We at the Health Access WeBlog will be hosting Health Wonk Review on Thursday. It's a bi-weekly compendium of the best of the health policy blogs. After a long while of being cited and linked, such as in the last compilation at HealthBlawg, we felt we should contribute, and recognize some of the really good analysis and commentary on the web.
The Assembly Health Committee heard several bills today. The committee passed Assemblywoman Mary Hayashi's bill, AB108, to shorten the time window that insurers can rescind coverage, and Assemblyman Dave Jones' bill, AB119, to prohibit insurers from charging different rates based on gender.
Tomorrow afternoon, Senator Leno is presenting SB 54, which is very similar to AB 119, in Senate Health Committee, at 1:30 pm in room 4203 of the State Capitol. State law already forbids health insurance companies from charging higher monthly premiums on the basis of race, religion, marital status and sexual orientation – but not gender.
The differences in rates that are appearing don't take into account differences in actual benefits--like maternity coverage. That's another bill, AB98(De La Torre), to ensure that all coverage includes maternity services, in the ongoing effort to bring some basic equity to the health insurance market.
Justice Anthony Kennedy today denied the motion by the Golden Gate Restaurant Association to prevent the ongoing implementation of the Healthy San Francisco program--including the minimum employer contribution. This is after the Ninth Circuit Court of Appeals upheld the program earlier this year.
As the City, as well as unions and others that objected to the restaurants' request for a stay, said in their filing: "... the City's program has become fully operational, the medium and large employers covered by the ordinance have been complying with the spending requirement for 15 months, and tens of thousands of previously-uninsured workers now have health coverage under the City's program. There is no basis for disturbing this status quo while the normal certiorari process runs its course."
The next step is to see if the Supreme Court take the case...
Frontline had a great documentary last year, entitled "Sick Around the World," which explored the different types of health systems in five other countries, and what our country could learn. Both the doucmentary and the website are worth your time.
Speaking on health reform in front of a community convening of AARP and LULAC this Saturday morning in South Sacramento, I couldn't help but reference the "trigger" cuts in the headlines (in the San Jose Mercury News, Associated Press, and elsewhere), including the elimination of benefits like dental, podiatry, optometry, psychology, etc, for the three million adults (parents, seniors, and people with disabilities) with Medi-Cal coverage.
I got lots of questions about this, including what benefits *exactly* would be cut, and when (july 1st). After the talk, when folks came up, I found out why the interest: I was actually delivering the bad news to some of the people directly impacted. An amputee who goes to a podiatry appointment every three months, and needs other services like dental and psychology. A person in a wheelchair who get much-needed help from an in-home supportive services worker.
They hadn't known about this. One asked, "so what do I do now?" Other than to make appointments with the impacted services before the benefits go away on July 1st, the best I could answer was to talk with their medical providers, and see what they would charge on a self-pay basis, or what they could recommend.
When the cuts impact literally millions, I shouldn't be surprised that in any crowd, there will people feeling the direct effects. And given these cuts are to the health system on which we all rely, we should have the constituency to fight to restore the cuts.
Yesterday, Senator Bernie Sanders (I-VT) introduced a universal single-payer health care bill in the U.S. Senate. There's been a proposal for years in the House with 90+ co-sponsors, H.R. 676 by Rep. John Conyers. But it's progress to also have a vehicle in the U.S. Senate, which I don't think has had one since that of the late Senator Paul Wellstone of Minnesota.
While there's only one Senate sponsor at the moment, it's good to have such a proposal on the table and in the discussion, just as in the California legislature with SB810 (Leno). There are political and procedural obstacles to this or any health reform at both levels: 60 votes in the U.S. Senate; 2/3 vote in the legislature for financing. But the bill allows policymakers to work on the policy, better understand the trade-offs and the politics, and figure out issues like an appropriate transition. It also is an organizing tool and a possible vision for the future
Some supporters will use the bill as a platform to argue against any other reform; Those of us who support single-payer can be more productive if this bill is used to advance key principles and key provisions in the health reform discussion at large. The long-term fight for single-payer can be complementary with the immediate push for more immediate health care reform this year.
For health and consumer advocates, SBX3 24 was a priority. It makes changes to Medi-Cal eligibility reporting for children, suspending the requirement imposed last year for status reports every six months. By reverting back to annual reporting, this meets the "maintenance of effort" requirements in the federal recovery package that enables California to receive its full share of enhanced Federal Medical Assistance Percentage funds for the Medi-Cal Program, not to mentione allow children to stay on Medi-Cal health coverage without the additional burdensome paperwork. All told, the bill enables California to receive $10.1 billion in additional federal matching funds through December 2010. The bill was authored by Senator Elaine Alquist (D-Santa Clara), chair of the Senate Health Committee.
That said, health and children's advocates are urging that this restoration be made permanent, to both improve the health of California’s children and position our state for additional federal funding.
It was disappointing that mid-year reports were not repealed outright. Instead, the mid-year status reports will resume in January 2011, and sunset in July 2012. If mid-year reports are not outright repealed, other federal funds are in danger: Under the recently-passed Children’s Health Insurance Program Reauthorization Act (CHIPRA), federal performance bonus funds are available, but it would be hard for California to get its portion of those $4.4 billion in funds with such administrative burdens in place. Mid-year reports are estimated to cause 175,000 California children to lose their coverage over an 18-month period.
So progress with SBX3 24, but not nearly enough...
Severe Health and Human Services "Trigger" Cuts To Go Through * Nearly Three Million Californians to Lose Dental & Eight Other Services * Cuts Would Counter Economic Stimulus & Intent of Medicaid Aid
More Updates on the Health Access WeBlog: Defining "Universal Access"; More on the "Trigger"; Prop 1A Update; Sen. Sanders Introduced Single-Payer; The Question is Moot.
Earlier today, Governor Arnold Schwarzenegger's Director of Finance Mike Genest and California Treasurer Bill Lockyer announced that they are not pulling the budget "trigger," thus letting additional cuts and taxes to go through.
The severe cuts being made in light of the "trigger" decision today would cut $183.6 million from health care, including from public hospitals and Medi-Cal benefits. The cuts would also prevent California from getting even more in federal matching funds as a result.
The cuts would eliminate dental, optometry, podiatry, psychology, and several other benefits for around three million California parents, seniors and people with disabilities. Health advocates argue that these cuts will incur new costs to our health system: these services often provide the preventative care needed to prevent full-blown, more expensive treatments later. For example, podiatry services often provide early-warning for diabetes and obesity.
In particular, health advocates argue that these cuts to Medi-Cal are counter to the spirit of the federal economic recovery package, which was supposed to prevent severe cuts in the safety net of the health system on which we all rely. New Medicaid funds were provided by the federal government with the notion of preventing cuts and being able to meet increased needs. Now, for every dollar we cut, California leaves even more money back on the federal table, money that our stretched health system and our struggling economy needs.
The "trigger" cuts included $183.6 million in health care cuts, including:
o a 10% cut to public hospital reimbursement rates (the Safety Net Care Pool), of $54 million, and
o eliminating specific Medi-Cal benefits for 3 million parents, seniors, and people with disabilities (Health Access has a fact sheet on the human 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
Some groups are exploring litigation against the "trigger" cuts and taxes. Others are seeking ways to fight for restoring some of the cuts.
Treasurer Lockyer, in a hearing last week, argued his decision was not to be of "policy" but only of "math." However, he did urge restoration of some cuts, including to dental and home care. As he stated:
I am deeply concerned about all of these consequences, both fiscal and human. In particular, I believe two programmatic cuts will produce harmful consequences that greatly outweigh any savings. Slashing $200 million in State funds for optional dental benefits and the minimum pay guarantee for in-home supportive services workers targets people who most need our help. I consider the suffering that would be caused by these particular cuts to be both severe and compelling. Further, the effect of these reductions would be greatly amplified by the fact the State would forego additional Federal matching and ovennatching funds. For these reasons, I strongly urge the Governor and Legislature to reconsider at least these two programmatic cuts before they take effect on July 1.
The Medi-Cal benefits, including Denti-Cal, will continue through June 2009. These services will continue after that for children 21 and under, although advocates are concerned about ripple effects in terms of access. Some providers and dental clinics who are losing their adult patient population might not be financial viable.
Christopher Beam at Slate took at look at the words in the proposal, and noticed the signficant use of "universal" access to health care in the document.
But what does it mean? As he points out, President Bush used to say that everybody had "access" through the emergency room--which is not really the case. (Hospitals only have to stabilize a patient, and they are free to bill you, oftentimes multiple times what insurers pay.) If you reduce the size of the problem, then your solution can be similarly small.
When talking the issue through with him, I was reminded about how the term "access" can be used as a low bar or a high bar. When some talk about "access" to care, they simply mean making sure a clinic is available in the county; or that a tax credit is available; rather than the provision of comprehensive health coverage which will provide financial security.
But lots of consumer and public health advocates actually take "access" to be a higher standard than simply coverage. We believe that coverage is crucial, but do providers take it? (CHCF's Mark Smith argues that Medi-Cal coverage is not access but simply a "license to hunt" for a willing provider, given that many doctors don't take the coverage.) Is access limited by significant cost-sharing? By an inadequate network of providers? By the lack of interpretation services so the patient can actually talk to their doctor?
Language matters, and sometimes we need to be specific about what we advocate, given the different definition of "universal" and "access."
But Beam's main point is one that we should take to heart. "Universal access" is something so popular that politicians of all stripes now embrace the term, even when trying to define it in different ways.
In Treasurer Lockyer's letter, he urges the legislature to undo some of the cuts, in particularly dental and home care:
I am deeply concerned about all of these consequences, both fiscal and human. In particular, I believe two programmatic cuts will produce harmful consequences that greatly outweigh any savings. Slashing $200 million in State funds for optional dental benefits and the minimum pay guarantee for in-home supportive services workers targets people who most need OUf help. I consider the suffering that would be caused by these particular cuts to be both severe and compelling. Further, the effect of these reductions would be greatly amplified by the fact the State would forego additional Federal matching and ovennatching funds. For these reasons, I strongly urge the Governor and Legislature to reconsider at least these two programmatic cuts before they take effect on July 1.
We understand that there's an announcement expected tomorrow at 10am about the budger "trigger," and thus the fate of the additional cuts and taxes that are under the trigger. At stake are a range of benefits for three million California parents, seniors, and people with disabilities, including dental, optometry, psychology, podiatry, and five others.
HEALTH ACCESS CALIFORNIA ALERT Thursday, March 26th, 2009
NEW BILL LIST; URGENCY LEGISLATION TO GET FEDERAL FUNDING ADVANCES * Bill to Suspend Additional Paperwork Burdens on Children Passes Senate * Bill Passes Assembly Health Committee to Expand Ability to Use New COBRA Subsidy * List of Bills of Interest to Health Consumer Advocates BELOW
ALERT:Click here and call Congress today to tell your Congressional member to tell them to vote to keep President Obama's health reserve in the budget. You can also call directly at 1-888-436-8427. Health reform depends on it!
More Updates on the Health Access WeBlog: Debating Massachusetts; Drawing Down Federal Stimulus Dollars; Twitter Happy; Action on Federal Reform; Wellpoint's Wrong Prescription; What Are Gold-Plated Benefits?; Becerra on a Public Health Insurance Option; The Sky Didn't Fall in San Francisco; White House Forums on Health Reform in LA on April 6th; The Cuts Depending on The Trigger; Judge Agrees on Prop 1A's Misleading Title; Unlikely Allies Against Proposition 1A; Why We Fight for Single-Payer; Sebelius for HHS; Timely ER Access; Obama on Health Reform This Year.
SACRAMENTO--The California Legislature is moving to allow our state to get our fair share of the economic recovery dollars made available.
On Monday, the California Senate passed, without opposition, SB24xxx (Alquist), a measure to suspend one of the cuts to children's coveage made last year. The increased federal matching funds for Medicaid was conditioned on whether states maintained their eligibility and enrollment procedures. In last year's budget, the legislature had imposed additional paperwork requirements for children: doubling the eligibility reporting, to once every six months, as opposed to once a year. That policy shift was expected to drop 250,000 children from coverage over three years. SB24xxx is focused on suspending the rule, at least until the federal dollars run out.
On Tuesday, the Assembly Health Committee passed, on a fully bipartisan vote, a bill to have California adapt its laws so patients have the better access to the federal subsidy to continue their coverage under COBRA after being laid off. AB23 (Jones) would allow those working in small employers (from 2-19 employees)--which are not covered by the federal COBRA law, but are under the state CalCOBRA law-- and others a second chance for those laid off late last year or early next to be able to sign up for the subsidy.
Both bills are urgency measures, requiring a two-thirds votes of the legislature. So far, they have gotten the bipartisan votes needed, but they are still making their way through the Legislature. Consumer and health advocates are supporting these measures through the Legislature and on to the Governor's desk.
Also in the Tuesday Assembly Health Committee was consideration of mandating maternity benefits, AB98, by Assemblymember De La Torre, which would provide equity for women purhcasing health coverage, and provide cost-saving, long-lasting preventative care.
The conversation on comprehensive reform continues. There are two bills that are being reintroduced, strongly supported by Health Access California and other health advocates, including the universal children's coverage proposal by Senate President Pro Tem Steinberg, and a bill establishing a universal single-payer health care system, now sponsored by Senator Leno, taking over for Senator Kuehl.
Finally, there are two "intent" bill, by the chairs of the Assembly and Senate Health Committees, Assemblymember Jones and Senator Alquist, to continue to pursue comprehensive health reforms--whether moving ahead with specific reform or, perhaps, implementing what is passed by President Obama. While there are no details in these bills as of yet, Health Access California is encouraged by the continued interest of the chairs in health reform.
* AB 1314 (Jones) COMPREHENSIVE HEALTH REFORM: Requires Department of Health Care Services in consultation with Legislature to develop and submit a Medicaid waiver to expand coverage. * SB 1 (Steinberg) UNIVERSAL CHILDREN’S COVERAGE: Expands Healthy Families to all children up to 300% FPL and creates a Healthy Families buy-in for children in higher income families. Support. * SB 56 (Alquist) COMPREHENSIVE HEALTH REFORM: Declares the intent of the Legislature to enact and implement comprehensive reforms in the state’s health care delivery system. * SB 810 (Leno) SINGLE PAYER UNIVERSAL HEALTH CARE SYSTEM: Would establish a single-payer health care system in California that would enable all residents to have health coverage. Support.
Market Reforms & Health Savings Accounts
* AB 326 (Garrick) HEALTH SAVINGS ACCOUNTS: Would allow a tax deduction for health savings accounts to be used with high-deductible health plans. Oppose. * SB 353 (Dutton) HEALTH SAVINGS ACCOUNTS: Would allow a tax deduction for health savings accounts to be used with high-deductible health plans. Oppose. * SB 92 (Aanestad) OMNIBUS HEALTH REFORM MEASURE: Narrows definition of medical necessity; allows association health plans; Health Savings Accounts for CalPERS, commercial HMOs and insurers, and Medi-Cal; allows sale of health insurance across state lines, voiding state consumer protections and financial solvency requirements; weakens utilization review requirements; eliminates mandates for pap smears, mammograms, childhood immunizations, diabetes supplies and numerous other protections but only for those below 350%FPL; changes Medi-Cal to defined contribution plan, including for persons with disabilities; and numerous other provisions. Oppose.
Medi-Cal Eligibility & Retention
* AB 23 (Jones) CONTINUOUS ELIGIBILITY: Would expand Medi-Cal continuous eligibility, which would no longer be limited to six months. Repeals semi-annual status reports. Support. * SB 438 (Yee) CHILDREN’S COVERAGE: Would create the Cal-Health program, allow providers to screen and temporarily enroll children in coverage. Makes changes in eligibility processes and procedures that may be steps back. Watch. * SB 337 (Alquist) CONTINUOUS ELIGIBILITY: Would expand Medi-Cal continuous eligibility, which would no longer be limited to six months. Repeals semi-annual status reports. Support. * AB 963 (Ammiano) ELIGIBILITY PROCESSES: Would update and streamline Medi-Cal computer systems and develop an electronic enrollment and renewal process. Support. * AB 1037 (Lowenthal) MANDATORY MANAGED CARE FOR SENIORS AND PERSONS WITH DISABILITIES: But only in Riverside and San Bernardino Counties. Oppose Unless Amended. * SB 114 (Liu) FOSTER YOUTH: Would simplify the Medi-Cal renewal process for youth in foster care. Support.
MRMIP High-Risk Pool
* SB 227 (Alquist) HIGH-RISK POOL: Would require insurers to accept members of the highrisk pool at the rate set by MRMIB or pay a fee used to fund MRMIP. Would also increase the tobacco tax funds dedicated to fund MRMIP. Support * SB 57 (Aanestad) HIGH-RISK POOL: Allows insurers to sell policies with “riders” that exclude coverage for a medically uninsurable condition. Creates a “rider” pool for applicants. Increase eligibility barriers for MRMIP, deletes cap on cost-sharing, requires MRMIP to include option compatible with Health Savings Accounts, increase the annual benefit limit in MRMIP plans to $150,000, and increase the tobacco tax funds dedicated to fund MRMIP. Oppose.
Insurance Oversight & Market Reforms
* AB 786 (Jones) INSURANCE MARKET STANDARDS: Would sort health insurance policies into five categories, ranging from “comprehensive” to “catastrophic.” Organization of plan into these categories would enable consumers to better track premium, benefits and cost-sharing, and assist consumers in making apples-to-apples comparisons between plans. Would weed out “junk” insurance by developing minimum benefit standards. Sponsor. * AB 1521 (Jones) BROKER DISCLOSURE: Would require health insurance brokers to have a fiduciary duty to the client and fully disclose the amount and source of compensation received by the broker. Sponsor. * AB 1218 (Jones) HEALTH INSURANCE RATE APPROVAL: Requires HMOs and health insurer to get approval for increases in premiums and cost-sharing from DMHC and DOI, respectively. Support if Amended. * AB 119 (Jones) GENDER RATING: Would prohibit insurers from charging different premium rates based on gender. Similar to SB54 (Leno). Support. * SB 54 (Leno) GENDER RATING: Would prohibit insurers from charging different premium rates based on gender. Similar to AB119 (Jones). Support. * AB 29 (Price) DEPENDENT COVERAGE: Would allow individuals up to age 27 to remain on a private insurance policy as a dependent. Support. * SB 316 (Alquist) CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio -- requiring every insurer to spend at least 85 percent of premiums on patient care. Support. * AB 722 (Lowenthal) PREEXISTING CONDITION EXCLUSION: Would prohibit insurers from denying coverage because of a pre-existing condition due to a history of mental health treatment or medication. Watch.
* AB 2 (De La Torre) INDEPENDENT REVIEW: Would create an independent, third-party review process when an insurer wishes to rescind a consumer’s health policy and also require approval from the Department of Insurance and Department of Managed Health Care before approval. Also raises the standard in existing law so that coverage can only be rescinded if a consumer willfully misrepresents his health history. Support. * AB 108 (Hayashi) TIME LIMIT: Would impose an 18-month time limit in which insurers have to rescind individual health care policies for fraud once consumers’ applications are approved.
* AB 98 (De La Torre) MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services. Support. * AB 214 (Chesbro) DURABLE MEDICAL EQUIPMENT: Would require group health plans and insurers to offer coverage for durable medical equipment, such as wheelchairs and shower seats. Support. * AB 244 (Beall) MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses. Support.
Health Care Providers
Doctor and Hospital Oversight
* AB 1503 (Lieu) EMERGENCY ROOM FAIR PRICING: Would limit the amount that emergency room physicians and surgeons can charge an uninsured patient with income below 350% FPL. Sponsor * AB 542 (Feuer) ‘NEVER EVENTS’: Bans providers from billing patients or insurers when they have made an avoidable mistake, such as operating on the wrong person, prescribing the wrong drugs, or leaving foreign objects inside a surgery patient. Support * AB 171 (Jones) CONSUMER PROTECTIONS: Would prohibit dentists’ offices from offering high-interest loans to patients while they are under the influence of anesthesia. Would also prohibit dental offices from charging lines of credit before services have been rendered. Support. * SB 196 (Corbett) PRICE TRANSPARENCY: Would prohibit confidentiality clauses, which keep secret information on pricing and health care quality from consumers, in contract between providers and insurers. Support.
California Hospital Waiver
* AB 342 (Bass) The Medi-Cal hospital waiver expires Sept. 2010. AB342 repeals the existing waiver authorization. It is a placeholder for the waiver discussions. Watch. * SB 208 (Steinberg) The Medi-Cal hospital waiver expires Sept. 2010. SB208 requires DHCS to apply for a new waiver. It is a placeholder for the waiver discussions. Watch.
Lessons, if any, from California & Massachusetts...
Wednesday, March 25, 2009
Back in the 1980s, Jesse Jackson hosted Saturday Night Live, and in one sketch hosted a *hilarious* game show called "The Question is Moot," where the answer to every question was, well...
I was reminded of this vignette when reading a back-and-forth at The New Republic's The Treatment, between Jonathan Cohn, Diane Archer, and Jonathan Gruber, talking about the Massachusetts health reform.
My response at The Treatment today is in that same vein: the debate over Massachusetts is moot for the national conversation because Massachusetts started from such a different place.
We learned that the hard way here in California. We've published several papers on the Massachusetts reform, and were struck by the differences. Partially due to the good work the advocates and policymakers had done previously, Massachusetts has to close a gap; California has to jump a chasm.
The comparisons we have made between California and Massachusetts are reinforced by new papers out this week published by Health Affairs, funded by the California HealthCare Foundation, that reveal lessons from the California experience. Many of the papers point out the wide gulf between California, with one of the worst rates of uninsurace, of employer-based health coverage, and of investment in the safety-net, as contrasted with Massachusetts, which ranked highly in those categories even before reform. The papers are worth the read.
Unfortunately, the rest of the country is closer to where California is than where Massachusetts is. I joke to national audiences that California is their ghost of Christmas future--where the nation will be in five or ten years if we don't pass health reform.
Today, the Assembly Health Committee considered another bill to help draw down federal money to California.
The federal economic recovery package included a subsidy so laid-off workers can get a 65% subsidy for premiums under COBRA. The bill considered today allows a greater number of Californians to take advantage of those resources.
Right now, the federal COBRA law, which allows workers to keep their groups coverage after they leave an employer, is only available to workers of employers of 20 or more. The new bill extends the COBRA subsidy to the state CalCOBRA law, which covers workers of employers from 2-19 workers. The new law would also give Californians who were laid off late last year or early this year better notice and a second chance to take advantage of COBRA.
This is crucial: Just over half of Californians get coverage from their employer. Losing their employer-based coverage is a big deal, for the sake of continuity of care, for getting the group-negotiated rate, and most of all, for not being denied for "pre-existing conditions," which is possible, even likely, in the individual market. But the problem is losing your job is a tough time to ask to pay full premium for coverage. That's why the subsidy is so important, especially as California reaches a 10.5% unemployment rate.
Earlier today, Health Access was pleased to participate in a press conference with Assemblymembers Dave Jones and Nathan Fletcher, chair and vice-chair of the Assembly Health Committee, respectively, as well as Insurance Commissioner Steve Poizner, and Joe Dunn of the California Medical Association. As that notably bipartisan event indicated, the bill passed later in the day without any "no" votes. That's a good thing, given it is an urgency bill, and thus requires a 2/3 vote.
Yesterday, the Senate passed on a bipartisan vote SB24xxx (Alquist), which despite its name, is a very decent proposal. It suspends the additional paperwork burdens imposed last year in the budget crisis.
The original cut would have doubled the reporting for children to maintain Medi-Cal benefits, from annually to every six months, which would have led to over 250,000 children to lose coverage over three years. The federal stimulus package conditioned billions in federal Medicaid matching dollars on maintaining eligibility and enrollment procedures. So to get the money, we have to void the mid-year status report requirement, at least for the duration of getting the enhanced matching funds.
Restaurant owners--the biggest opponents to Healthy San Francisco--made broad predictions about the universal health care reform's impact to the city. Now, after over a year of implementation, many of those owners are accepting the change, in more ways than one.
The Golden Gate Restaurant Association proclaimed all sorts of dire impacts in the employer contribution requirement was passed, and has pursued legal action against the law, even though they have been rejected by the full 9th Circuit Court of Appeals. They are continuing to appeal to the U.S. Supreme Court, although it seems the restaurant community has just taken the changes in stride, as reported by Heather Knight at the San Francisco Chronicle
At the bustling French bistro Zazie in San Francisco's Cole Valley, one dollar goes a long way. That's how much owner Jennifer Piallat charges each customer to pay for health care for her 32 employees.
The dollars add up to about $11,000 a month - enough to provide Kaiser Permanente medical insurance, dental insurance and a 4 percent employer match on 401(k) retirement accounts. She said only 1 percent of her customers have complained about the surcharge. "And they were the 1 percent we didn't want to come back anyway," she said.
The Zazie experience is playing out at restaurants around the city, as most owners pass along the costs of city-mandated health care coverage to their customers - and say they're delighted to finally be able to afford it. Most customers say they're OK with paying extra.
But if it's all going down as smoothly as a glass of Cabernet after a long day at work, why is the Golden Gate Restaurant Association asking the U.S. Supreme Court to overturn the employer spending mandate - even asking Wednesday for an emergency injunction to block the program?
Why indeed? The sponsor of the bill, now-Assemblyman Tom Ammiano, is baffled. One theory is that even though it is going fine on the ground, national ideological interests are weighing in:
Deputy City Attorney Vince Chhabria said national groups could be pressuring the restaurant association to persevere in its case it to nip the issue in the bud before it expands elsewhere.
Otherwise, he said he's mystified because restaurants profess to support the program. He has collected several cards handed out by restaurants explaining their surcharge for health coverage, almost all saying they're proud to support this landmark program.
SF Supervisor Campos wrote the restaurants, asking them to drop the lawsuit:
"That restaurants make supportive statements about Healthy San Francisco, while simultaneously fighting in court to undermine this very program, raises questions about whether they are dealing with their customers in good faith," he wrote.
Campos also implies in the letter that the varying surcharges raises questions about whether some restaurants are spending all the extra money on health care. Piallat, the owner of Zazie, said her experience of having money left over after charging $1 a customer tells her that restaurants with 4 and 5 percent fees are profiting.
"I think a lot of people are making money off of this deal," she said. "Do the math." Other restaurant owners interviewed by The Chronicle said that's not true, especially as the recession means diners are spending less overall.
Piallat dropped her membership with the restaurant association after it asked members to contribute money to fund the lawsuit. She said that even if the association ultimately wins at the Supreme Court, she'll keep the $1 surcharge on her menu.
"I plan to still keep the buck," she said. "I'll change the wording to say, 'A dollar per person provides full benefits to our staff. Thank you so much.' "
There is always the suspicion that some businesses might be using the opportunity of the law to pocket some change, but the question is whether they provide benefits. Piallat's commitment to benefits is appreciated, but without the law, she might be undermined. The reason setting a minimum employer contribution is so essential is that those who want to provide coverage have to compete with those that don't provide coverage. That's why we feel it's important to set a floor--whether a minimum wage, or a contribution to health care.
The key takeaway: health reform, including a meaningful employer contribution, has been implemented in San Francisco, and the dire predictions of opponents have yet to materialize. Meanwhile, more people are getting access to care, and there's more stability for the health care system that all San Franciscans depend on. Some restaurants are charging a buck more, but many feel that's change they can believe in.
Here's some salient sections for health advocates (emphasis added). First, the notion that it would prevent the restoration of the severe cuts we have seen in the past year:
The revenue forecast amount established by Proposition 1A, which limits spending from the state’s existing tax base, would be significantly below the Governor’s “baseline” spending forecast, a forecast that assumes that the cuts proposed by the Governor in his New Year’s Eve budget release continue. For example, in 2010-11, the first year when the Director of Finance would be required to calculate whether the state has received “unanticipated revenues,” the revenue cap would be an estimated $16 billion lower than the Governor’s “baseline” spending estimate for the same year. The gap would widen in 2011-12 and 2012-13 to $17 billion and $21 billion, respectively.
By basing the new cap on a level of revenues that is insufficient to pay for the current level of programs and services, Proposition 1A would limit the state’s ability to restore reductions made during the current downturn out of existing revenues.
Here's another section reiterating that point, that the money from the reserve could also not be used for such restoration:
Proposition 1A limits the amount that can be used from the reserve in “bad budget” years to the difference between anticipated revenues and prior year’s spending adjusted for population growth and the CPI. It does not allow the reserve to be used to support a “current services” or “baseline” budget, even if sufficient funds would be available in the reserve to do so. The discrepancy arises from the fact that the CPI – the inflation measure used by Proposition 1A – is designed to measure changes in the cost of goods purchased by households, not governments. Thus, the CPI does not accurately measure the year-to-year increase in the cost of delivering the same level of public services. Specifically, the CPI does not take into account the fact that government spends a larger share of its budget on items – such as health care – for which costs have risen faster than the rate of inflation. Between 1990 and 2007, for example, national per capita health care expenditures more than doubled, rising by 164 percent, while the CPI for California, which measures inflation in households’ purchases, rose by just 61 percent.
The particular concern for health care is noteworthy. If the formulas in Prop 1A don't take into account medical inflation, an aging population, or other impacts--like the erosion of employer-based health coverage--then existing health programs are threatened.
Another issue of concern is that the mesaure seems to require "deposits" into the reserve even in bad year. That's money that would be diverted from general fund priorities, including health and human services, at a time when cuts would already be on the table.
[The CBP] analysis found that Proposition 1A would have required contributions to the reserve in a number of years where the state experienced a moderate deficit. In November 1995, for example, the Legislative Analyst’s Office projected that the cost of a General Fund “current services” budget would increase by 8.6 percent from 1995-96 to 1996-97. However, in that same year, because revenues exceeded the “expenditure forecast” amount, a BSF contribution of $2.0 billion would have been required, which would have left available revenues $1.0 billion – 2.2 percent – below the amount needed to support a current services budget.
Proposition 1A also would have required both a transfer to the BSF and a shift of “unanticipated revenues” out of the General Fund in 2005-06. These shifts would have been required despite the fact that by most measures, 2005-06 was a “bad budget” year, which required $5.9 billion in “solutions” to bring the budget into balance. Had Proposition 1A been in effect, $1.4 billion in additional “solutions” would have been needed to provide sufficient resources to make the mandatory 1.5 percent transfer to the BSF. At the end of the year, an additional transfer of revenues out of the General Fund would have been required since estimated collections were in excess of the revenue cap.
Most people would question a so-called "rainy day" fund that required money while it was raining. When you can't pay the rent, that's not the time to divert money to the savings account, as worthy as that might be.
Finally, Prop 1A gives the Governor new, unilateral power to make cuts.
SB 8 (Ducheny), passed as part of the recent budget agreement, gives governors the unilateral authority to cut spending if available resources decline or expenditures increase “substantially” mid-way through a budget year. This provision would only take effect if Proposition 1A is approved by the voters. The new authority would allow an appointee of the governor, the Director of Finance, to reduce appropriations that support the operations of the state by up to seven percent...
SB 8 also allows the Director of Finance to suspend cost-of-living adjustments or rate increases for up to 120 days and, if the governor declares a fiscal emergency, cost-of-living adjustments would not be made until the Legislature sends the governor one or more bills addressing the emergency.
New powers to make cuts, but not to raise revenues. State budgets are fundamentally about education, health, and public safety. For those who are concerned about health care, there's reason to be concerned about the impacts of Prop 1A.
There will be continued talk about comprehensive health reform, and specific efforts for consumer protections and increased access to care. Even without the federal debate, there'll be a lot to blog on...
Those who followed health reform in 2007 recognized that any legislative proposal has three proving grounds: not just an executive, but both houses of the legislature. While much has been written about the U.S. Senate, both as an obstacle (60 votes!), and as a leader in shaping policy with Sens. Baucus and Kennedy, some new articles give some insight into the other arenas:
The powerful chairmen and subcommittee chairs of the House of Representatives--mostly Californians like Waxman, Miller, Stark, etc.--are working together to produce one health reform bill from the House, according to Robert Pear at the New York Times. As reported also by Ezra Klein at The American Prospect, and overheard at the White House Forum on health reform, there is some common framework, including "shared responsibility," including that of individuals and employers, as well as a choice of public or private plans. There's lots of details in how that would be crafted, but it's a start.
Also Jonathan Cohn at The New Republic does some reporting about the internal conversations in the White House that led the Administration to continue to emphasize health reform as a top priority this year, and to set aside real money to invest in it. The short answer is that the commitment keeps coming back to the President himself, who continually reasserts his interest despite concerns from his advisors.
Finally, the action isn't just in DC, as outside forces impact the federal conversation. There's my article at The New Republic's The Treatment about the real prospects of Healthy San Francisco helping spur reform not just in other states, but at the national level.
While there's a lot going on today, with the trigger hearing in Sacramento, and press events decrying the cuts in the Bay Area, Los Angeles, and elsewhere, we would be remiss if we neglected a speaker from out-of-state.
The title is "Achieving Responsible Health Care Reform…and Getting It Right.”
Is it President Obama? Chairman Waxman? A prominent academic? No, amazingly (and gallingly, given the title), it is Angela Braly, the CEO of Wellpoint, the largest insurer in California ever since they managed Anthem Blue Cross of California.
Braly is speaking at Town Hall Los Angeles. We'll be there, too, not to disrupt, but to educate Californians about the toxic role of Wellpoint/Blue Cross, both in the marketplace and in the public policy debate.
The groups leafletting, including Health Care for America Now and others who are actively working for health reform to win quality, affordable health care this year, will provide speech-goers and passers-by with information about Wellpoint’s actions, including premium rate hikes, rescissions, denials of care, and previous efforts attacking health reform. Wellpoint’s record shows why they and other insurers can’t be trusted to reform the health care system.
In addition to a range of organizations, we'll also have the participation of a Blue Cross patient who found that her policy didn't cover the breast cancer she eventually got.
But I simply find it shocking that Wellpoint, of all stakeholders, of all companies, is lecturing the rest of us on "responsible" reform and "getting it right." Here in California, they opposed health reform from the beginning, as described at the website http://www.sickofbluecross.org/.
We'll see what she says, but there's no reason that we should trust her, Wellpoint, or the insurance industry with health reform.
The biggest "trigger" cut in health care is the elimination of adult dental coverage. What does losing access to dental care mean?
The elimination of adult dental benefits will cause considerable harm not only to the 3 million low-income parents, seniors and persons with disabilities that depend on Medi-Cal. They will either go without, or fall into medical debt.
The impact won't stop there. The almost 4 million children who rely on Medi-Cal and Healthy Families for dental benefits may also lose access to care. Experts tell us that the elimination of Medi-Cal adult dental benefits will have the effect of collapsing the entire provider network. Clinics and others who now subsist on Denti-Cal would not be able to survive just on children's services... they may very well close altogether. In other words, this will impact not just the "age blind and disabled," but children as well.
Pain due to lack of dental care was the most common cause of missed school days in the LA Unified School District as well as other school districts prior to the creation of Healthy Families. The elimination of adult dental and the concomitant collapse of the provider network could very well return California to those days.
Today is the hearing regarding the infamous "trigger." Health Access will be there, as always, opposing some devastating cuts.
In the budget deal, the Governor and Legislature made an unusual deal: if California was able to count over $10 billion in new federal money to the general fund, then the Director of Finance Mike Genest and Treasurer Bill Lockyer can prevent a package of severe cuts and increased taxes from happening.
Part of the issue is accounting, part of it politics. As the California Budget Project indicates, there's over $50 billion coming to the state in one way or another. The question is whether enough is cocunted toward the $10 billion "trigger" threshold.
What places a shadow is the continuing fiscal crisis. The consequence, on one hand, is that the projected budget deficit would be even bigger.
But the consequences of the "trigger" cuts are very real as well. In health care, these are severe cuts to public hospitals, at exactly the time they are needed most.
As the chart shows, the list of Medi-Cal benefits to cut share one striking characteristic: elimination of these benefits is not cost-effective and instead is likely to cost the state more to provide care to the same population. For example, the elimination of optometry services means that Medi-Cal beneficiaries will go to ophthalmologists. The elimination of podiatry means more expensive and less expert care from physicians. The elimination of incontinence creams and washes will lead to Stage 3 and 4 bedsores---bedsores that would be reportable as adverse events or “never events” if they occurred in a hospital. But because they will happen to persons with disabilities trying to live in the community, they will result in the institutionalization of those who could otherwise have remained in the community. Penny-wise and pound-foolish does not begin to describe these cuts.
We need to prevent these cuts, for not just the individual Californians impacted, but for the health system we all rely on, and the economy we are trying to revive.
In the NY Times over the weekend, and in other publications on other days, there is talk in DC about taxing health benefits of employees.
This is not something that comes up in state level reform, even in states like California with a personal income tax, because the level of state income taxes is so much less than the federal income tax.
Tax types seem to think this makes sense because the tax deductibility of health benefits is regressive---that is, it is worth more as you go up the income scale.
There is some truth to this, but it is also true that eliminating the deductibility of health benefits practially impacts the middle class.
Is a single individual making $55,000 a year with health coverage rich? Or an insured family of three living on $90,000? No, certainly not in most of California. They are not poor, but they are watching their budget in our high cost-of-living state. Yet both those instances are people over 500% of federal poverty.
So does it make sense to tax the health benefits of a family living on $90,000 a year?
And what exactly are “gold-plated” benefits? When some talk this way, usually they are referring to low cost-sharing---low deductibles, low copayments---precisely the benefits that are needed by those in the middle to make sure they get routine care. In an era in which lots of Americans are skipping medications, skipping doctor visits, not getting needed lab tests because of health care costs, now there is talk of taxing the kind of health benefits that make prescription and doctor visits affordable for working families.
Good health benefits encourage primary and preventive care. Good health benefits make possible management of chronic conditions like diabetes and heart disease. People with these conditions face a lifetime of drugs, devices, doctor visits, and lab tests. Taxing the benefits that make it possible for people to manage these conditions feels very wrong.
We find it ironic that some of those in the US Senate, sometimes called the millionaires club, think it is wrong to limit income tax deductions that the most affluent taxpayers claim but somehow right to tax the health benefits of the middle class. We might expect this from a Senator who own seven houses, but it is disappointing to hear it from others.
The Jon Stewart-Jim Cramer interview wasn't the only smackdown this week. Here's California Representative Xavier Becerra, who is a member of the House leadership, and represents part of downtown Los Angeles (including Health Access' LA office), on the need for a choice of a public health coverage option:
But I also wonder why the heavy pushback on the concept. In California, we have lots of public health insurers at the county level, from Alameda Alliance for Health, to LA Care. The health reform negotiated between Governor Schwarzenegger and Speaker Nunez included a potential expansion of these existing entities to become a viable competitor. At the federal level, the opportunity exists for a more robust public health insurance competitor, but the concept isn't new.
As Rep. Becerra says in the video: veterans, seniors, and others have such a choice of public and private plans now.
Rep. Becerra is also right about how the public sector takes a lot of risk that would otherwise fall on the private insurers. Insurers undertake massive efforts to avoid risk, and yet they still whine in public policy forums about "adverse selection." Yet private insurers let the public sector take on the populations most at risk of getting sick: seniors, people with disabilities, and very low-income families. So to the extent that "adverse selection" exists, it is limited to within healthier part of the population.
We are glad that Rep. Becerra will have an important voice in this debate, to speak up about the need for a public health insurance option, and other issues of import to California consumers.
Earlier today, the Health Access California board re-affirmed its position to oppose Proposition 1A. Also today, we were joined by the League of Women Voters. From their release opposing 1A, 1C, 1D, and 1E:
“We oppose these measures because they are NOT the solution to our long term financial crisis, with the continuing structural deficit in the state budget and flawed budget process,” said Janis R. Hirohama, president of the League. “We make this decision with regret. We would support real reform to make the state budget process more accountable and give the Legislature and Governor effective tools to advance state priorities. However, these hurriedly drafted propositions, produced at the end of a flawed process that kept both the public and most legislators in the dark, will only make our fiscal situation worse.”
Proposition 1A is touted by its proponents as the way to bring stability to the budget process. But what it will really do is tie the hands of the Legislature and Governor as they face changing needs for state and local government services. It will keep them from taking into account the state’s changing demographics and growth in the actual cost of important services like health care.
“Although some claim there is an urgency to pass Prop. 1A to resolve our state’s budget problems, we disagree,” said Hirohama. “Most of its provisions will not take effect for two years—two years that we should spend hammering out real solutions to our budget and fiscal challenges.”
The League believes elected officials should be allowed to carry out their responsibilities with flexibility. Years of “ballot-box budgeting” and formulas for auto-pilot spending have greatly eroded that flexibility. Prop. 1A, however, adds to the problem. For example, it dictates how half the funds that must be transferred to the “Budget Stabilization Fund” are to be used; it removes the Governor’s ability to suspend transfers to the fund in difficult years; and it imposes new formulas for calculating “unanticipated revenues” and specifies how they can be used in good years. And, after the deep cuts made during these strapped times, it could lock in a reduced level of services by failing to properly take account of increased caseloads and program costs.
If Prop. 1A passes, the Governor would be given new power to make mid-year cuts and suspend COLAs in state programs without legislative oversight. The League believes that mid-year budget adjustments should require joint action of the legislative and executive branches so that checks and balances are maintained...
The League of Women Voters recognizes that California is facing the worst budget crisis in its history, with the worldwide recession severely affecting state revenues and the need for state services. Moreover, our budget system is broken and in desperate need of reform. This year illustrates the need to abandon the two-thirds vote requirement for passing budgets and raising revenues, and we must also look at other budget reforms. In the meantime, a new tax commission is considering ways to broaden or stabilize our revenues. “There is much that needs to be done,” Hirohama stated, “but we are certain that the propositions on the May 19 ballot are not the answer.”
Other organizations will be making decisions in the next few weeks. Let's remember, these Propositions were only placed on the ballot a few weeks ago. And with Prop 1A, etc., there was no public hearing or analysis or opportunity to review the measures before the legislative vote in the middle of the night. So organizations are acually being relatively quick in their decision making progress, but it does take some time. We'll see how the opposition shapes up in the next few weeks...
With the good news about the court case regarding Healthy San Francisco, I was reminded that Mayor Gavin Newsom did his State of the City address this year by YouTube, and had a 45-minute segment focused on health care. In the first 14 minutes, he gives his perspective about Healthy San Francisco, which is becoming the focal point of health services in the city by the Bay.
Mayor Newsom focuses on certain aspects of the San Francisco plan, which are central to his perpective running a city and county; while there may be other aspects that are more relevant to the national health reform debate, such as aggressive enrollment efforts, employer responsibility, or investment in safety net institutions. Either way, there's a lots to learn.
At the Assembly Health Committee hearing, Tangerine Brigham, the director of Healthy San Francisco, did indicate that other localities were looking at it. In fact, Howard County in Maryland has replicated the "access plan" aspect that connects patients to the local safety net, in an effort called, somewhat humorously, the Healthy Howard plan.
Health Access was pleased to be among many, many advocates and organizations this morning at the press conference regarding the introduction of SB810(Leno), the newest incarnation of a universal, single-payer health care reform.
In our 20 year history, Health Access has supported previous single-payer bills, including those by Senator Kuehl in the past few years, to Proposition 186 and those by Senator Petris a generation ago.
But at the press conference today, it's clear that the term "single-payer" now is used as a stand-in for a host of principles and advocacy points, ones that are assumed among supporters as part of SB810, but are not made as explicit as they should be for those we are working to convince.
When we fight for single-payer, what are we fighting for? * a universal system, that offers coverage and care to everybody, rather than having so many millions uninsured, and so many more millions who are at risk of becoming uninsured; * an accessible system, where people are not turned down or given a higher rate because of their "pre-existing conditions." * a progressively financed system, where what we pay for health care is based on what we can afford, rather than how sick we are; * a cost effective system, which pools patients together and uses their bulk purchasing power to negotiate the best price from providers; * a comprehensive system, where people have a basic standard of benefits, rather than left to wonder if their coverage will actually cover them when they need it; * an efficient system, which streamlines the bureaucracy associated with the marketing, underwriting, administration, and profit-taking of private coverage; and * a prevention-oriented system, which has the incentive to invest in wellness in the first place, rather than simply the incentive of insurers to avoid risk.
There are other reasons as well. Looking at the crowd, those of us who support single-payer and/or other health reforms do so for different reasons: some value the simplicity and potential economic savings; others the social mission to expand coverage to all; some really don't like insurance companies.
But as we continue to work at both the state and federal levels, it's a good reminder to remember the reasons why we support health reform, so we can better explain our passion to others, and to evaluate how any reform advances and makes progress on any of these goals.
We know a little more: there will be a White House Regional Forum on Health Reform in Los Angeles on Monday, April 6th, hosted by Governor Arnold Schwarzenegger. While President Obama is not expected to be there, other members of the Administration involved with health care are.
The court upheld the Healthy San Francisco program, particularly the requirement for set a minimum contribution by employers toward their worker's health coverage. The program allows employers to meet that requirement by offering private coverage, or by paying into a new, affordable public health plan option that would provide access to San Francisco health services.
This is big news for the city, and for the tens of thousands of San Franciscans who get coerage through Healthy San Francisco, or who have gotten or kept private coverage due to the law.
But this is even bigger news for the states. For years, many have said that states can't do health reform because of the federal ERISA law, which preempts state regulation of worker benefits. But this decision shows what a state can do without violating the constraints of ERISA.
Whether it was AB x1 1 in 2007, SB2 in 2003, or other health reform proposals in California, the possibility is there. Coincidentally, the Assembly Health Committee, chaired by Assemblyman Dave Jones, is having a hearing this afternoon about how to move ahead with state health reform. They have new possibility today.
Coming off the strong start of President Obama's "White House Forum on Health Reform" last Thursday, the buzz is strong that the President is taking the show on the road, right here to California. From the White House press release:
Building on Thursday’s White House Forum on Health Care Reform, President Obama Announces Series of Regional White House Forums to be Held Across Country
California, Iowa, Michigan, North Carolina and Vermont to host regional forums to continue discussion about bringing down health care costs, expanding coverage for all Americans
WASHINGTON, DC – Building on Thursday’s White House Forum on Health Care Reform, President Obama announced a series of Regional White House Forums on Health Reform that will bring the conversation about health care reform directly to communities across the country.
In keeping with the Obama administration’s commitment to a transparent, accountable government, the forums will be an opportunity for Americans from all over the country to voice their concerns and ideas about reforming our health care system.
"Health care reform is a fiscal imperative," President Obama said. "Skyrocketing health care costs are draining our federal budget, undermining our long-term economic prosperity and devastating American families. The time for reform is now and these regional forums are some of the key first steps toward breaking the stalemate we have been stuck in for far too long. The forums will bring together diverse groups of people all over the country who have a stake in reforming our health care system and ask them to put forward their best ideas about how we bring down costs and expand coverage for American families."
The Regional White House Forums on Health Care Reform will be hosted by the states’ Governors and will include participants ranging from doctors to patients to providers to policy experts. They will be open conversations with everyday Americans, local, state and federal elected officials – both Democrat and Republican -- and senior Obama administration officials. The events will begin with a video recorded by the President, a summary of the findings from the Health Care Community Discussions that took place in December, and an overview of the discussion that took place at the White House Forum on Health Reform.
The meetings in California, Iowa, Michigan, North Carolina and Vermont will take place in March and early April. Further logistical information about the forums is forthcoming.
It makes sense for the Obama health care road show to come to California. Key Congressional committee chairmen with responsibility over health reform are from California. By making Governor Schwarzenegger host, it spotlights a Republican Governor interested in health reform, who ultimately endorsed a framework similar to the Obama proposal, even if there are some differences in the details.
And finally, the health crisis is particularly acute in California. For the rest of the nation, California is the ghost of Christmas future: it's where the country will be in ten years without health reform.
It doesn't sound like the President will come. But health policy wonks can still swoon over Orzag or another key health care principles. An Emanuel brother, perhaps?
We've gotten several calls about this just in the last day, but this is what we know at the moment. Hopefully there will be more later...
As potential Medi-Cal cuts loom, one cut from prior years may get restored. As reported by Timm Herdt at the Ventura County Star (in an article worth reading), approximately $11.23 billion in increased federal Medicaid matching funds from the economic stimulus plan is pending...
The only requirement is that California keep its Medi-Cal eligibility and enrollment rules the same. After all, the point of the money is to allow states to prevent health cuts, keep health care jobs, and to be able to meet increased needs in an economic downturn.
One problem: in last year's late budget, California imposed semi-annual reporting requirement on children, for the purpose of getting savings as those families don't fill out the paperwork and end up falling off coverage. We projected that over 250,000 children would lose coverage over three years as a result of the cynical, burdensome paperwork.
This new enrollment barrier would make us not eligible for the $11 billion. Now there's a debate over whether to eliminate this requirement--which was bad policy to begin with--or to "suspend" it, although the latter option may not be enough to get the federal economic stimulus dollars, or other sources of funding.
Whatever happens, it needs to happen quick, or the state could lose the big bucks from the federal government.
We have reportedbefore about the "trigger," a part of the budget deal where depending on the amount & type of money received through the federal economic recovery package, Treasurer Lockyet and Finance Director Genest have to make a decision by April 1st. At stake is whether an additional income tax and a series of additional cuts (including to Medi-Cal benefits) are made.
The question is whether we hit a $10 billion threshold from federal funds. Let's be clear: California is getting a lot more than $10 billion from the economic stimulus package; the question is what "counts" toward the threshold. The question is how much federal funds go to the state general fund, and when it comes
There's a huge amount at stake, from cuts to public hospitals to Medi-Cal benefits. Most concerning is the potential elimination of dental coverage for 3 million parents, seniors, and people with disabilities. If this cut is made, it will be very hard to build that infrastructure back up.
It's been a while since I lived in DC, so I was pleased to walk into a restaurant I didn't know earlier this week and bump into Ezra Klein walking out. The former Californian blogs about food, and also about health policy, and blogged the heck out of the White House Forum on Health Reform.
Judge orders changes to misleading Prop 1A language...
A California Superior Court judge today ordered changes to the measure’s title and summary that will appear in the state’s Official Voter Information Guide for the May 19, 2009 Special Election.
After two hours of oral arguments and give and take, California Superior Court Judge Michael Kenney repeatedly described--in a written ruling--the original ballot language as “misleading” and found “the effect of the non-neutral language causes the Ballot Label and Title and Summary to become misleading.”
Today’s ruling is a result of a suit filed on Monday by the "strange bedfellows" of me and the Howard Jarvis Taxpayers Association, to correct both the ballot label and the title and summary of Prop 1A.
For the six measures to be considered by voters on the May 19 Special Election ballot, the Legislature has taken the responsibility for preparing the ballot label and title and summary away from the Attorney General and has imposed its own ballot label and title and summary for each of these proposed measures.
In particular, the judge took out of the official description the words “reform” and “overspending,” as well as the phrase “limiting sustainable spending of one-time spikes in revenue." He left in “rainy day.” “Stabilization” is in in one place, “stabilizes” is out in another. He did not make any correction regarding the omission of tax increases.
Here are some examples of the changes:
The ballot label used to read: Reforms the budget process. Limits future deficits and overspending by increasing the size of the state "rainy day" fund and requiring above-average revenues to be deposited into it, for use during economic downturns.
* It now reads: Changes the budget process. Could limit future deficits and spending by increasing the size of the state "rainy day" fund and requiring above-average revenues to be deposited into it, for use during economic downturns and other purposes.
The ballot label used to read: STABLIZES STATE BUDGET. REFORMS CALIFORNIA BUDGET PROCESS. LIMITS STATE SPENDING. INCREASES "RAINY DAY" BUDGET STABILIZATION FUND.
* It now reads: STATE BUDGET. CHANGES CALIFORNIA BUDGET PROCESS. LIMITS STATE SPENDING. INCREASES "RAINY DAY" BUDGET STABILIZATION FUND.
There are other changes as well. These are significant changes, although it leaves it the Orwellian "rainy day budget stabilization" title. The bottom line: Even a judge ruled that Prop 1A effort is misleading, and changed most egregious language in ballot title and summary. The more we learn, the more Prop 1A doesn't do what the proponents say it does.
After the President's speech, I am seeing a bit of the back-and-forth in their "breakout" sessions. Lots of legislators, but some stakeholders as well. It's an interesting event where General Mills (representing the Business Roundtable) and the Blue Cross Blue Shield Association speak favorably about reform... we'll see how much they support health reform at the end, not just the beginning, of the process.
Here's a full list of forum attendees, including consumer groups like Health Care for America Now and Families USA, and Californians like Dr. Ho Tran of the Asian and Pacific Islander Health Forum (and HAC board member), Jeff Caballero of the Association of Asian Pacific Community Health Organizations and John Arensmeyer of Small Business Majority. There's also many national organizations attending that are represented in their state affiliates in the Health Access board, including Alliance for Retired Americans, AFT, AFSCME, AFL-CIO, National Education Association, Planned Parenthood, Physicians for a National Health Plan, and many other allied aorganizations, like AARP, CDF, PICO, American Cancer Society, National Council of La Raza, and others
Just back from DC, where the momentum for health reform is palpable. Just in the last week, there was a presidential speech with a strong commitment to act, a budget with committed dollars, and key appointments to fill out the team.
Today, Thursday afternoon (Eastern time), there's a White House Forum on health reform to be broadcast on CSPAN.
Also today, there's oral arguments in the lawsuit regarding the false and misleading language in the Prop 1A title, summary, and analysis. We'll need a longer effort to detail the budget cap proposals' impact on health care, and defend core programs.
Only a few years ago, it used to be Washington seemed to be a quagmire, where health advocates were simply preventing the worst, whereas California was pointing the way with active movement. Now, we are on offense in DC, and defense in Sacramento. How quickly things change.
Opponents of Proposition 1A are coming from all ends of the ideological spectrum, as the San Francisco Chronicle reports. Some will oppose the extension of tax increases from 2 years to 5 years. Others oppose the spending cap that will prevent restoration and reforms to health programs and in fact force cuts, next year and thereafter, to health and other vital services.
But I think any observer can agree that the ballot title, summary, and analysis of this proposal is s simply false and misleading. Prop 1A was hastily drafted with no public input, and now they are using false and misleading language in ballot materials in a clear effort to distort what the measure will actually do.
At issue is the process used to communicate fair and impartial information to voters. In a normal election cycle, every ballot measure is included in a ballot pamphlet distributed to the voters to protect them from being misled. The ballot pamphlet typically includes the following: the text of the measure to be considered; a 100-word title and summary and shorter ballot label prepared by the Attorney General; an "impartial analysis" prepared by the Legislative Analyst's Office; and the arguments and rebuttals for and against the measure.
However, the legislation setting the special election, SB 19, changed this process significantly. For the six measures to be considered by voters, the Legislature has taken the responsibility for preparing the ballot label and title and summary away from the Attorney General and has imposed its own ballot label and title and summary for each of these proposed measures.
Dr. Geroge Lakoff, a professor of cognitive linguistics at the University of California, Berkeley, in an analysis of the current Prop 1A title and summary, notes that it contains phrases like "over-spending," "rainy-day fund" and "reform." "None of the words and phrases discussed is neutral," said Lakoff. "In each case, the language prejudices voters towards passage of the proposition and toward the political and economic views of the proponents of the proposition."
So today, Anthony Wright of Health Access California joined a suit with the Howard Jarvis Taxpayers Association in Superior Court to correct both the ballot label and the title and summary of the measure. The lawsuit contends the language chosen by the Legislature to describe these measures, including Proposition 1A, is not "fair and impartial," but is extremely one-sided and is written in such a way as to persuade voters to adopt the Legislature's proposals.
Another glaring omission in both the ballot label and title and summary is the absence of any reference to the extension of tax increases which are currently tied to approval of Proposition 1A. Specifically, there is no mention anywhere in those materials that Proposition 1A, if passed, would authorize the extension of three tax increases totaling some $16 billion which were adopted by the Legislature as part of the "budget package" in late February of 2009.
Unlike the arguments for and against a measure, those portions of the ballot pamphlet prepared by the government---the title and summary, the ballot label and the fiscal analysis---are required to be impartial and complete to protect voters from being misled.
With Secretary-designate Sebelius, President Obama announced today his new White House health refom "czar." There's a lot to do, and a short amount of time to do it. She will have to hit the ground running: This Thursday afternoon, there will be a "health care summit" to start the process. From the President's press release:
Nancy-Ann DeParle, one of the nation’s leading experts on health care and regulatory issues, will serve as Counselor to the President and Director of the White House Office for Health Reform. As commissioner of the Department of Human Services in Tennessee, she saw firsthand the health care system’s impact on workers and families. In the Clinton Administration, DeParle handled budget matters for federal health care programs, and took on the tremendous task of managing Medicare and Medicaid.
Jonathan Cohn of TNR's The Treatment has a detailed write-up and reactions from many, including Ron Pollack of Families USA and erstwhile Californian Peter Harbage of the Center for American Progress.
Big news: President Obama will nominate Kansas Governor Kathleen Sebelius to be the new Secretary for Health and Human Services. Here's a photo from her gubernatorial website showing her comfort negotiating with the myriad of stakeholders in health reform:
For us in California, it is good that the head of HHS will have someone with considerable background in health policy, and in particular with a state's role in health care. As insurance commissioner, she had the political backbone to stop a Anthem from taking over the state Blue Cross plan, a merger that was not going to benefit Kansas policyholders. She negotiated with a range of interest to win privacy protections for consumers, and worked for lower prescription drug prices. As Governor, she has run and prioritized the state's Medicaid program even in a time of cuts, and sought to raise revenues to expand coverage to more children.
As her experience shows, states have a big role in health policy, from regulating insurers to running their Medicaid programs. Even though Kansas and California are different, it is good to have a prominent voice in the federal health reform debate to have first-hand knowledge about the experience, jurisdiction, and challenges of states and their role in health care.
There are parts of health reform that can best be done at the federal level, but any federal reform will need to be partially implemented at the state level. At the same time, state health reforms are best done when we have a partner, rather than an obstacle, in the federal government. For example, California is starting the process of renegotiating our Medicaid hospital financing waiver, and negotiating with a Secretary Sebelius is a much better choice than some of the other options considered.
In any time, HHS is a huge job: it has 65,000 employees and is the largest department outside of Defense. But in this crucial moment, the nomination of Secretary-designate Sebelius is good for the prospects for both federal and state reform.