave Cox--who may before the end of the night be the swing vote on the budget--has spent over a year raising questions about Prop 10, and this evening/morning proposed amendments to redirect even more money, and even eliminate all of the 58 county First Five Commissions. Those amendments were tabled, but this is the "compromise" that is going before voters.

Senator Cox makes the point that the First Five money should be prioritized to go to health coverage, such as Healthy Families--obviously a cause close to our heart. However, Senator Cox's amendment did not include an actual expansion of eligibility for children's coverage--nor are we convinced that diverting money from preschool and other children's services makes sense.

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posted by Anthony Wright | Permalink | 12:23 AM


 
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St. Valentine's Day massacre...

Saturday, February 14, 2009
 
It's late on a Saturday night, and the Legislature is in session, moving on a budget deal.

There is no budget language to be had for the public, so we can't do any specific analysis that we usually offer.

The only public document about the deal as a whole is an Assembly floor summary, available here:
http://www.assembly.ca.gov/acs/newcomframeset.asp?committee=4

For health care, the biggest impact is the spending cap, which would force cuts into the future. And don't forget the permanent tax cuts and giveaways that will create budget pressure in future years, especially after the temporary increases expire.

But let's not forget the health care cuts being voted for tonight. They include:

* $24.7 million cut to counties from suspending the 2009 Medi-Cal Administration cost of doing business increase

* $183.6 million, depending on the federal economic recovery funds California gets, from both
* a 10% cut to public hospital reimbursement rates (Safety Net Care Pool), and
* eliminating the following Medi-Cal benefits
* Adult dental
* Acupuncture services
* Audiology Services and speech therapy services
* Chiropractic services
* Optometric and optician services, including services provided by a fabricating optical lab
* Podiatric services
* Psychology services
* Incontinence creams and washes

The public hospital and Medi-Cal benefit cuts would be part of a package that would be "triggered off" if Calfornia get enough federal funds from the economic recovery package. Health Access has a fact sheet on the financial and health impacts if these benefits are cut.

Will we get enough federal funds? We haven't seen the trigger language, but the rough guess is that we would need at least $9.1 billion in general fund money--many people assume that's the case, but we understand the final decision maker is Director of Finance Mike Genest by April 1st. It would not be a funny April Fool's joke.

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posted by Anthony Wright | Permalink | 11:33 PM


 
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Not a valentine...

 
Steve Harmon at the Contra Costa Times reports about the biggest problem in the budget deal: the artificial spending cap that will force cuts into the future. As we wait for the budget vote that is scheduled for 5pm today, Saturday, it's worth a read...

Joel Fox seems to have more details, about how the using money from the reserve is tied to "budget adjusted for population and CPI growth," which does not take into account medical inflation, increased demand due to an aging population, etc. Jean Ross at the California Buget Project has a chart that suggests how the cap could cut deeply into existing programs and services. But then, for the proponents of this cap, that's the point...

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posted by Anthony Wright | Permalink | 10:15 AM


 
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Stimulating...

 
The House and Senate yesterday passed the economic recovery package, which includes several key health provisions. It is now headed to President Obama's desk, where he expects to sign it on Monday.

A lot has been made of the margin which it passed, and I do find it remarkable that California Congressional Representatives, those who were Republican, decided to oppose a package that included both tax cuts and significant and desperately needed aid to California.

The budget being discussed in the state Capitol does take into account these funds, with much of the money already accounted for to plug the hole in the deficit, and depending on how much the state gets, with triggers to offset some cuts in health and other programs.

On health care, we understand that the Medi-Cal cuts on the "trigger" list are:
* elimination of around nine benefits for the three millions adults on the Medi-Cal program, including dental, optometry, podiatry, and psychology.
* a 10% cut in reimbursements to public hospitals.

Hopefully it is enough money. One health care cut in the budget proposal that will be made even with the billions in health care dollars coming to California is a $24 million cut to counties in their administration of the Medi-Cal program. The likely result is that there will be fewer social workers able to enroll Californians in Medi-Cal coverage.

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posted by Anthony Wright | Permalink | 9:38 AM


 
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Comparative goals..

Thursday, February 12, 2009
 
The economic recovery package includes $1.1 billion for "comparative effectiveness" research, a comparatively small amount of money in a very big bill, but it's getting a lot of scrutiny and attention, as Victoria Colliver in the San Francisco Chronicle reports.

The attack against comparative effectiveness ranges from anti-health reform hack Elizabeth McCaughey to drug and device manufacturers. The unfair attack is that such research is "rationing." Since when is getting better information on cost and quality a bad thing?

As the links above indicate, a lot has been written on this subject already, but I think as consumer advocates we have a particular focus on this issue.

As consumer advocates, we have a long and proud history of working to make sure that patients get the care they need. For example, we sponsored the HMO Patients' Bill of Rights, which provides for independent medical review of insurers' decisions to deny such care.

At the same time, we are not for allowing drug and device manufacturers to sell anything they want at any price. There is a role for steering patients to the most appropriate, most effective medications and treatments, based on the most relevant research.

Drug and device companies may attempt to use the language of consumer advocates, but their interest is profoundly anti-consumer. We need more transparency and information, not just about the cost and quality of their products, but about their tactics in the coming health reform debate.

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posted by Anthony Wright | Permalink | 10:56 PM


 
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Insult to injury...

 
I appreciate that California is in a deep, deep budget hole, and with a $42 billion deficit and the state running out of cash, any budget solution will be ugly: cuts, taxes, and borrowing to make the budget balance.

And the this year's budget framework, even after $16 billion in cuts in previous years, is reported to have such a mix: $15 billion in spending reductions, $14.4 billion in new and increased taxes, and $12 billion in borrowing.

But there are elements of the proposal that make it far worse than it needs to be:

* It makes cuts and raises revenues, but the cuts are permanent, while the taxes are temporary.
* It contains an artificial cap on spending that would force cuts in future years.
* It contains roll-backs in worker and environmental protections

And at the same time we are cutting health, education and other services, the proposal includes hundreds of millions of dollars in tax breaks for corporations! In trying to deal with a budget deficit that was created by tax giveaways in past years, the solution is to pass additional tax giveaways.

Where does this all end us up in five+ years?
* California will have made billions in cuts, on top of billions in cuts already made.
* California will have permanent tax cuts that rob money from the general fund, forcing additional cuts to health, education, and other vital services.
* California will see the temporary taxes expire, creating budget pressure to force even further cuts to these services.
* Even without the lost revenue, the spending cap will make sure that services--especially health, which rises at a greater rate than inflation--will be forced to cut existing programs and services, continually, into the future.

The details of the deal matter, and we believe we have some, and we are still getting more of them. But there are multiple mechanisms to force cuts in future years--and health care is particularly vulnerable.

But for those who care about the state of our health care system, the outline is bleak. And far bleaker than it should be.

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posted by Anthony Wright | Permalink | 8:17 PM


 
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California continues its strong voice...

 
Rep. Lois Capps (D-Santa Barbara) has been named Vice Chair of the Health Subcommittee of the Energy and Commerce Committee of the U.S. House of Representatives. A former nurse who has been passionate on health issues, Capps is also a supporter of the Health Care for America Now principles.

This simply reinforces California's strong voice in health reform matters, along with Speaker Nancy Pelosi, and top people from each of the three committees that have relevant jurisdiction: Energy & Commerce Chairman Henry Waxman, Education & Labor Chairman George Miller, and Ways & Means Committee Health Subcommittee Chair Pete Stark.

Another voice could be within the Obama Administration: another rumor in the Washington Post and Sacramento Bee is that up for consideration for HHS Secretary is Lloyd Dean, CEO of Catholic HealthCare West nonprofit hospital chain, who was involved in both health reform conversations in creating Healthy San Francisco, and in advancing AB x1 1 in 2007. Regardless who is picked, there is a lot for national health reformers to learn from those experiences.

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posted by Anthony Wright | Permalink | 5:15 PM


 
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The federal help on health, and what's missing...

 
HEALTH ACCESS UPDATE
Thursday, February 12th, 2009


FEDERAL ECONOMIC RECOVERY PACKAGE PENDING IN THE CONGRESS
* Major Economic Package Includes Significant State Aid; COBRA Subsidies, Health IT
* State Medi-Cal and Public Hospital Cuts Dependent on Amount of Federal Aid

* State Budget Alert: State Spending Cap Could Force Cuts in Forever Into the Future

New on the
Health Access WeBlog: Fast Breaking Budget News; Economic Stimulus Updates; Health Reform & HHS: It's Not the Name, It's the Numbers; This COBRA Won't Bite; SCHIP Passed and Signed!; Who Should--and Shouldn't--Be HHS Secretary; President Obama: Health Care Reform in Year One


Governor Arnold Schwarzenegger and legislative leaders continue to negotiate around a budget package, reported to include significant cuts, taxes and revenues, and borrowing, along with rollbacks of worker and environmental protections and a spending cap.

At the same time, in Congress, a federal economic recovery package is pending for final approval, which includes needed financial assistance to the states, especially around health care issues.

In fact, the state proposal is reported to use much of the $11 billion to deal with the existing deficit hole, which is $42 billion and growing. According to the framework of the budget compromise, significant cuts--including to Medi-Cal benefits and to public hospitals--are pending, to be triggered on or off depending on the amount of general fund money received in total from the federal package.

FINAL ECONOMIC RECOVERY PACKAGE PENDING

Earlier this week, leaders in the U.S. House and Senate agreed to a final compromise between their two different economic recovery packages. Among other provisions, the compromised economic recovery package includes the following health-related items that would:

* Increase federal Medicaid matching funds by $87 billion, based on a formula that inlude 65% spread evenly, and 35% targeted to states, like California, with high increases in unemployment rates. California is roughly estimated to get $11.23 billion over the 27 months of the stimulus period, although that number is subject to change.

* Subsidize COBRA health coverage, for those eligible who lose employer-based coverage, with over $24.7 billion to cover 60% of the cost of premiums for as long as nine months. This would not include those who are over certain income requirement, who left employment before September 2008, and who don't qualify for COBRA (for example, if the employer folded.) The final package also does *not* include a House provision allowing for some workers to stay on COBRA for a longer period through to Medicare eligibility.

* Provide $19 billion for health care information technology to implement electronic health records. There would be bonuses between $44,000 and $64,000 for physicians, and as much as $11 million for hospitals. Physicians and hospitals must implement EHRs by 2014 or face the loss of Medicare reimbursements.

* Increase funds to the National Institute of Health by $10 billion for biomedical research;

* Provide $1.1 billion for research to compare the effectiveness of medications and medical devices, an important first step in health reform and cost containment efforts.

* Establish a new Prevention and Wellness Fund with $1 billion.

MEDICAID EXPANSION NOT INCLUDED: Most disappointing for health advocates, the economic recovery package does not include a provision in the House version that would have allowed states to expand Medicaid coverage to recently unemployed workers, as well as low-income adults without children at home--who currently are not eligible in California for Medi-Cal.

Since many unemployed Californians may not be eligible for COBRA, or may find it unaffordable even with the subsidies in this package, the loss of the Medicaid expansion is a disappointment. While the economic recovery package will help many Californians, it won't prevent a spike in uninsurance that will accompany the spike in unemployment.

THE STATE BUDGET NEGOTIATIONS CONTINUE

Back in California, there are reports of the details of a budget deal between the Governor and both Democratic and Republican legislative leaders

Reports indicate that the deal includes a "spending cap," which is of great concern to health advocates. By definition, the point of a spending cap is to prevent more spending--but even to areas like health care where we have underinvested.

The concern for health advocates is that a spending cap would lock us in to:
* the lowest per-patient Medicaid spending in the nation,
* over 6 million uninsured Californians,
* and the current broken health system for all of us, preventing increased Medi-Cal provider reimbursement rates, coverage expansions, or other reforms and improvements, and investments of our shared health system.

More concerning, a spending cap wouldn't just prevent progress, but it would inevitably force cuts into the future. Even indexed for inflation and population growth, an artificial limit on spending won't take into account:
* medical inflation, which typically goes up at a rate greater than regular inflation. Even public programs, which do a better job in keeping costs down than private health coverage, would be forced to cut; and
* the aging of our population, a significant trend which will put a greater strain on health and human services in California and nationwide.

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 | 3:16 PM


 
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Deals coming down...

Wednesday, February 11, 2009
 
There's reports on a budget framework of a deal, in the Los Angeles Times, Sacramento Bee, and other publications. Jean Ross at California Budget Bites has some analysis as well.

The deal includes many cuts, some temporary taxes, and--most concerning to health advocates--a spending limit.

A spending cap would force cuts in health care and other vital services, well into the future. With health care inflation and an aging population, a cap would simply force additional cuts to the health system we all rely on. A cap won't just lock us into a broken health system where we are 50th in the nation in per-patient Medicaid spending--it would force automatic cuts, into the future.

It looks like there are some health care cuts, and even more severe ones depending on whether we get enough from the federal economic recovery package--which had the differences yesterday between the Senate and the House.

The economic recovery package is essential to help California prevent even more devastating cuts to health care and other vital services. While the federal package includes important help for California's high number of newly unemployed residents, it falls short of what is needed, and what the House of Representatives proposed. Some unemployed will be able to keep their coverage because of this package, but we will still see a spike in uninsured Californians because of the provisions taken out of the final deal.

More to come.

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posted by Anthony Wright | Permalink | 4:09 PM


 
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A economic recovery deal?

 
Word that there's a deal on the economic recovery package between the House and Senate.

From CQ: Negotiators also split the difference on a formula for allocating a Medicaid funding increase to states. Sixty-five percent of the funding would be doled out on an across-the-board, flate rate basis to each state, while 35 percent would be distributed based on increases in unemployment, according to House Commerce Committee Chairman Henry A. Waxman , D-Calif. The House had used a 50-50 formula, while the Senate preferred an 80-20 split.

From other sources: On COBRA, there appears to be $21.4 billion, for eligible workers to help with 60% of the premium for COBRA for 9 months. Income eligibility would be capped at $125,000 (single) and $250,000 (couple). Most disappointing for health advocates, it does not look like the temporary Medicaid expansion is included.

More to come.

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posted by Anthony Wright | Permalink | 12:53 PM


 
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90% the same, but...

Tuesday, February 10, 2009
 
Pro Publica has a good chart showing the dollar-figure differences between the House and Senate versions of the economic recovery package. You can see some of the differences in health care aid, and in aid to states.

It's useful, although it doesn't detail the policy differences, just the totals. So, for example, you can't tell that the COBRA subsidies in the House version come with some changes for older workers can stay on COBRA coverage longers, until they reach Medicare age. Or that Senate version would provide a 50% subsidy for COBRA, rather than the Senate's 65% subsidy. (I blogged more about the need for help people keep group coverage at The Treatment.)

And while the dollar figures look very similar for Medicaid matching funds, there is real difference in how the money in allocated: the House version targets the money more to states with particularly high unemployment rates. According to the Center for Budget and Policy Priorities, California would get over $1.4 billion more in the House version that the Senate.

The Center for Budget and Policy Priorities has lots of good analyses on heir website, including a discussion of the temporary Medicaid expansion for newly unemployed workers that is in the House--but not the Senate--version. A new study from the Robert Wood Johnson Foundation shows how this Medicaid expansion is needed--not just the COBRA subsidies, given how many people would still be left out or priced out.

Frank Davies of the San Jose Mercury News has more about the differences in the House and Senate version.

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posted by Anthony Wright | Permalink | 10:57 PM


 
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Beware the spending cap...

 
No budget deal announced yet, as many of us await news of a deal.


The biggest concern is whether such a deal includes a spending cap, which has potential to do severe damage not just now, but into the future, forever.

A spending cap, like the ones the Republicans have proposed in the legislature, would not just prevent future additional spending on health care and other vital services: it would certainly force cuts in the future.

Our health care system would be especially savaged by a spending cap.

By definition, the point of a spending cap is to prevent more spending--but even to areas where we have underinvested. A spending cap would lock us in to:
* the lowest per-patient Medicaid spending in the nation,
* over 6 million uninsured Californians,
* and the current broken health system for all of us, preventing increased Medi-Cal provider reimbursement rates, coverage expansions, or other reforms and improvements, and investments of our shared health system.

But a spending cap wouldn't just prevent progress, but it would inevitably force cuts into the future. Even indexed for inflation and population growth, a cap won't take into account:
* medical inflation, which typically goes up at a rate greater than regular inflation. Even public programs, which do a better job in keeping costs down than private health coverage, would be forced to; and
* the aging of our population, a significant trend which will put a greater strain on health and human services in California and nationwide.

In addition, health and human services lacks the protections that other parts of the budget have, making these programs even more vulnerable.

A cut in health care this year will be horrific, especially during these economically tough times when the need is greatest. A spending cap is going nuclear, preventing any recovery in the future.

We'll be watching...

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posted by Anthony Wright | Permalink | 1:23 AM


 
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Not the names, but the numbers...

 
There's continued speculation about who is the possible next Secretary of Health and Human Services.

This is an important position, and I certainly have opinions. (It really shouldn't be TN Gov. Phil Bredesen, for example.) But some are using this as a marker in the overwrought speculation of whether health reform will happen this year.

It's not the name, it's the numbers.

* It's the constant data and statistics that prove the need and the urgency for reform: the increasing rate of health care costs, the number of people losting job-based coverage, the 47 million uninsured, the poor ranking of the U.S. compared to other industrialized nation in health, the

* I've argued before the the name that matters wasn't Tom Daschle, but Barack Obama. During the campaign, Obama made health care a top priority, and invested over $100 million in ads on health care reform-- over 75% of his TV buy in October. Will Obama put his money where his mouth is again? Jonathan Cohn's reporting at The Treatment suggests he will, and the President's budget will reflect health reform as a priority--something that people will be watching closely.

* But the final numbers that are needed for health reform are our own. It's not enough for there to be a serious problem or crisis, or even a committed President. We need public opinion to support health reform, and for millions of Americans to mobilize in favor of key principles. We are working with Health Care for America Now! to build such a movement and many state and national groups have their own campaigns and efforts.

Those are the numbers that matter more than the names. It's up to us.

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posted by Anthony Wright | Permalink | 12:55 AM


 
a


Cloture!

Monday, February 09, 2009
 
After passing the amendments by Senators Collins of Maine and Nelson of Nebraska, the Senate just voted to close debate on the economic recovery package, 61-36. A full vote on the package is then expected tomorrow. That will trigger a conference committee to work out the differences between the House and Senate versions.

Health care in California has a lot riding on the House version prevailing on a couple of key items. We'll see what happens.

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posted by Anthony Wright | Permalink | 2:53 PM


 
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Unleashing the power of COBRA

Sunday, February 08, 2009
 

COBRA has been getting a lot of attention, since lots of people are losing their jobs, and likely their health coverage.

One option is COBRA (which stands for the Consolidated Omnibus Budget Reconciliation Act, the law that created in 1985), where you can sign up to keep the coverage you had at work--but you have to pay the employer's share of premium.

Bobby Caina Calvan at the Sacramento Bee report has a front page article on COBRA, where I point out that this can seem like a devil's bargain, especially given that you are asked to pay the full cost at exactly the moment where many lose income. As has been pointed out before, the cost is an outrageous percentage of a standard unemployment benefit.

But let me be clear: COBRA is often the best and last option for many consumers:

* First, you get the coverage you had with your job, with the same network of doctors and providers, offering continuity of care.
* Second, you get the group rate: large employers, representing hundreds or thousands of potential "covered lives" are able to bargain for much better rates than individuals, representing just themselves.
* Sure, you may be able to buy something that has a cheaper premium in the individual market, but it likely won't be as comprehensive. There's a lot of "junk" insurance, especially in the individual market, that seems like a good price, but when you find out when it's too late what it does and doesn't cover. You are more likely to have a better, more comprehensive standard of benefits with the group coverage through your past employer under COBRA.
* Finally, and most importantly, it may be your only option, because in the individual market you can be denied for "pre-existing conditions." Not do with group coverage, particularly COBRA.

Health Access worked to pass AB356(Chan) a few years back, so consumers were given appropriate notice when leaving group coverage, about the very real possibility of being denied for coverage. As the Department of Insurance website reads:

"Please examine your options carefully before declining group coverage or continuation coverage, such as COBRA, that may be available to you. You should be aware that companies selling individual health insurance typically require a review of your medical history that could result in a higher premium or you could be denied coverage entirely."

It then goes on to list all the reasons you could be denied coverage, for things you may or may not know about. It's a bit chilling.

COBRA is expensive, but it's not just the best option for many, but for some it's the last option. That's why the subsidies in the Economic Recovery package are so important. The House version has more extensive help, both with COBRA, and with a Medicaid expansion... let's see how the negotiations go in the U.S. Congress on this.

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posted by Anthony Wright | Permalink | 8:24 PM


 
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The World's Most Deliberative Body...

Saturday, February 07, 2009
 
The Senate debate over the economic recovery package provides some sobering context for the upcoming debate on health reform.

It looks, as of this writing, that a package will go through, but with a bare minimum of the Republican votes needed to get the 60+ votes to pass something. In order to get those "moderate" Democratic and Republican votes, they had to cut out tens of billions of dollars for state fiscal stabilization and school construction, and other items. On health, the compromise removes $5.8 billion for Health Prevention Activity and $2 billion for HIT grants. (Medicaid matching funds and COBRA subsidies seem intact.)

Health reform will be harder--by a lot--filled with tougher decisions and ideological issues, major conflicts between interested stakeholders, and tough trade-offs on financing and regulation.

The ideological divide on the economic recovery--on which there is an economic consensus on the urgency and the general framework--is stark, where only a handful of Republican Senators were even willing to entertain the notion of compromise.

The debate in the Senate seems to suggest that if health reform happens, it won't be with 70 or 80 votes; but it would still need to be seen as acceptable to centrist Republicans and Democrats in order to get the needed 60 votes to pass.

Don't get me wrong: the SCHIP win a few days ago shows that the terrain has shifted somewhat, with the ability to pass a bipartisan bill that raised tobacco taxes to cover children, and even remove some unneeded barriers to coverage.

We're not even in March yet, but given the pace we have a good lay of the land for the health reform debate. If politics is the art of the possible, then we are getting a better sense of what is possible.

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posted by Anthony Wright | Permalink | 9:32 PM


 
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A weekend in the Senate...

Friday, February 06, 2009
 
C-SPAN 2 has been fascinating today. We're still getting reports about the apparent deal in the Senate, so we'll see how the health items fared: there were health elements that were under attack from Republican Senators, most of whom have announced they aren't going to vote for the package anyway.

It looks like some aspects of state aid were cut, but not the temporary increase in Medicaid matching funds. However, there is still the issue of the formula, which downplays the economic condition of the states, unlike the House version.

We'll see how other provisions, such as the COBRA subsidies, fared. The Senate version never had the temporary Medicaid increase for the newly unemployed... another key issue when the two version go into conference next week. The Senate vote on the package is expected Monday.

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posted by Anthony Wright | Permalink | 11:43 PM


 
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Undoing the damage...

Thursday, February 05, 2009
 
After a long fight, the signing of the SCHIP bill is not the only good thing that President Obama did around children's coverage this week... He vacated a Bush Administration letter, imposed unlaterally two years ago, that imposed limitations on how far states could go in their efforts to expans coverage to children.

Here's the entirety of the memo, to be published in the Federal Register:


MEMORANDUM FOR THE SECRETARY OF HEALTH AND HUMAN SERVICES

SUBJECT: State Children's Health Insurance Program

The State Children's Health Insurance Program (SCHIP) encourages States to provide health coverage for uninsured children in families whose incomes are too high to qualify for Medicaid but too low to afford private insurance. Since 1997, when SCHIP was enacted, States have had the authority to set their SCHIP income eligibility levels, subject to available funding. In recent years, as the cost of private insurance has increased, States have raised eligibility levels to offer health care coverage to more families, with families paying a share of the cost based on their income.

On August 17, 2007, the Centers for Medicare & Medicaid Services (CMS) issued a letter to State health officials limiting the flexibility of States to set income eligibility standards for their SCHIP programs. On May 7, 2008, CMS issued a subsequent letter restating the policy set forth in the August 17, 2007, letter.

The August 17, 2007, letter imposes additional requirements that States must meet in order to cover children under SCHIP plans, including plans that CMS had previously approved. These requirements have limited coverage under several State plans that otherwise would have covered additional, uninsured children. As a result, tens of thousands of children have been denied health care coverage. Unless the August 17, 2007, letter is withdrawn, many more children will be denied coverage.

By this memorandum, I request that you immediately withdraw the August 17, 2007, and May 7, 2008, letters to State health officials and implement SCHIP without the requirements imposed by those letters.

This memorandum does not create any right or benefit, substantive or procedural, enforceable at law or in equity by any party against the United States, its departments, agencies, or entities, its officers, employees, or agents, or any other person.

You are hereby authorized and directed to publish this memorandum in the Federal Register.

BARACK OBAMA

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posted by Anthony Wright | Permalink | 8:50 PM


 
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SCHIP Signed!

 
Cheers! Yesterday, President Barack Obama signed the reauthorization of the State Children’s Health Insurance Program (SCHIP), also known in California as the Healthy Families program.

After two vetoes by former President Bush that threw the program into uncertainty, this action helps ensure that the over 900,000 children already enrolled in Healthy Families will continue to get the health coverage they need. Here's the stirring video of the signing ceremony:




California now needs to do its part, to fully fund and expand these programs that cover children, especially in these economically tough times when the need is greatest.

Last week, the U.S. Senate voted to support SCHIP 66-32, with the support of virtually all Democrats, including California Senators Dianne Feinstein and Barbara Boxer, and many Republicans. The U.S. House passed the bill on January 14, with all Democrats and Republican Congresswoman Mary Bono. The bill raises the federal tobacco tax to extend SCHIP for four and a half years.

The SCHIP bill provides a solid foundation for health reform, providing the 2-1 match from the federal government for children already enrolled in Healthy Families--including some that California did not get federal funds for previously. It allows for additional expansion up to three times the poverty level ($55,000 for a family of three)--right now, Healthy Families only covers children up to 2.5 times the poverty level ($46,000 for a family of three.)

This efforts on children's coverage is a good first step to crucially-needed health reform--we can't give up yet. Pending health reforms all build upon this foundation today, and it's important to get to work.

We will continue to pursue reforms at the state and federal level, since it's imperative we make sure that all Americans--children and adults, insured and uninsured--are secure that coverage will be there for them when they need it.

Here are President Obama's remarks transcribed, which are really, really good (emphases mine):

Today, with one of the first bills I sign – reauthorizing the Children’s Health Insurance Program – we fulfill one of the highest responsibilities we have: to ensure the health and well-being of our nation’s children.

It is a responsibility that has only grown more urgent as our economic crisis has deepened, health care costs have exploded, and millions of working families are unable to afford health insurance. Today in America, eight million children are still uninsured – more than 45 million Americans altogether.

It’s hard to overstate the toll this takes on our families: the sleepless nights worrying that someone’s going to get hurt, or praying that a sick child gets better on her own. The decisions that no parent should ever have to make – how long to put off that doctor’s appointment, whether to fill that prescription, whether to let a child play outside, knowing that all it takes is one accident, one injury, to send your family into financial ruin.

The families joining us today know these realities firsthand. When Gregory Secrest, from Martinsville, Virginia lost his job back in August, his kids lost their health care. When he broke the news to his family, his nine year-old son handed over his piggy bank with $4 in it, and told him, "Daddy, if you need it, you take it."

This is not who we are. We are not a nation that leaves struggling families to fend for themselves. No child in America should be receiving her primary care in the emergency room in the middle of the night. No child should be falling behind at school because he can’t hear the teacher or see the blackboard. I refuse to accept that millions of our kids fail to reach their full potential because we fail to meet their basic needs. In a decent society, there are certain obligations that are not subject to tradeoffs or negotiation – health care for our children is one of those obligations.

That is why we have passed this legislation to continue coverage for seven million children, cover an additional four million children in need, and finally lift the ban on states providing insurance to legal immigrant children if they choose to do so. Since it was created more than ten years ago, the Children’s Health Insurance Program has been a lifeline for millions of kids whose parents work full time, and don’t qualify for Medicaid, but through no fault of their own don’t have – and can’t afford – private insurance. For millions of kids who fall into that gap, CHIP has provided care when they’re sick and preventative services to help them stay well. This legislation will allow us to continue and build on these successes.

But this bill is only a first step. The way I see it, providing coverage to 11 million children through CHIP is a down payment on my commitment to cover every single American. And it is just one component of a much broader effort to finally bring our health care system into the twenty-first century.

That’s where the Economic Recovery and Reinvestment Plan that is now before Congress comes in.

Think about this – if Congress passes this recovery plan, in just one month, we’ll have done more to modernize our health care system than we’ve done in the past decade.

We’ll be on our way to computerizing all of America’s medical records, which won’t just eliminate inefficiencies, save billions of dollars and create tens of thousands of jobs – but will save lives by reducing deadly medical errors. We’ll have made the single largest investment in prevention and wellness in history – tackling problems like smoking and obesity, and helping people live longer, healthier lives. And we’ll have extended health insurance for the unemployed, so that workers who lose their jobs don’t lose their health care too.

Now, in the past few days I’ve heard criticisms of this plan that echo the very same failed theories that helped lead us into this crisis – the notion that tax cuts alone will solve all our problems; that we can address this enormous crisis with half-steps and piecemeal measures; that we can ignore fundamental challenges like the high cost of health care and still expect our economy and our country to thrive.

I reject these theories, and so did the American people when they went to the polls in November and voted resoundingly for change. So I urge members of Congress to act without delay. No plan is perfect, and we should work to make it stronger. But let’s not make the perfect the enemy of the essential. Let’s show people all over our country who are looking for leadership in this difficult time that we are equal to the task. Let’s give America’s families the support they need to weather this crisis.

In the end, that’s really all that folks like the Secrests are looking for – the chance to work hard, and to have that hard work translate into a good life for their kids. I’m pleased to report that their story had a happy ending – it turned out that Gregory’s two sons were eligible for CHIP, and they are now fully covered, much to his relief. I think Gregory put it best when he said: "Kids look at us and think ‘they’ll take care of us.’ That is our job – to keep them safe and healthy."

That’s what I think about when I tuck my own girls into bed each night. That is what I want for every child – and every family – in this nation. That’s why it is so important that Congress passes our recovery plan – so we can get to work rebuilding America’s health care system.

It won’t be easy – and it won’t happen all at once. But the bill I sign today is a critical first step. So I want to thank all the state and local officials, advocates and ordinary citizens across America who’ve fought so hard to pass it. I want to thank all the members of Congress who have worked so tirelessly, for so long, so that we could see this day. And I want you all to know that I am confident that if we come together, and work together, we can finally achieve what generations of Americans have fought for and fulfill the promise of health care in our time.

Thank you.

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posted by Anthony Wright | Permalink | 11:57 AM


 
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Business wonkery...

 
David Williams at the Health Business Blog hosts Health Wonk Review this week.

While we are linking around, The Health Care Blog and Ezra Klein have good reports from the Academy Health conference, featuring reports from the comments of White House health reformer Jeanne Lambrew, Senator Max Baucus and California Congressman Xavier Becerra, all saying good things about the urgency and timing of health reform.

There's lots of consternation at The Treatment and elsewhere about the possibility of Tennessee Governor and managed care executive Phil Bredesen--who mercilessly slashed TennCare a few years ago--being a replacement for Senator Daschle. It seems outrageous unimaginable--but perhaps some are unsettled by the notion of Commerce Secretary Judd Gregg. Bredesen is as jarring--but in the largest and key department. That won't happen, especially since there is a long list of qualified, experienced, passionate folks on this issue.

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posted by Anthony Wright | Permalink | 11:22 AM


 
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Does the name game matter?

Tuesday, February 03, 2009
 
Here's the White House response to the Daschle withdrawal:



As spokesman Robert Gibbs said: "the issue of affordable health care for every American is bigger than one person; and the job of ensuring health care reform will outlast any person nominated for the Secretary of HHS and likely anybody that serves in this administration."

Many think it stalls the process, although some weren't fans of Daschle (see John Nichols at The Nation). Many have had fun with the name game of who might be replace Daschle in either or both of his roles, as HHS Secretary, and as Director of the White House Office of Health Reform.

Some are having too much fun: The New Republic's Jonathan Cohn: Arnold? --working for someone besides himself? The American Prospect's Ezra Klein: Kim Belshe? Time's Karen Tumulty: Mitt Romney? --the guy who vetoed large parts of his own reform? They all admit these are not serious candidates--just ideas when you don't have word limits as a blogger.

At some level, the person matters, but not as much as their boss, President Obama. There will be some internal fights in the White House where a skilled and experienced and knowledgeable person makes a difference, but only until it reaches the President's desk. Individuals matter more in Congress: that's why Senator Kennedy's health and Congressman Waxman's ascent to Energy and Commerce chair are probably more significant than Daschle's replacement.

Don't get me wrong: The Department of Health and Human Services is the largest agency in the Cabinet, with the possible exception of Defense. It is significant in budget, reach, activity, and to the millions which it serves. The quality and integrity and caliber of people who run it matter immensely. But the most important person in the Administration--especially on the issue of health reform--will always be the President.

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posted by Anthony Wright | Permalink | 4:12 PM


 
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Daschle withdraws...

 
...as Secretary for Health and Human Services. Health reform is bigger than any one person, but this doesn't help. There will be some regrouping at the White House. Short-term impact is that Congress may have to take a greater lead.

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posted by Anthony Wright | Permalink | 9:57 AM


 
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The Crisis in Conference Naming...

Monday, February 02, 2009
 
This Wednesday in Sacramento is the conference of Insure The Uninsured Project, entitled this year, "Bridging the Gap During a Time of Crisis."

Health Access California is pleased to be among those honored this year during lunchtime, in celebration of our recent 20th anniversary.

Given the state budget crisis, the tone is likely to be more anxious than at the national Families USA conference, which is more focused on the federal opportunities. But even here in California, there are real possibilities for progress in the next two years, through bills and the ballot. (Of course, that may change is the Legislature decides to tie our hands with a spending cap that forces future cuts and prevents progress on our unmet needs.)

Speakers include Secretary of Health and Human Services Kim Belshe, and Assembly Health Chair Dave Jones. There's a very large stakeholder panel at the end of the day (on which I'll participate), which might be interesting only to see if any alliances have shifted with time, and how different stakeholders might be thinking differently now that federal reform is pending.

Information about the wonkfest is available at their website.

...

While we are on the subject, another conference coming up soon is that of the California Budget Project, March 19th, also at the Sacramento Convention Center, entitled "From Meltdown to Rebound: A Crisis is a Terrible Opportunity to Waste." You know things are bad when conferences planned for months in advance refer to the "crisis" with no assumption that it will be remedied soon.

CBP has good speakers planned, including UC-Berkeley economist, media scold, and blogger Brad DeLong, who is always worth reading.

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posted by Anthony Wright | Permalink | 5:34 PM


 
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Cuts and Caps to Harm Health Care?

 
HEALTH ACCESS ALERT
Monday, February 2, 2009


BUDGET ACTION ALERT: STATE LEADERS NEAR BUDGET DEAL

* Budget Expected to Include Significant Additional Cuts & Spending Cap
* Cap Could Future Health Cuts, Prevent Action on Key Unmet Health Needs
* ACTION: Call State Legislators to Oppose Cruel Cuts & Cap TODAY

* Federal Economic Recovery Act Update: Senate Version Fall Short in Help to CA
* ACTION: Call U.S. Senators to Urge House Provisions on Medicaid

Click for What’s New on the
Health Access Weblog: Report from Families USA Conference in DC; Health Help in the Back; The Responsibilities of a Nonprofit Hospital; The Problems with a Spending Cap; Comments Sought on Timely Access to Care Regulations; Max Healthroom; Contributing to the National Conversation on The Treatment; A Sailing SCHIP…


Big decisions are pending in Sacramento and Washington , DC , that will have a big impact on our health care, our economy, and our budget.

Cruel Cuts---and a Spending Cap That Would Force More Cuts in the Future

As California ’s budget crisis deepens and the state starts to run out of money, the pressure mounts for the Governor and state legislative leaders of both parties to come to a budget deal. After $16 billion in cuts in recent budgets, there has been a deadlock in the legislature—which needs a two-thirds vote to pass a budget or taxes—about how to deal with the over $40 billion deficit for the year and a half through June 2010.

At this late date, there have been indications that, after years of sticking to a “no new taxes” pledge and withholding the votes needed to get to two-thirds for a balanced budget, legislative Republicans may be willing to support some forms of taxes and revenues. However, their price for such support has been even harsher cuts, and a strict spending cap, one that would likely force to health and other vital services in the future and would prevent any attempt to meet existing unmet needs in California .

ACTION: Call your state Assemblymember (www.assembly.ca.gov) and state Senator (www.sen.ca.gov) to urge them to OPPOSE ADDITIONAL CUTS and especially to OPPOSE A SPENDING CAP that forces future cuts and prevent the state from meeting our existing health care needs. CALL TODAY! The Legislature could act quickly.


Federal Help for Health Care in Economic Recovery Act

The state is slated to get some much-needed help from the federal government in the form of the economic recovery bills being considered in the U.S. Congress. On health care, the bills provide for increased matching fund for Medi-Cal, new funding for health informational technology, and temporary subsidies for coverage for the unemployed.

There are two key differences between the two measures:

* The House version would increase federal matching funds based on a formula that targets some money to states with the worst economic climate; The Senate version largely does not. The difference to California could be $1.5 billion.

* While both versions provide some subsidizes to help some unemployed with COBRA payments so they can pay for coverage, only the House version funds a 100% federally funded temporary Medicaid expansion for unemployed adults.

While even the most generous economic recovery package will only make a dent in the state’s dire budget situation, every bit helps.

ACTION: Call Senators Boxer (202-224-3553) and Senator Feinstein (202-224-3841) to urge them to argue for more help for Californian and California ’s unemployed—and then urge them to pass the economic recovery package without delay or dilution. Also urge them to support the House version of Medicaid matching funds, and the temporary Medicaid expansion for unemployed adults.

For more information, contact Health Access California, at 510-873-8787, or www.health-access.org. 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 | 2:00 PM


 
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Page One...

 
Growing up, the front page of a newspaper was a powerful thing. This is especially true in New York, where there are newsstands and subways and other venues where even those who don't regularly read the paper will certainly see a memorable headline.

But even in this days of weakened newspapers, the printed words matters. And the MediaNews group of 11 papers decided to make a statement, with a front page editorial on the state's budget mess, with pointed words (emphasis mine):
The once great state of California today becomes a national disgrace.

While the federal government races to revive a failing economy, leaders in Sacramento wallow in finger-pointing and self-righteous bluster. Their failure to pass even an interim solution to the state's $40 billion deficit by today's deadline exponentially deepens the fiscal crisis.

The state will stop paying some of its bills and start issuing IOUs to cities such as Los Angeles, to school districts such as LAUSD and even to you.

It will stiff people due income tax refunds, students depending on Cal Grants to stay in college and contractors who have performed work. If the days without a budget continue, economic havoc will spread like a virus, and the state's bad faith and credit will infect every corner of the state.

Californians should be furious. We are.

That's why the Daily News is taking the rare step of running an editorial on the front page. This inaction is so serious that it threatens the economic stability of every resident and business of this state.

We encourage others to raise their voices as well. The political cost of delay must become too high for lawmakers to cling to principles that grim economic reality have rendered meaningless.

Gov. Arnold Schwarzenegger and the Legislature must adopt a new budget now. The people should demand it.

The governor and all 120 legislators share responsibility for this. But most of the blame for the immediate crisis falls on Republicans in the Legislature, who last summer - to a person - signed a pledge not to raise taxes. Since then, Democrats and the Republican governor have offered significant compromise, but GOP lawmakers cling to ideological purity - schools, health care and other essential responsibilities be damned.

This day didn't sneak up on anyone. It's the result of too much borrowing and too little political courage over too many years. A systemic problem years in the making can't be solved in a day. But the immediate crisis can. It comes down to cutting costs and raising taxes. No thoughtful person can seriously expect spending cuts alone to get us through this budget year without irreparable harm to our educational system and our economy.

Paralysis is destroying this state. Compromise is the only answer. It must happen now.

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posted by Anthony Wright | Permalink | 12:44 PM


 
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Daschle update...

 
There was a "Blackberry moment" Friday evening, during a Washington, DC conference of health care reform advocates--which had been filled with cautious optimism after years of waging mostly defensive battles at the national level.

Health wonks and hacks huddled over their phones to get the news that broke late in the evening about Sen. Daschle's tax issues, and it caused some to order another drink at the hotel bar. Many believe Senator Daschle has the right good mix of both the policy and political experience and savvy to shepard health reform as the Secretary-designate of Health and Human Services. He released a letter of explanation and apology today, Monday. President Obama has expressed his continued strong support for his nominee.

Ezra Klein at the American Prospect has several posts today on the specifics and the implications. The need and urgency for health reform is bigger than any one person, but every hiccup hurts the momentum...

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posted by Anthony Wright | Permalink | 10:54 AM


 
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House rules...

Sunday, February 01, 2009
 
There's help, and there's help. The two economic recovery bills that passed by the House and Senate both provide significant help for health in California... but is it enough? The need is great, especially with our sky-high 9.3% unemployment rate and a corresponding rising uninsured rate.

With regard to federal matching funds, Evan Halper and Richard Simon at the Los Angeles Times report that the House version would provide $1.5 billion more to California, because the formula takes into account a state's economic climate. The Senate version largely does not, and reflects the inequity of the standard funding formula, where California gets the lowest possible matching rate.

There's another difference that Californians also should care about: Both the Senate and House versions include some subsidies for COBRA for the umemployed, but only the House version has a temporary Medicaid expansion for the unemployed. That would be a big boon to California, given our unemployment rate.

Californians will make a big effort to see if the House version prevails.

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posted by Anthony Wright | Permalink | 7:43 PM


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