In total, nearly one in seven non-elderly adults in California (13 percent) have some kind of medical debt...
In addition, Californians with medical debt were much more likely than those without debt to delay getting the care they needed. Those with debt were twice as likely to report delays in care: 32.3 percent reported delays in getting needed care, compared with 16.1 percent of those without medical debt...
Also, medical debt can lead to loans and bankruptcy: Among those with medical debt, more than half (55.4 percent) reported financial consequences ranging from an inability to pay for basic necessities to credit card debt to a declaration of bankruptcy.
The study shows that Californians are appropriately concerned about the cost of getting needed care--even when they have coverage. We need action on health reform so we are not at such high risk of losing coverage, and to ensure that such coverage is comprehensive. When people pay a premium, they shouldn't then be saddled with debt for simply getting the care they need.
Here's two pieces of legislation to address the issues, both state and federal, and specific and comprehensive:
* AB786(Jones) would better label insurance products and ensure that all health insurance plans had a cap on out-of-pocket costs, so no plan left premium-paying patients with unlimited financial risk. The bill was approved by the Senate Appropriations Committee last week and is scheduled to be voted on by the full Senate next week.
* H.R. 3200, the comprehensive health reform package in the U.S. House of Representatives, would not only secure, stabilize, and expand health coverage for nearly all Americans, but it would also cap out-of-pocket costs. It would set minimum benefit standards and abolish "caps" on benefits that leave insured people with significant medical bills. The bill has passed the three committees of jurisdiction and is expected to get a vote on the House floor in September.
Today, the UCLA Center for Health Policy Research put out its biannual report compiling data from the California Health Interview Survey (CHIS), the most comprehensive look at health coverage and issues in our state. It's a seminal source of information for health policymakers and advocates, and we'll have a lot to say and post about its findings--especially about the new and disturbing information about medical debt--in the next few days and months. But we should take a moment to send not just our congratulations but our good wishes to E. Richard Brown, UCLA Professor in the School of Public Health, the Director of the Center for Health Policy Research, and the Principal Investigator for CHIS. Beyond being one of California's foremost academic experts on health policy, he's been a good resource, friend, and colleague of Health Access over many years.
On August 10th, Rick had the unfortunate opportunity to experience the health care system first hand when a brain aneurysm ruptured. The good news is that we have heard he has just recently been transferred out of the ICU to a regular hospital bed at UCLA.
We wish him the best for a safe and speedy recovery, and our thoughts are with him. He's an important and valued member in the health policy and advocacy communities, and we look forward to working with him soon!
It looks like Anthem Blue Cross of California is willing to be the bad guy again in the national debate. As Ben Smith in Politico writes and excerpts, they have sent a mass E-mail to their subscribers, making false charges and repeating scare tactics about health reform proposals.
With a 33 million customer list, insurance giant Wellpoint is now actively fueling the misinformation campaign against health insurance reform and America’s Affordable Health Choices Act. In a recent email to customers, California insurer Anthem Blue Cross, a Wellpoint subsidiary, attacked the bill on key fronts.
Myth: The House bill will cause “tens of millions of Americans to lose their private coverage and end up in a government-run plan…”
Fact: Actually, according to non-partisan Congressional Budget Office (CBO), private insurance coverage will expand by 16 million under reform. And under the House bill, no one can ever be forced onto the public health insurance option. The only way someone would be in the public plan is as a result of their own individual choice...
Myth: The House bill will limit “customers' choices of the products they can purchase and how they can purchase health coverage…"
Fact: The heart of the House bill is actually to create MORE choice and MORE options – and to help more Americans afford those options. If you have a private insurance plan now, the House bill:
* provides competition to help make your plan more affordable,
* ends the insurance company practices of discrimination based on age, pre-existing condition, or a newly discovered illness,
* ends copays for preventive care, caps what you pay out-of-pocket, but eliminates yearly or lifetime cost caps on what insurance companies pay, and
* requires a minimum set of benefits to help protect you from the fine print in a flimsy plan.
If you need to purchase health insurance, the bill creates an Insurance Exchange, providing one-stop shopping where you can compare and find the best and most affordable plan for you. All those using the Insurance Exchange will have a range of choices – various private plans, and the public plan.
Myth: The House bill will increase the “premiums of those with private coverage by imposing new mandates and coverage requirements.”
Fact: The House bill promotes competition—designed to make your private insurance premiums more affordable—and offers affordability credits to those who need them. The bill’s minimum benefit requirements (the so-called “coverage requirements” under attack) are modest (less than the average benefit offered today), will NOT lead to increased premiums, and are designed to protect Americans from insurance company whims and fine print.
Furthermore, the bill contains numerous provisions to lower your costs, with caps on what you pay but not what insurers cover, no copays for your preventive care, and ending discrimination against you for getting sick or having a pre-existing condition...
For more health insurance reform myth busting, please click here.
Changing the channel and the health reform debate..
Saturday, August 29, 2009
Are the tea party protest fading? Health Access staffers and allies have been to many Congressional town halls in the last few weeks. Despite the media narrative, my sense is that after the first week of August, health reform supporters have matched and often outnumbered opponents. In some areas, like the town halls of Rep. Diane Watson or of Rep. Judy Chu, they don't show up with any visible presence at all. The "tea party"activists have called protests against Representative Henry Waxman, Senator Dianne Feinstein, and others, yet the number of health reform supporters have outnumbered the opponents by 5 to 1.
Has the opposition already peaked? While focused more on environmental issues, the Sacramento "tea party" rally had a significant turnout on Friday, but fell it well short of the 10,000 people advertised, and also was significantly less than the turnout earlier at a previous protest in April. Maybe the reason was that this time, it didn't feature a Fox News star, Neil Cavuto, as a headliner.
Fox News certainly has played a role in organizing the opposition. But even the mainstream media has promoted bad behavior, focusing on the tactics of disruption rather than the substance of the debate.
The town halls have been more like Fox's reality show programming than their baseball coverage, by focusing and encouraging outrageous behavior. The town hall coverage has been like if Fox focused on the fights in the stands rather than the game on the field. Fox does show most of the people in the stands, the cheers and jeers, and the signs supporting or opposing a certain team. But if someone runs onto the field, the camera turns away, not to encourage people from doing the same and ruining the event for everyone.
Beyond Joe Buck and Joe Millionaire, the Fox network provides another model for a way out of August into the fall season—American Idol. It starts with large casting calls--frankly bigger than any of the protests opposing reform. It goes on to give 15 minutes of fame to the most outrageous, most outlandish of performers. (This could include protest from the British representative--perhaps Simon Cowell could have tweeted #WeLoveTheNHS). But as we go into the fall, quality of voice matters. Popular support matters.
As health reformers, we need talk to our friends and neighbors. The novelty acts fall away as we concentrate on some key voices, even if we’ve heard the words before. And hopefully like health reform, a winner passes through the final gauntlet—maybe not everyone’s top choice, but one that is deserving.
This report, prepared as the last week for fiscal committees to take action is winding down, is by Health Access advocate Beth Capell:
Today, the Senate Appropriations Committee took action on numerous important health measures; some of the news is good, some of it is bad.
In a very difficult state budget year in the midst of the worst economic downturn since the 1930s, it is not surprising that Appropriations members would be cautious about letting out measures that increase cost. Still the bad news is never pleasant.
Good news: bills that passed....
AB786 (Jones-D), the Health Access-sponsored bill to provide consumer protections in the individual market.
AB2 (DeLaTorre-D) on independent review of rescinded policies.
AB98 (DeLaTorre-) on maternity coverage for products regulated by the Department of Insurance.
AB108 (Hayashi-D) limiting the period in which rescissions may take place to 24 months.
AB1142 (Price-D) on minimizing balance billing of Medi-Cal patients by requiring hospitals to notify doctors if patients have Medi-Cal coverage.
AB1269 (Brownley-D) on working disabled adults being covered by Medi-Cal, although implementation was delayed until 2011.
Bad news: bills that were held....
AB1521 (Jones-D) on health insurance agents, Health Access sponsored.
AB730 (DeLaTorre-D) fines for rescission of policies.
For Healthy Families: Some possible good news, some troublesome choices....
This morning, MRMIB acted by emergency regulations to increase co-pays for children on Healthy Families, for everything from doctor's visits to prescription drugs to emergency room visits.
Based on the savings from the increased co-pays and the funding from the First Five commission that will help to cover children ages 0-5, MRMIB voted to delay disenrollment from October 1 to November 1, with notices going out to families deferred from September 1 to October 1.
Sadly, the waiting list has now grown to 70,780 children as enrollment remains closed.
Within the hour of MRMIB's action, the Senate Appropriations Committee voted on AB1422 by Assembly Speaker Karen Bass (D). This measure reconfigures an assessment on Medi-Cal HMOs from a provider fee to a smaller gross premium tax that will be used to draw down federal funds to restore Medi-Cal rate cuts to Medi-Cal HMOs and to provide funding for the Healthy Families program. This is an urgency measure that requires a two-thirds vote.
AB1422 will also increase premiums for the low-income children who depend on the Healthy Families program. The combined actions of MRMIB and the provisions of AB1422 will increase costs for low-income families through both premiums and copays.
The effort to enact AB1422 has been led by the HMOs that serve Healthy Families enrollees. It is also supported by Health Access, the 100% Campaign, California Primary Care Association and others.
AB1422 has had cautious bi-partisan support in the three committees that have now heard the measure: Senate Revenue and Taxation as well as Senate Health yesterday and Senate Appropriations today.
In agreeing to vote for the measure today, Senate Appropriations Vice-Chair Dave Cox (R) said he was willing to vote for the measure because of the increased premiums, increased cost sharing and the commitment by the First Five Commission to help fund to Healthy Families coverage for children ages 0-5.
Cox also noted that given the threat of H1N1 virus at the start of the school year, he was not willing to take the risk to the health of the community by having 600,000 children losing health coverage. But again, he said that his vote was only good for this committee and he had further concerns that needed to be resolved.
Five Senate Republicans have now supported AB1422: Roy Ashburn, Cox, Jeff Denham, Abel Maldonaldo and Mark Wyland. The only "No" vote so far has been Senator Mimi Walters, R-Tustin.
Seeing a slightly brighter financial picture on the horizon, the Managed Risk Medical Insurance Board on Thursday postponed for one month the process of kicking kids out of the Healthy Families program.
Disenrollment will begin with notices mailed to families on October 1, instead of September 1 as originally planned.
Board members and staff voiced hope that, somehow, more funds will surface to save them from having to follow through with the disenrollment plan, adopted by voice vote earlier this month.
Perhaps coincidentally, the 30-day reprieve came as the nation marked the death of Senator Edward Kennedy, an original author of the nationwide children’s health insurance program, or SCHIP, which in California is known as Healthy Families.
President Obama’s ARRA economic stimulus initiative called for an expansion of SCHIP, pledging beefed-up funding of $2 in federal matching funds for every $1 that states invest in the program.
While at least a dozen states have managed to use the added federal funds to grow their SCHIP programs to cover more children than ever, California’s stubborn budgetary problems due to the lingering recession has led to cutbacks -- and less services for fewer children.
The final version of the state budget crafted by the Legislature and Governor Arnold Schwarzenegger targeted Healthy Families with $194 million in cuts.
That amounted to a substantial financial blow to the program for low-income, working, taxpaying families in California – those whose income is too high to qualify for Medi-Cal and too low to afford health insurance for their kids on the open market.
Still, the blow was softened greatly by an $81.4 million commitment from the voter-approved First Five Commission, which pitched in funds to cover about 200,000 children ages 0 to 5 for one year.
Childrens’ advocacy groups and coalitions such as Children Now, The 100% Campaign and the Children’s Health Initiative have been persistent in urging MRMIB to tread cautiously while implementing program cutbacks due to insufficient funds.
One advocate stood up from her seat in the MRMIB auditorium Thursday upon hearing the board discuss delaying disenrollment. Called on by a puzzled Chair Cliff Allensby, the advocate blurted out: “Thanks. I just wanted to say ‘thanks.’’’
Meanwhile, the number of children whose names have been added to a waiting list for access to Healthy Families coverage has grown to 70,788, following a consistent trend of an 11 percent increase since the last count was released on August 20.
Most of the children seeking access to Healthy Families live in Southern California, the board’s staff reported, where population density necessitates greater services than elsewhere in the state. More than half of the children signed up on the waiting list reside in five Southern California counties.
A portion of the brighter financial picture for Healthy Families comes from higher fees to be paid by the families served. Generally, co-pays that were $5 for services will rise to $10 -- or up to $15, in the case of paying for prescription name-brand drugs when a generic version is available.
Visits to the emergency room will result in a co-pay hike from $5 to $15 whenever hospitalization is not required.
Premiums for those families with incomes that are 150% to 200% of the federal poverty level will increase from a family maximum of $36 to $48.
Premiums for families earning from 200% to 250% of the federal poverty level will rise from a family maximum of $51 to $72.
The changes seem bound to remain in place even if more funding is found, something that staff told board members is almost certain to materialize through an anticipated "complicated array of solutions.”
With the passing of Senator Ted Kennedy, much will be made of his famous family, and his longstanding efforts to pass comprehensive health reform and universal coverage, including taking a major leadership role this year, despite his brain cancer.
He did sponsor various efforts at health reform in previous years and era. In our national rememberance, it should not go unnoticed the bills he did help pass into law, that make a difference in people's lives today: Sen. Kennedy led efforts to pass COBRA and HIPAA so those leaving job-based coverage could keep it, the Ryan White AIDS Care Act, the Mental Health Parity Act, and the State Child Health Insurance Program (SCHIP) to cover low-income kids.
There's a historic picture in my colleague Beth Abbott's office of President Johnson signing Medicare over 40 years ago, with an elderly President Truman, who had championed universal health care a generation earlier, looking on. It is sad that Senator Kennedy won't join President Clinton when President Obama signs health reform this year.
Health reform can and should pass on its own merits, not to eulogize anyone. But Senator Kennedy's career is a testament that such reforms can have direct, powerful, meaningful improvements in people's lives.
Just a quick update: Senate Appropriations met on Monday. They heard and considered some key health bills, which then were placed on suspense.
The bill including AB786(Jones), to limit out-of-pocket costs and better label products in the individual insurance market; AB1521(Jones) to limit unfair reimbursement practices for brokers; and SB1142(Price), which prevent Medi-Cal patients from getting unfair bills.
The committee will decide soon whether they are held for the year, or they proceed to the Senate floor.
TWO burning questions are at the center of America’s health care debate. First, should employers be required to pay for their employees’ health insurance? And second, should there be a “public option” that competes with private insurance?
Answers might be found in San Francisco, where ambitious health care legislation went into effect early last year...
The early results are in. Today, almost all residents in the city have affordable access to a comprehensive health care delivery system through the Healthy San Francisco program...
Although not formally insurance, the program is tantamount to a public option of comprehensive health insurance, with the caveat that services are covered only in the city of San Francisco. Enrollees with incomes under 300 percent of the federal poverty level have heavily subsidized access, and those with higher incomes may buy into the public program at rates substantially lower than what they would pay for an individual policy in the private-insurance market.
To pay for this, San Francisco put into effect an employer-health-spending requirement, akin to the “pay or play” employer insurance mandates being considered in Congress. Businesses with 100 or more employees must spend $1.85 an hour toward health care for each employee. Businesses with 20 to 99 employees pay $1.23 an hour, and businesses with 19 or fewer employees are exempt. These are much higher spending levels than mandated in Massachusetts, and more stringent than any of the plans currently under consideration in Congress. Businesses can meet the requirement by paying for private insurance, by paying into medical-reimbursement accounts or by paying into the city’s Healthy San Francisco public option.
There has been great demand for this plan. Thus far, around 45,000 adults have enrolled, compared to an estimated 60,000 who were previously uninsured. Among covered businesses, roughly 20 percent have chosen to use the city’s public option for at least some of their employees. But interestingly, in a recent survey of the city’s businesses, very few (less than 5 percent) of the employers who chose the public option are thinking about dropping existing (private market) insurance coverage. The public option has been used largely to cover previously uninsured workers and to supplement private-coverage options.
Through our experience working on health-care-reform efforts in California and Washington (one of us worked for President George W. Bush’s Council of Economic Advisers), we have seen how concern over employer costs can be a sticking point in the health care debate, even in the absence of persuasive evidence that increased costs would seriously harm businesses. San Francisco’s example should put some of those fears to rest. Many businesses there had to raise their health spending substantially to meet the new requirements, but so far the plan has not hurt jobs.
As of December 2008, there was no indication that San Francisco’s employment grew more slowly after the enactment of the employer-spending requirement than did employment in surrounding areas in San Mateo and Alameda counties. If anything, employment trends were slightly better in San Francisco. This is true whether you consider overall employment or employment in sectors most affected by the employer mandate, like retail businesses and restaurants...
The San Francisco experiment has demonstrated that requiring a shared-responsibility model — in which employers pay to help achieve universal coverage — has not led to the kind of job losses many fear. The public option has also passed the market test, while not crowding out private options. The positive changes in San Francisco provide a glimpse of what the future might look like if Washington passes substantial health reform this year.
We need to ensure that the California delegation takes these lessons from San Francisco back into the debate in DC.
There are 47 million Americans without health insurance, and we all pay for their health care through our taxes and in increased insurance premiums. How do we cover them at a cost that doesn't break the U.S. treasury?
There are at least 12 million Americans who have "pre-existing conditions," allowing insurance companies to deny coverage or put them in a costly high-risk pool with high deductibles and limited coverage. This must be fixed because this is one of the most unfair parts of the current system. The concept of pre-existing conditions was developed by insurance companies to pad their profits by limiting their payouts. Insurance is based on spreading risk among a broad pool of people. But if the insurance companies only have to cover healthy people, why have insurance at all? People with health problems must be covered at a fair cost.
Millions of Americans are stuck in their jobs because they fear losing their health insurance if they go to another job. We must find a way to allow workers to move from job to job without worrying about whether they'll have health coverage.
We must make an investment in preventative care to limit the overall cost of health care. That will improve the quality of life of individuals and be a wise financial decision in the long run by treating illness before they require costly hospital care. There must be incentives for Americans to lead healthy lives, including maintaining a healthy weight and stopping smoking.
We must rein in the escalating costs of health care in a way that does not compromise care. That can be done in many ways through efficiencies such as improving the wasteful and duplicative billing and insurance claims system.
It's time to step back and look at ways to improve the nation's health care system for everyone. But right now the debate is being seen through a political lens, and that is a losing proposition.
Access to quality health care at an affordable price should not be a political issue.
The Central Valley will have a key role to play before health reform is done.
We often hear predictions about the dire consequences if health reform passes. When Healthy San Francisco was passed a few years ago, opponents from a portion of the business community--largely fast food and chain restaurants that don't provide coverage to their workers-- foretold of awful job losses as a result.
San Francisco's first-of-its-kind universal health care program and its mandate that employers provide health care has not resulted in feared job losses, according to a new study by a UC Berkeley researcher.
Crunching quarterly data from the U.S. Labor Department, the researcher found that since the inception of Healthy San Francisco's employer mandate in 2008, the city's growth rate across all employment sectors was similar to or better than other Bay Area counties. While San Francisco saw its employment rate shrink due to the struggling economy, it actually shrank less than other counties.
This held true in retail, food service, restaurants and hotels, the sectors most strongly impacted by the health care ordinance because they traditionally have a lot of low-income workers and aren't as likely to offer health insurance as higher-paying industries.
"The San Francisco experiment is working, and it's working well," said Ken Jacobs, chair of the university's Center for Labor Research and Education. "There's no evidence of any impact of the ordinance on employment in San Francisco."
The statistics were unveiled Thursday as part of a push by big-name labor leaders and Mayor Gavin Newsom to hype Healthy San Francisco as a public option that's working - and that could be a model for the rest of the country as it remains mired in a heated debate over health care reform.
"The sky has not fallen - the world as we know it did not come to an end," said Newsom, adding the controversial policy didn't prompt businesses to leave, bureaucracies to sprout up or the city's economy to crater.
For those who predict gloom-and-doom with health reform, the real question should be what does the world look if there is no reform. The status quo isn't an option--the situation on health care will get worse.
Not much has changed, that is, except for these two things: Group health insurance premiums have gone up another 11 percent, more than double the rate of inflation, and about 1 million more Californians have lost their insurance because they were either laid off or their employers dropped coverage.
Those two developments alone ought to be enough to cause any mortal to demand that Congress not blow this latest opportunity to fix a badly broken system.
They show that the existing system is not really a system at all, doesn’t work and is getting worse.
In 1999, as data collected by the Kaiser Family Foundation show, the average group health insurance premium for a family of four, was $5,791. By 2008, the cost had more than doubled to $12,680. In four of those nine years, there were double-digit annual percentage increases. In none of those years was the increase less than 5.5 percent.
Employers have been squeezed, hospitals have bled red ink, doctors have been pinched and ordinary folks have seen their healthcare costs soar. The employee share of costs for employer-based policies shot up 117 percent from 1999 to 2008, from $1,543 to $3,354, and that added cost was compounded by higher deductibles and copays.
Through it all, health-insurance companies have largely remained profitable.
But this annual process of raising premiums by twice or three times the rate of inflation cannot go on forever, or even much longer.
Look at that figure of the average cost of a group health plan for a family of four —$12,680 — and ask yourself this: At what price will your employer be forced to throw in the towel? Will it be when a family policy costs $15,000? $20,000? $25,000?
With prices that high, how can anyone feel secure that he or she will have health insurance next year or the year after that?
Having closely followed the health-reform efforts in California two years ago, I know that it is complicated stuff. There are a lot of moving, interrelated parts: providers, private insurers, consumers, employers, labor unions — and not even all the players in the same categories have the same interests.
But while health reform is complicated, it’s not rocket science.
A system built on shared risk cannot work unless everyone, or nearly everyone, is sharing the risks — and it doesn’t work now because about one in five Americans does not have insurance. That’s why the failed California bill, the bill now in the House and the bill now in the Senate have as their principal focus the goal of getting everyone insured.
Each includes a mandate that everyone have insurance, a requirement that all employers either provide a policy to workers or pay a fee, a framework of subsidies to make sure everyone who is forced to buy insurance can afford it, and a requirement that insurance companies respond to a universal-coverage mandate by making their products universally available.
And there is one other common element: an attempt to force price discipline on an insurance industry that will be handed millions of new customers as a result of the mandates...
If the momentum for reform is squandered this time, all America will look back two years from now and see the same price for failure that Californians have seen: 6,380 people losing their health coverage every week and the cost of a family policy marching relentlessly upward toward a day when the private insurance system will collapse under the weight of its own expense.
Without health reform, we didn't just get stuck with the broken status quo. It got worse, just like everyone predicted.
So which predictions should we listen to this time: the unfounded, unsupported warning of those opposed to reform, or the real consequences if we do nothing?
Tough times = 63,000 kids wishing, waiting for health care
Thursday, August 20, 2009
Continuing its trajectory of growth, the waiting list for Healthy Families has reached 62,955 California children whose families are seeking affordable health care coverage for their kids.
The list has grown by about 3,000 children per work day since the state’s Managed Risk Medical Insurance Board started taking names instead of enrollees July 17 because of state budget cuts.
The new tally was announced Thursday at a MRMIB meeting, one of a series held to consider cost-cutting options for its insurance programs of last resort for low-income, working Californians unable to afford health care coverage on the open market.
The meeting took a somber tone as MRMIB, its staff and children’s advocates continued with their task of doing the least harm to their programs while following the mandate of Governor Schwarzenegger to “live within our means,” through severe state budget cuts.
For every dollar in state general funds denied to Healthy Families, at least $2 in federal matching funds is lost. Schwarzenegger and the Legislature slashed $194 million from the children’s health care program in the last round of budget cuts.
No one in the MRMIB auditorium on Thursday seemed eager to embrace the brutal consequences of drastic program cutbacks looming on the horizon.
Nonetheless, the staff of MRMIB made several recommendations, mainly embracing the least onerous cutbacks or cost-sharing proposals that require families to pay more out-of-pocket -- or lose coverage for certain health care services. The board was reminded that, although they must ultimately vote to recommend changes, they “are not the deciders.” Only after statutes are approved by the Legislature would any changes get enacted. Among the recommendations the board must ultimately make are:
Come October 1st, continuing with plans to disenroll children from Healthy Families, barring a miracle of additional funds being pledged. Already, the First Five Commission has offered up $81.4 million to cover an estimated 200,000 children up to age 5 for a year. On Thursday, it was clear that many people still held out hope that an angel funder will yet surface – whether from the public or private sector.
Placing tens of thousands of children – and likely more – on the bulging waiting list during the fiscal year that ends July 1, 2010.
Imposing higher co-pays and premium payments on families lucky enough to have their children still covered, for now, by Healthy Families program. Board staff on Thursday recommended that, for emergency room visits, co-pays rise from $5 to $15, a proposed hike that is less severe than those earlier considered. Co-pays for non-preventative health, dental and vision would increase from $5 to $10, and co-pays for brand name prescription drugs would increase from $10 to $15, with generic drugs increasing from $5 to $10. Staff recommended against increasing subscriber premiums, saying the hike was “a bit too much in this economic environment.”
Eliminating whole categories, or levels, of health care services for current enrollees. Staff recommended rejecting proposals to eliminate vision, mental health and substance abuse treatment. Dental services would be cut back to a level consistent with what state employees get.
Freezing new enrollment in the Access for Mothers and Infants, or AIM, program for pregnant women receiving prenatal care. It turns out that, because fewer women have enrolled in the program, the date to freeze pregnant women out has been delayed from January 1, 2010 to March 1, 2010. And, babies born to women in the program would be guaranteed coverage in Healthy Families for their first year of life.
Pulling funding from Rural Health Demonstration Projects underway in a number of counties. So far, seven dental care programs and two health care programs have been cut.
Several children’s groups urged the board and its staff to approach program cutbacks so that those who most need the health care services get top priority. A letter from the California Children’s Health Initiatives asked the board “find solutions that do the least harm to vulnerable children and those needing care.” Krystal Moreno Lee of Children Now told the board, “The clock is ticking. We hope you look at and exhaust every avenue available to avoid disenrolling children from the program.”
CA LEGISLATURE RECOVENES; HEALTH BILLS PENDING IN LAST MONTH * Key Bills Pending Include Insurer Oversight: Capping Out-Of-Pocket Costs, Rescissions * One Month to Get Bills Passed Last Committee, Floor Votes, and Onto Governor's Desk * Initiatives Include Continued Post-Budget Efforts to Restore Some Cuts
* More Updates on blog.health-access.org: Tough Choices at MRMIB; Mad Men: Donald Draper on Prevention and Health Reform; Coverage in the Counties; Health Reform Made Easy; The Public Option Is In Our Court; President Obama, Editorialist; The Budget Battles Aren't Over; Good and Bad News on Healthy Families; Will Health Reform Get the Colbert Bump?; The Launch of HospitalBillHelp.Org; The Plight of the Underinsured; The Lawsuits Against the Line-Item Vetoes; Is Bigger Better? Health Reform: What's In It For You?; We're 4th (Worst) in Coverage in California; etc...
* Follow Health Access California on Facebook at www.facebook.com/healthaccess and on Twitter, at @healthaccess, or www.twitter.com/healthaccess for quick updates on budget, bills, and federal health reform. Our Twitter followers were the first to find out about MRMIB's actions on Healthy Families last week, and we will cover the board meeting again this week!
This week, the California state Legislature returned from a recess to begin a final month of deliberations on a range of bills and policy issues. In addition, both Senate President Pro Tem Darrell Steinberg and Assembly Speaker Karen Bass have indicated that a top priority will be to attempt to restore some of the health and human services cuts made by Governor Schwarzenegger under a disputed line-item veto authority.
In terms of legislation that is largely not related to the budget, key health bills focus on additional insurer regualtions and oversight, including the better labeling of health plans and capping of out-of-pocket costs; preventing gender discrimination in the pricing of health insurance; limiting the insurer practice of rescissions; mandating certain key benefits like maternity and mental health; and prohibiting certain types of compensation to brokers.
AB 786 (Jones): INSURANCE MARKET STANDARDS: Would sort health insurance policies into a number of categories, based on benefit comprehensiveness and cost-sharing. Organization of plans into these categories and standard terminology would enable consumers to better track premium, benefits and cost-sharing, and assist consumers in making comparisons across plans. Health Access California is the sponsor.
AB 1521 (Jones): BROKER COMPENSATION: Would place limits on how health insurance brokers are compensated by insurers. Health Access California is the sponsor.
AB 119 (Jones): GENDER RATING: Would prohibit insurers from charging different premium rates based on gender.
AB 2 (De La Torre): INDEPENDENT REVIEW: Would create an independent review process when an insurer wishes to rescind a consumer’s health policy, create new standards and requirements for medical underwriting, and requires state review before plan approval. Also raises the standard in existing law so that coverage can only be rescinded if a consumer willfully misrepresents his health history.
AB 730 (De La Torre): POSTCLAIMS UNDERWRITING: Would impose fines on insurers unlawfully engaging in post-claims medical underwriting.
AB 108 (Hayashi): TIME LIMIT: Would impose a 24-month time limit in which insurers have to rescind, cancel, or limit individual health care policies or charge higher premiums because of fraud once a consumer’s application is approved.
Insurance Benefit Mandates
AB 98 (De La Torre): MATERNITY COVERAGE: Would require most health plans to cover maternity services.
AB 244 (Beall): MENTAL HEALTH PARITY: Would require most health plans to provide coverage for all diagnosable mental illnesses.
Medi-Cal Eligibility & Retention
AB 1142 (Price): PROOF OF ELIGIBILITY: Would require hospitals, as soon as they have proof of a person’s Medi-Cal eligibility, to provide all information regarding that person's Medi-Cal eligibility to all other providers.
AB 1269 (Brownley): DISABLED WORKERS: Would allow, to the extent that federal financial participation is available, workers with disabilities who are otherwise eligible for Medi-Cal but are temporarily unemployed to elect to remain on Medi-Cal for a period up to 26 weeks.
Doctor and Hospital Oversight
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.
SB 196 (Corbett): HOSPITAL CLOSURES: Requires public notice of hospital closure or reduction/elimination of emergency medical services.
Hospital Financing & Waiver
AB 1383 (Jones): HOSPITAL COVERAGE DIVIDEND FEE: Would, per federal approval, impose a coverage dividend fee on hospitals for the purpose of drawing down federal funds for increased reimbursement and children’s coverage expansion.
This small board (pictured in this somewhat outdated photo), which directs a relatively small staff, has the privilege (or burden) of running three health care programs--all of which are closing their doors to new enrollment.
The cuts have been made by the Governor and the Legislature. For AIM for pregnant mothers, MRMIP for those denied by private insurers for "pre-existing conditions," or Healthy Families for low-income children, the question is now *how* these are made. It involves some ugly choices. In order to save some money to keep some more kids covered, do they cut benefits for all remaining children? Do they terminate coverage for some kids immediately, or wait--with the risk they will have to kick off more kids as a result?
For the biggest of the programs, Healthy Families, they should hold off and see if the last month of the legislative session yields some assistance that might prevent some more children from being kicked off coverage. The calvary needs to come.
We'll twitter from the MRMIB meeting any news at @healthaccess, or www.twitter.com/healthaccess and also blog here later in the day to keep you up-to-date.
Plenty has changed since 2006, the latest year that the uninsured of California was counted by the U.S. Census. But even then, many months before the current recession hit, the percentage of people living without health insurance in our state was startling.
This week, the Sacramento Bee laid out the statistics, finding quite a disparity between those with health insurance and those without. Just in the five-county region The Bee covers, Yolo County posted an uninsured rate of 22 percent of people under 65, while the more prosperous Placer County -- with more employment-based coverage -- posted a 13.7 percent rate.
That's quite a disparity, and the article by Phillip Reese and Anna Tong is worth reading. But the Bee doesn't limit information to its circulation area, it also posts online a comprehensive rundown of each of California's 58 counties' uninsured rate, along with an interactive map of the state and rollover charts.
Here's a sampling of what the authors wrote:
"The uninsured present an immense fiscal and public health challenge: 18,000 Americans die each year because they aren't covered, according to the Institute of Medicine, a nonprofit research organization. This is because having insurance is closely tied to health outcomes: The uninsured won't see a doctor regularly, and if they seek care it is likely to be inadequate or too late.
Moreover, the uninsured are a cost for society: One economist recently estimated the tab at $56 billion per year, 75 percent of which is paid by governments. In cash-strapped California, that cost is critical: 6.6 million residents went uninsured in 2007, more than in any other state, according to the California Healthcare Foundation."
You can bet that, with massive layoffs and small businesses closing since that Census count, the number of those among us -- members of our communities -- who are going without health insurance is a great deal larger. Factor in the Governor and Legislature's cuts in health and insurance programs for lower-income Californians, their children and the elderly, and you get an unimaginable sum of fellow Californians without access to affordable, quality health care -- notably, preventative health care, with better outcomes.
This is what the conversation about health care reform boils down to, not pumped-up talking points and hyper-emotive protests based on misinformation. This is not a partisan issue. It is a people issue. And the bottom line is that the majority of Americans have already voted -- for substantive change for a better future for our country.
The big TV event this weekend was the season premiere of Mad Men, the AMC show that depicts the life of New York advertising executives and their families in the early 1960s.
It is smartly written and filmed to highlight the differences in everything from fashion to gender relations. Guest New York Times columnist Timothy Egan made a fascinating contribution about the changes in public health:
My parents and their friends were nicotine fiends, the women smoking even during late pregnancy. The high point of tobacco addiction was around 1964, when 42 percent of adults smoked. Today, the figure is less than 20 percent — a modern low.
I remember rattling around inside a station wagon filled with secondhand smoke. No seat belts, of course. And after the ride, we 6-year-olds reeked of Lucky Strikes.
Now, smokers are such pariahs that the actors on the set of “Mad Men” can’t even puff real cigarettes; they have to use herbal ones, or run afoul of the law.
If a driver of that station wagon had a drink or two before getting behind the wheel, so what? Drunken driving was a respected social skill. Last year, 11,773 Americans died in accidents involving drunken driving — tragically high, but down by more than 50 percent from a generation ago.
Roger Sterling, the silver-haired sybarite in the “Mad Men” ad agency, suffered a major heart attack, telegraphed from his first three-martini lunch. Today, coronary heart disease is still the leading cause of mortality in the United States, but the death rate from heart attacks is down 72 percent since 1960.
The brooding, unfathomable ad man at the center of the show, Don Draper, has high blood pressure. When his doctor asks how much he’s boozing, he admits, after some hesitation, to five drinks a day. He also has sexual problems, unable to match the passion of his stunning wife, a Grace Kelly look-alike who is a shrink session away from going full Betty Friedan.
...Is all of this progress, a march toward a more tolerant, equitable, less socially inauthentic society? Sure. Plus, Don Draper would have Lipitor for his heart and Viagra for his sexual troubles.
For a show in the 1960s, explicit politics and policy is only in the background on the show--in the premiere on Sunday, the only reference was to an ad executive bemoaning the 60%+ upper-income tax brackets of the day. And the serious health care issues that led to the passsage of Medicare and Medicaid in the late 60s are not shown.
But there's a lot here to inform our health reform debate. It's a useful reminder about the significant progress that there has been in not just sexual politics, but in the realm of prevention and public health:
* Tobacco control, which has included taxation, limiting its use in public spaces, medical research, educating young children, litigation, major public awareness efforts, and the overall changing of social mores.
* Drunk driving reductions through changes in law and increases in penalties and enforcement, as well as a major public education effort that includes changing its social acceptability.
* Seat belts took a combination of ensuring that they were provided as standard in cars, and then a variety of public education strategies to get people to use them.
These things, by themselves, have saved untold lives and increased are life expectancy. Like the cause of gender and racial equality, these didn't happen overnight or without struggle. Each of these efforts were long, concerted, multi-year, multi-pronged campaigns by many players. And it's not over yet: For example, while the three martini lunch may not be as prevalent, we may not have some to terms with the full health impact of alcohol, so there is more work to do for groups like the Marin Institute.
The current conversation on health insurance reform, as the President not calls it, is less about people's health, and more about the health of their finances, and the health of the economy. That's not a bad thing: it's essential to prevent people who go bankrupt for medical reasons, or to remove the economic insecurity that so many people feel when they need care, either for age or accident.
There are elements of the reform bills that focus on prevention, doing more research, focusing on public health efforts, and making sure that there are no financial barriers to screening and preventative care. Here's a prevention fact sheet on H.R.3200:
Beyond the policy specifics, my hope is that once we finally make a public policy commitment for quality, affordable health care for all, that such a changes creates a platform and investment to move toward a healthier environment and society.
So I can imagine another form of entertainment 50 years from now, where our current technology looks quaint, our fashion looks sophisticated, our music is nostalgic, and some of our current diet and lifestyle choices, as well as current policies and industry practices, look as unhealthy and silly as the smoking and drunk driving scenes in Mad Men today.
Reformers typically must wage battle on two front: one against the opponents who argue the facts, and those who do so with confusion, lies, and mistruths. Defenders of the status quo don't have an easier job: they don't necessarily have to make a cogent argument against reform, or for an alternative. They merely have to sow enough confusion, distrust and doubt to get people to fear the unknown.
Health reform can be legitimately complicated, and so it is particularly vulnerable to this kind of attack. But health reform doesn't have to be complicated. Like an iPod, it can be complicated on the inside, but reasonable easy to understand for the regular user.
I watched the Sunday shows this weekend, and yet most media outlets picked up on a story that I didn't, that the White House was seeming to back away from the "public health insurance option" as part of its health reform plan.
That was the headline in the New York Times, Washington Post, AP and other stories. But the text of all of these articles don't reference some internal document or leak by White House staff. It's all based on a tea-leaf reading of these Sunday shows, where the Obama Administration officials have said what they have said on these shows for weeks and months: that the public health insurance option is part of the President's proposal, something he argues for every time he talks about the bill, but he's not drawing any lines in the sand at this point.
An administration official said tonight that Health and Human Services Secretary Kathleen Sebelius "misspoke" when she told CNN this morning that a government run health insurance option "is not an essential part" of reform. This official asked not to be identified in exchange for providing clarity about the intentions of the President. The official said that the White House did not intend to change its messaging and that Sebelius simply meant to echo the president, who has acknowledged that the public option is a tough sell in the Senate and is, at the same time, a must-pass for House Democrats, and is not, in the president's view, the most important element of the reform package.
A second official, Linda Douglass, director of health reform communications for the administration, said that President Obama believed that a public option was the best way to reduce costs and promote competition among insurance companies, that he had not backed away from that belief, and that he still wanted to see a public option in the final bill.
"Nothing has changed," she said. "The President has always said that what is essential that health insurance reform lower costs, ensure that there are affordable options for all Americans and increase choice and competition in the health insurance market. He believes that the public option is the best way to achieve these goals."
The public health insurance option is not the only part of health reform, but it is important. With regulation of the insurance industry, it makes sure that individuals are not left all alone at the mercy of the big insurers. It provide competition and choice, especially if the insurers continue some of their abusive practices. The CBO has scored that it will save money for both consumers and taxpayers alike.
But I think the coverage was overblown because the issue isn't the White House; it is Congress. The President can't sign a bill that Congress doesn't place on his desk. So while the President has some influence, it's ultimately up to Congress. And that means it is up to us.
Virtually all the Democrats in California, even the "Blue Dogs," said they support a public health insurance option. Many California leaders in House of Representatives, from Speaker Nancy Pelosi to Congressional Black Caucus Chair Barbara Lee have stated that a public health insurance option is a top issue for them.
We as health advocates need to continue our advocacy for health reform in general, and for a public health insurance option, to support these champions, and to shore up waverers. President Obama is committed to sign health reform with a public option. We should encourage him to continue to speak up and fight for it.
But it's up to Congress, and that means it is up to us...
UPDATE: From the Swampland blog at Time magazine, here's a transcript of White House spokesman Robert Gibbs, indicating the White House hasn't changed its support of the public health insurance option, and the bills in play still contain a public health insurance option:
Q Just to be completely clear, has anything changed on the public option?
MR. GIBBS: No. I challenge you guys all to go back and see what we've said about this over the course of many, many, many, many months, and you'll find a boring consistency to our rhetoric.
Q The rhetoric, as you say, might be consistent, but the movement on the ground, so to speak, toward legislation hasn't been. Is there any recognition now that a public option is looking less likely to be part of a final deal?
MR. GIBBS: Let me make sure I understand your question, because I want to know if it's -- is this predicated on legislative developments since Congress has been out of session, or are we trying to match the stampede of a series of stories to if not the consistent language that we've all been saying to some now legislative vote?...
Q But you guys have -- you haven't exactly come out publicly since Sebelius' statement yesterday, come in front of the cameras to speak to us, to downplay --
MR. GIBBS: Because nothing has changed.
Q But you haven't downplayed the remarks and the coverage either.
MR. GIBBS: No, no, I think many people talked to you all yesterday. I think people sent e-mails. David Axelrod called people... Nothing has changed. I mean, we can go out and say nothing has changed, but that seems sort of silly since nothing has changed.
Look, in terms of the political realities, obviously there's a public plan -- or public option in the House bill. There is a public option in the HELP bill. I don't know what the Senate Finance Committee will come out with.
As if President Barack Obama didn't have enough to do, today he weighed in as a New York Times op-ed contributor, describing health reform. He makes the case not to the uninsured, but to the insured. It's interesting because it is a compelling case, but also how he makes the pitch. Here's some snippets:
I don’t have to explain to the nearly 46 million Americans who don’t have health insurance how important this is. But it’s just as important for Americans who do have health insurance. There are four main ways the reform we’re proposing will provide more stability and security to every American.
First, if you don’t have health insurance, you will have a choice of high-quality, affordable coverage for yourself and your family — coverage that will stay with you whether you move, change your job or lose your job.
Second, reform will finally bring skyrocketing health care costs under control, which will mean real savings for families, businesses and our government....
Third, by making Medicare more efficient, we’ll be able to ensure that more tax dollars go directly to caring for seniors instead of enriching insurance companies... And our reforms will also reduce the amount our seniors pay for their prescription drugs.
Lastly, reform will provide every American with some basic consumer protections that will finally hold insurance companies accountable. A 2007 national survey actually shows that insurance companies discriminated against more than 12 million Americans in the previous three years because they had a pre-existing illness or condition. The companies either refused to cover the person, refused to cover a specific illness or condition or charged a higher premium.
We will put an end to these practices. Our reform will prohibit insurance companies from denying coverage because of your medical history. Nor will they be allowed to drop your coverage if you get sick. They will not be able to water down your coverage when you need it most. They will no longer be able to place some arbitrary cap on the amount of coverage you can receive in a given year or in a lifetime. And we will place a limit on how much you can be charged for out-of-pocket expenses. No one in America should go broke because they get sick.
Most important, we will require insurance companies to cover routine checkups, preventive care and screening tests like mammograms and colonoscopies. There’s no reason that we shouldn’t be catching diseases like breast cancer and prostate cancer on the front end. It makes sense, it saves lives and it can also save money.
Can you talk about cuts without talking about them?
Saturday, August 15, 2009
The Bee editorial board this Saturday bemoans that "after months of haggling... the two most powerful men in California government are still not on the same page." Yet its condemnation is not for Governor Schwarzenegger, who unilaterally cut another half-billion dollars in vital services, beyond his agreement with legislative leaders.
Their misplaced scolding is for Senator President Pro Tem Steinberg, who is suing (as are several groups) over the Governor's authority to make such cuts.
What's remarkable about the editorial is that it makes no attempt to acknowledge the serious constitutional issues about unchecked gubernatorial power to cut outside the once-a-year budget, without legislative approval or oversight. Voters rejected "spending cap" proposals that included similar power grabs (although with differences in the details) in both 2005 and earlier this year. Yet the Governor is assuming this power anyway.
What's misleading about the editorial is that it treats the legislature as a monolith. It says the legislature rejected over $1 billion in budget solutions, without specifying it was, by many accounts, specifically the Assembly Republicans who balked. Instead, the Governor didn't punish them, but rewarded them with cuts to the safety-net that they had sought, with the fallout on the vulnerable Californians who rely on the services he cut.
And yes, what's most shameful about the editorial is that nowhere does it mention the actual substance of the cuts, mostly to health and human services. How can these cuts be discussed without even mentioning what they are, and their impacts--such as zeroing out state funding for community clinics and battered women's shelters, or additional, steep cuts to maternal and child health, AIDS and HIV treatment and prevention, and children's health insurance.
The legislature had already agreed to cuts that were beyond the pale, for example forcing California to actively kick children off of Healthy Families coverage--but the Governor's additional cuts threaten the viability of the program as a whole. The Budget Conference Committee spent several weeks to be deliberate in making cuts, and all that was undone by the Governor's veto pen. If anything, the legislature already had went too far, too deep, and we--and particular our children--will suffer the consequence.
These would be inconvenient facts to mention in the editorial's desire to be "safely beyond the budget debate." Whether those that directly are served by these programs, or for all Californians who rely on our health system, the rest of us are hardly beyond the debate, but are going to start feeling it first hand.
Those who are suing the Governor--which includes but is not limited to Senator Steinberg, since several health provider, social service, and other community groups are as well--are right to do so, both to preserve check-and-balances, and on the sheer human impact of the cuts. Too bad the Bee didn't want to even tell it readership what we were talking about.
The good news for the Healthy Families program on Thursday was an $81.4 million commitment from the First Five Commission to keep 200,000 children ages 0-5 enrolled in the program for the remainder of the fiscal year.
The bad news? Despite at first seeming to want to delay the decision, the Managed Risk Medical Insurance Board, or MRMIB, voted to begin kicking kids off the health care program this fall.
On advice of staff, MRMIB declared that insufficient funding forced the board to prepare to disenroll children from Healthy Families beginning October 1.
Families with kids getting health care through the program – those who don’t benefit from the First Five funding, that is -- will get 30-day disenrollment notices as their annual re-enrollment dates approach. Those children can then be added to the end of a long wait list to get re-enrolled if the program’s finances improve.
Since the list was established July 17, an average of more than 3,000 children per work day have been signed up for the waiting list. Currently the list stands at 55,202 children of working families that can’t afford health insurance, but whose household incomes are higher than the threshold for MediCal.
Health care under the program is not free. The taxpaying, working families pay co-payments for services and prescriptions, as well as premiums to get their kids in Healthy Families, known nationally as SCHIP, a program expanded by President Obama earlier this year.
As California watched its fortunes dwindle this year, the Legislature and Governor Schwarzenegger ordered severe cutbacks in health and human services. Meanwhile, at least a dozen other states have managed to take the $2 in federal matching funds for every state dollar spent and use the augmentation to grow and expand their SCHIP programs.
Counting the forgone federal matching funds, California’s health care economy, not to mention children’s care, is losing a total of $533.4 million – thanks to the cuts made by the governor and Legislature.
This has left Healthy Families with a $194 million funding deficiency, staff members told the board, as well as an inability to continue serving the bulk of the program’s 921,787 child clients.
Even with the First Five’s $81.4 million, the California Budget Project estimates that nearly 800,000 kids will lose access to affordable health care because of Healthy Family’s decline. The cutbacks could not come at a worse time for working Californians trying to weather the persistent recessionary storm clouds that linger over the state.
Children’s advocates applauded and praised the generosity of the First Five Commission, which at first was expected to allocate around $30 million to help keep Healthy Families alive for kids through age 5. As it is, the much larger gift will allow for coverage of 200,000 children only through June 2010.
Wendy Lazarus, director of the Children’s Partnership, urged MRMIB members to exercise caution in making decisions about the future of the program.
“I ask that you consider that the next 45 days are going to be critical,” Lazarus said. “You’re going to have to look at what is safe, and what is riskier for children. At this point, we think that fewer kids will be served by the program than you do.”
Pending are lawsuits filed by several parties that specifically challenge the legality of the governor's deep cuts, made through line-item vetoes after a budget deal was already negotiated with the Legislature. MRMIB announced it will meet again August 20th, and August 27th. Among the decisions to be taken up is how much more money to charge families whose kids remain in Healthy Families, and what medical services can be eliminated or pared back.
The options currently before them are less severe than those listed as possibilities during last month’s MRMIB meeting. They now include:
• Increasing family co-pay maximums from $250 to $300. • Increasing program co-pays for health services, drugs, dental services and vision care from $5 to $10 for non-preventative services. • Increasing co-pays for name-brand drugs (when a generic version is available) to $10 to $15. The standard co-pay for generics would remain at $10. • Increasing co-pays for emergency room visits from $5 to $25 unless hospitalization is required. • Increasing subscriber premiums to $20 per child, with a maximum of $60 per family whose income falls within 150-200 percent of the federal poverty level. • Increasing subscriber premiums to $30 per child, with a maximum of $90 per family whose income falls within 200-250 percent of the federal poverty level. • Eliminating vision benefits. • Eliminating mental health and substance abuse benefits. • Scaling back dental benefit coverage. • Eliminating benefits for biofeedback, acupuncture or chiropractic care.
The Colbert Report last night featured an interview with Jonathan Cohn of The New Republic (who edits the blog The Treatment where I contribute occasionally) making the case for health reform against the host, who in his wacky way was actually was more reasonable than the current opposition arguments.
Cohn makes the important case for reform, and refutes one of the worst myths out there, that somehow everybody already has access to healthcare. He points out that access to the emergency room isn't the same: in the best case scenario, we want people to have access to care so they don't need to go to the ER later.
But he points out not just the health but financial consequence of being uninsured: when you go to the emergency room, you get a bill. If anything he understates it, since that bill is likely to be 3-4 times what an insurer pays for exactly the same service.
This points out the reason for the Hospital Fair Pricing Act and the new www.HospitalBillHelp.Org website that we unveiled today, which informs people of their consumer rights and financial options.
But given that those options are often limited and inadequate, it also spells out the desperate need for health reform.
With California's large and growing uninsured & underinsured population, we at Health Access are really pleased to unveil a new website--http://www.HospitalBillHelp.org--to help California patients know their consumer rights and financial options to deal with the biggest bill they get in their entire life. Here's the release that announces the new resource:
New Consumer Protection Website Informs Consumers against Underinsurance and Overcharging By Hospitals and Health Providers
HospitalBillHelp.org provides help for growing number of uninsured and underinsured in CA; informs consumers about their rights and financial options, including under new, first-in-nation fair pricing law
On Wednesday August 12th leading consumer protection groups in California announced the launch of HospitalBillHelp.org, a new consumer information website that helps patients deal with hospital and other medical bills, including inflated charges, “junk” insurance, and aggressive collections practices. The new site is part of a collaborative effort called the California Health Initiative on Overcharging and Underinsurance (IOU), led by Health Access and including Consumers Union, Western Center on Law and Poverty, ACORN, CALPIRG, Congress of California Seniors, and other consumer and community groups.
Visitors to HospitalBillHelp.org will find many resources informing them about their consumer rights and financial options in dealing with hospital, including under California’s first-in-the-nation Hospital Fair Pricing Act, a 2006 law authored by Assemblywoman Wilma Chan and sponsored by Health Access California, which limits the common practice of charging uninsured and underinsured patients more for care than everybody else pays.
Typically, hospitals and doctors overcharge self-pay patients three to four times what insurance companies and government programs pay for exactly the same procedures. The Hospital Fair Pricing Act, effective since January 2007, limits the amount that most uninsured and underinsured patients have to pay to the amount that a public insurer would pay for the same care. In most cases, this will be the Medicare price, which is 65-85% less than the inflated price. The Hospital Fair Pricing Act also requires hospitals to adequately inform patients about their charity care and discount policies.
However, despite clear rules outlined in the Hospital Fair Pricing Act, many California hospitals are still failing to inform uninsured and underinsured patients about their right to a fair price.
"In our current health system, self-pay patients lack bargaining power, and are asked to pay more than anybody else for needed care. HospitalBillHelp.org is a new and unique one-stop shop for the nearly 10 million Californians who are either uninsured or underinsured. HospitalBillHelp.org lets Californians know what their consumer rights and financial options are, so that individual patients get what insurers already get: a fair price for hospital care, " said Anthony Wright, Executive Director of Health Access. "If you have a large hospital bill and need help paying it, or if you need hospital care and can't afford it, this website can help you."
Medical debt is a growing problem for low- and middle-income consumers, especially those who are self employed or between jobs. Some go without health coverage and others purchase “junk” or “catastrophic” insurance plans with extreme gaps in coverage. Both scenarios put consumers at tremendous risk of overwhelming medical debt or delay receiving treatment when needed.
The case of Laura Burwell of Chico, CA is demonstrative of the way in which deceptive “junk” insurance policies and the failure of hospitals to inform patients of their options can have traumatic consequences. Laura thought she was buying comprehensive coverage when she purchased health insurance with a $281 monthly premium, a $500 deductible and $50,000 in hospital coverage. She didn't realize that her hospital coverage was capped at $3,000 a day, until a rattlesnake bite landed her in the Intensive Care Unit and with a $73,000 hospital bill.
"There I was thinking I was covered for $50,000," Burwell said, “but my insurance only paid $3,000 and then I was responsible for the rest.”
Fortunately for Laura, she was protected by California ’s Hospital Fair Pricing Act, which prohibits hospitals from charging underinsured and uninsured patients more than Medicare would pay for the same care. In her case, that meant her final bill was reduced to $7,300, one-tenth the original bill. Laura hopes HospitalBillHelp.org will help other consumers faced with high hospital bills.
"The hospital never told me I was entitled to a discount. I had to do a lot of research on my own before I even found out about the Fair Pricing Act. This new website is going to make it a lot easier for Californians to get a fair price for hospital care,” she said.
The site also provides a wide variety of tools, features, resources and information to help consumers better understand their legal rights and financial options, including links to public health insurance options and applications, information on how to get discounted health care and even an Underinsurance Calculator to figure out whether you count as underinsured under any of the definitions commonly used.
“In May 2009, Consumer Reports published an article describing seven signs that a health insurance plan might be ‘junk’ insurance. Consumers can use HospitalBillHelp.org and use the site’s resources to discover loopholes in their own insurance plans, or as a helpful guide when purchasing new plans,” said Laurie Sobel, senior attorney with Consumers Union. “The site provides important information to help consumers make informed decisions when purchasing health insurance and steps to take to ensure that hospitals recognize their rights as stipulated under California ’s fair pricing law.”
When visiting HospitalBillHelp.org consumers can also research ways to get a discount on an existing bill, who to call for help and instructions on what to do when a hospital doesn’t follow the law. Furthermore, the site features a directory to help patients locate the closest and most affordable hospitals where they may be eligible for discounted care, regardless of their income.
"Western Center has long advocated for the needs of low-income uninsured people who are saddled with unaffordable hospital bills,” said Jen Flory, attorney with the Western Center on Law & Poverty. “We're pleased to have a website that breaks down into plain English the complex programs that are available to help and provide information to those who might qualify."
Other useful resources available on the site include information and steps on troubleshooting other common hospital and insurance billing problems, such as getting an independent medical review if an insurance company denies an individual coverage, and finding information on the prohibition against balance billing of HMO patients for out of network Emergency Room visits.
While the site serves as an important resource for consumers, including providing steps and information on how Californians can take advantage of our state's strong consumer protection laws, the major problems in our health care system require broad federal health reform, like that proposed in H.R.3200, and further steps to ensure that self-paying patients and consumers are sufficiently protected against overcharging by health providers, like AB1503(Lieu), and inadequate private health insurance policies, like AB786(Jones).
"Whether it is overcharging, underinsurance, or care that is just plain unaffordable, the need for health reform is urgent. This website helps inform consumers about their rights and options, but they are limited. If anything, our work on HospitalBillHelp.org only reaffirmed our urgency for comprehensive health reform, like that which President Obama has proposed." said Anthony Wright of Health Access California. "And California can continue to take the lead with specific reforms pending in the state legislature, by passing AB1503(Lieu) to prevent overcharging by emergency room doctors, and AB786(Jones) to prevent people being trapped in plans that leave them with unlimited financial risk."
Whether it's been the policy debates on the web, or the less-than-civil discourse at some of the town hall meetings held by Congressmen, Health Access has been following, and reporting, on the health reform debate on Twitter, at @healthaccess, or www.twitter.com/healthaccess.
Feel free to follow us!
Here's a few selected tweets and links from the last few days of activity. For the uninitiated, all tweets must be less than 140 characters, so abbreviations are a must. Some other codes: #healthreform is a "hashtag" that allows the "tweet" to be easily searchable. RT means "re-tweet," meaning we are repeating what another Twitter user (which all start with an @) is saying and passing it along, sometimes with a comment.
The disconnect between the political rhetoric of health reform, and the substance of health reform, is staggering.
Back in 2003, California had passed the first of several recent attempts at health reform: a requirement on employers to cover at least 80% of the coverage of their workers. (It would be signed by Governor Gray Davis, but narrowly overturned the next year by referendum, leading to a renewed sense that victory was possible.)
After following committee hearings and being immersed in the details of the bill, the legislation finally came to a vote on the Assembly and Senate floor. I was struck then about how those floor debates were so broad as to mischaracterize the bill, which Health Access supported. Republicans railed against “socialized medicine” and “Hillarycare.” Democrats argued that “health care is a right.” The bill, which neither provided socialized health care, nor health care as a right, seemed merely a vehicle to talk from existing worldviews and talking points. I guessed that made sense for legislators not on the relevant committees and not versed in the issue.
But in the various state-based health reform debates, I hadn’t seen that gulf as wide as it is now, with talk of “death panels” and “euthanasia” that have no basis in any bill. Maybe the national spotlight brings out the extremes, or the stakes are higher, but wow.
Some have made the case that perhaps another bill would have been harder to demonize. I take the opposite lesson: the opposition seems content just to make stuff up out of thin air. Thesubstance of the bill has no bearing on the vitriol and attacks against it. The only solace for the supporters is to have a bill where the substance makes it possible to be able to make declarative statements to counter the lies.
The major federal health reform bills, like H.R.3200, all require coverage to have a maximum out-of-pocket limit, up to $10,000. At the state level, Health Access California is sponsoring AB786(Jones), which would also require a cap, in addition to labelling insurance plans so people can better comparison shop.
Why is this necessary? Because there are some dubious plans being sold right now:
Burwell was weeding her backyard vineyard last summer when she was bit by a rattlesnake. She rushed to a Chico hospital for antivenin and morphine, which eased the pain during an overnight stay.
Then came the unexpected sting of a $73,000 hospital bill – and shock upon learning her health insurance would cover a mere $3,000.
"It was one of the longest, most stressful periods in my life," said Burwell, a self-employed wine shop owner whose financial security was shattered by the snake bite.
"I'm probably a typical insurance purchaser," said Burwell, who had to scramble to find a solution for the steep bill. "I believed what I was told by the person selling it to me...."
Burwell, 60, thought she was getting a deal four years ago when her COBRA coverage ran out and she found a low-cost, low-deductible plan. She bought a policy from a friend – an insurance broker who, she said, was looking out for her.
Burwell's policy was underwritten by a Texas-based firm that initially charged her a $281 monthly premium. She had a $500 deductible and was promised $50,000 in hospital coverage. She didn't realize the hospitalization coverage was capped at $3,000 a day.
The story is worth the read. In addition to AB786(Jones), it's good that the health reform bills in Congress answer the challenge of the article's title, "Don't forget us, underinsured say."
Senator Steinberg announced that using his campaign funds, he would personally sue Governor Schwarzenegger over the additional $500 million in blue-pencil line-items cuts.
Lots of groups impacted were interested in suing, but they were, by definition, the folks hard-pressed to find the resources to sue: community clinics, AIDS services providers, battered women's shelters, low-income families with uninsured children, etc.
It raises troubling questions about the power and purview of the governor and about whether he can take for himself some of the authority to impose midyear spending cuts that he has tried, and failed, to win at the ballot box. California needs to know the answers.
Remember that the Legislature passed, and the governor signed, a budget in February... Last month, lawmakers sent Schwarzenegger a package of appropriations and cuts, and no one disputes the governor's power to veto any of the appropriations. But he also vetoed some of the cuts, not to reject them but to deepen them -- to, in effect, use the opportunity presented by the Legislature's majority-vote cuts to reopen appropriations that the Legislature made, and that he signed, in February. But if an appropriation requires a two-thirds vote, and if a cut is adopted on a simple majority, how can it be deemed an appropriation?
California vests lawmaking power in the Legislature and properly limits the executive by allowing him to veto appropriations, line-by-line if he likes, but not to unilaterally alter those already on the books.
Human services providers want to restore some of the cuts that never got legislative approval, and it's hard to blame them. But there's an even more important reason to subject the vetoes to scrutiny: They amount to a power shift -- one that may well be outside the lines of the state Constitution and beyond the principle of separation of powers.
While the Governor’s vetoes provide a stark reminder of the scope and magnitude of the reductions in the recent budget agreement, they represent a tiny fraction – just 3.0 percent – of the total cuts in the July package. The $50 million “blue penciled” from the Healthy Families Program, for example, is less than the $124 million cut approved by the Legislature. Debate over the legality of the Governor’s vetoes shouldn’t divert attention from the underlying fact that absent additional revenues, future budgets will continue to erode the quality of public services that Californians and the future of the state’s economy depend on.
As the Sacramento Bee's Kevin Yamamura, quoting Assemblyman John A. Perez, it's up to those impacted to file suit against the cuts. But the cruel irony is that the legal and financial burden to file suit is on the very underfunded, struggling families and service providers--community clinics, battered women's shelters, low-income families with uninsured children, maternal and child health providers--they are so negatively impacted by the Governor's draconian cuts.
The Governor should not add insult to injury with regard to these immoral and illegal cuts. The Governor should not wait for a lawsuit... With this decision, he should agree to withdraw the cuts unilaterally, just as he made them.
Jon Stewart seems concerned that the bill is 1,000+ pages long.
But first of all, bills in Congress use bigger font and have super-big margins, more than most of the children's book I read my 2-year old.
But more specifically, health care is complicated! Or more relevantly, the current status quo is complicated. The bill has to recognize that people currently get health coverage in lots of different ways: from employers, many different government programs, and buying it on their own. You want to provide safeguards to prevent unintended consequences.
Even the single-payer bill in California, SB810(Leno), which is promoted in part for the simplicity of the concept, is many pages, and would probably need more to fully spell out the transition from the current complicated, confusing, fragmented system. Even if the solution is simple, the path to the solution is not.
H.R. 3200 work to make people secure in the coverage they have--however they have it, throught employers, government programs, or the individual or small group markets--while also providing new choices and guarantees.
An iPod is complicated inside, even though the user's experience is simply. No one should be concerned about the length of the bill, but how the patient experiences his or her health care afterwards. And H.R. 3200 would improve that experience by securing and expanding coverage, and working to bring down the costs and financial risk to families.
• People who have no health insurance or have health insurance that leaves them vulnerable to high medical bills. This group of 71 million Americans would have affordable, reliable health insurance through health plans that meet standard benefit requirements and offer income-related premium assistance.
• People with insurance who have to change coverage frequently, and often not by choice, or one-third of insured Americans. This group would have the option to have stable insurance through the new national insurance exchange so that every time there is a transition—new job, divorce, graduation—there isn’t a potentially dangerous gap in health insurance coverage.
• People at risk of falling into medical debt. These people would be protected by a standard benefit floor and would no longer have to live with insurance that doesn’t cover the care they need.
• People who work for small businesses—a total of 49 million Americans. These employees would have access to more affordable premiums and better benefits because risk would be pooled across employers of all sizes.
• People buying their health insurance on the private market. This group of 14 million Americans would have better, more affordable health insurance available to them because all Americans would be required to have coverage, eliminating underwriting and achieving a 26 percent drop in administrative costs.
Ron Pollack of Families USA says that beyond the uninsured getting coverage, the benefits for the middle-class includes:
Meaningful health care reform means more than covering the uninsured: It means making existing coverage more stable, more affordable, more secure, and less at the whim of an inadequately regulated insurance industry. For the insured middle class, health reform will:
* offer stability of health coverage, ensuring that good, affordable coverage remains available when people change or lose jobs or start their own businesses;
* keep health coverage and care affordable, both by decelerating health care costs and by providing sliding-scale subsidies;
* ensure accountability from insurance companies, preventing them from denying coverage or charging discriminatory and unaffordable premiums to people who get sick;
* increase health coverage options for people who want more choices of health plans;
* provide prescription drug help for seniors who need multiple medicines by closing the infamous "doughnut hole" that makes needed medicines unaffordable; reduce the "hidden health tax" - the surcharge that is added to insurance premiums to pay for the uncompensated health care provided to the uninsured - which the actuarial firm Milliman, Inc. estimated to be $1,017 on average for family coverage in 2008; and
* protect small businesses by providing subsidies, reducing the "hidden health tax," enabling pooling of coverage through "exchanges" that should secure economies of scale, and stabilizing premium costs if a worker gets sick.
As more and more families experienced increases in premiums, deductibles, and co-payments in the past years, and as working families experienced stagnant wages due to employers' burgeoning health care costs, there has been a growing appreciation that the status quo is unsustainable. Indeed, the status quo, in this respect, is a misnomer: Inaction on health care reform will take away families' peace of mind as affordable, quality health coverage and care can no longer be taken for granted.
The media focus has been so focused on the give-and-take process of health reform, but no the policy; a focus on the costs of health reform without a discussion of the benefits. Hopefully, we can use August not to talk about the tactics of opponents disrupting town hall meeting, but of what the actual goals of health reform actually are.
The Census Bureau came out with new data today, and it's not pretty. California jumps from the 7th highest in the nation in uninsured rate--to 4th. Here's Sacramento Bee's Capitol Alert:
The new data, based on a 2006 survey, indicate that California has the nation's fourth lowest level of medical insurance, with 21.3 percent of its residents under 65 years old lacking coverage - and recent reductions in Healthy Families and other state-sponsored medical care programs will, authorities say, push that number higher...
Only Florida, Louisiana and Texas have lower levels of health insurance, with Texas last at 27.6 percent uninsured. The Census Bureau data, which confirm earlier estimates by state officials and health care advocates, found that 6.8 million Californians lacked health insurance in 2006 out of 32 million Californians under 65. (Those over 65 are not counted because it's presumed they have Medicare coverage.)
At the other end of the scale, just 9.4 percent of under-65 residents of Minnesota, 9.6 percent of those in Massachusetts, 9.8 percent of Hawaiians and 9.9 percent of Wisconsinites lack insurance.
Where are California's Representatives so far on federal health reform?
HEALTH ACCESS UPDATE Monday, August 3rd, 2009
U.S. HOUSE COMMITTEES PASS HISTORIC HEALTH REFORM * House Energy & Commerce Committee Passed H.R.3200 Friday Before August Break * H.R.3200 Would Secure & Expand Health Coverage, Prevent Insurer Abuses, Contain Costs * Bill Set for Full House Vote in September; August Recess Critical for Fate of Health Reform * Californians Voices Key, from Leaders to Chairmen to Blue Dogs to Progressives * Call Congress to support health reform at 877-264-HCAN, or click here.
* More Updates on blog.health-access.org: The Case Against Health Reform; Governor Schwarzenegger's Health Reform Letter, Annotated; Historic Vote in the House; No Good Options at the MRMIB Hearing on Healthy Families; Consumer Protections In President Obama's Health Reform; Bass on the Budget; Are These Cuts Legal?; The Governor's Line-Item Budget Cuts to Health & Human Services; Updates on Federal Health Reform...
On Friday, the Energy and Commerce Committee of the U.S. House of Representatives approved historic health reform legislation, moving such a proposal farther than previous attempts in the modern era, and setting the stage for a House vote in September after an August recess.
Health and consumer advocates are gearing up to use the August recess to build momentum for health reform. Call your member of Congress in support of health reform at 877-264-HCAN, or click to help pass reform.
THE BILL: The House proposal, America ’s Affordable Choices Act, H.R.3200, would dramatically secure and expand health coverage: * making it more likely than people get and keep their on-the-job health benefits; * improving and expanding public health coverage programs like Medicaid; * providing significant subsidies for low- and moderate-income families to be able to afford health coverage; and * placing new rules and oversight over insurers to protect consumers, from prohibiting denial for pre-existing conditions, to limiting out-of-pocket costs; to ensuring a minimum benefit package; to providing a public health insurance option for consumers to choose.
Intertwined in the overall package is a range of efforts to contain rising health care costs, from prevention and public health initiatives to better use of information technology and bulk purchasing.
Especially as this bill gets negotiated with what might come out of the Senate, there will be specific issues and advocacy around affordability, financing, employer responsibility, inclusivity, benefits, and the public health insurance option. But moving the bill is crucial to attain those goals, and the House bill, H.R.3200, is a comprehensive vehicle that is supported by dozens of leading consumer, labor, community, patient, and provider organizations, including Health Access California.
THE AUGUST RECESS AND AFTERWARDS: The August recess, as both Senators and Representatives spend more time in their states and districts, is seen by both supporters and opponents of health reform as a crucial time to sway Congressmembers on the high-profile issue.
In addition to a House vote after the recess, the Senate Finance Committee is planning to unveil and consider its’ version of health reform after the break by September 15th. Under this new timeline, a product from that committee would be joined with the Senate Health Committee passed a few weeks ago, and be considered on the Senate floor soon afterwards.
THE ACTION IN THE HOUSE: The Energy and Commerce Committee passed H.R. 3200 by a vote of 31-28. The vote was supported by all but five Democrats, and included the support of the six California Democrats on the panel: Chairman Henry Waxman, as well as Anna Eshoo, Doris Matsui, Jane Harman, Lois Capps, and Jerry McNerney. All Republicans opposed the measure, including the two California Republicans: George Radanovich and Mary Bono Mack.
This committee was the last of three committees to consider and pass out the historic legislation.
* In the House Education and Labor Committee, all the California Democrats voted for H.R.3200, including Chairman George Miller, as well as Lynn Woolsey, Susan Davis, and Judy Chu. The California Republicans voted against it, including Howard “Buck” McKeon, Tom McClintock, and Duncan Hunter.
* In the House Ways and Means Committee, chaired by Rep Charlie Rangel of New York, all the California Democrats voted for H.R. 3200, including Health Subcommittee Chairman Pete Stark, as well as Xavier Becerra, Mike Thompson, and Linda Sanchez. California Republicans voted against it, including Wally Herger and Devin Nunes.
Health advocates are urging members to THANK the members that voted for the health reform bill.
CALIFORNIANS IN CHARGE: California consumers are uniquely suited to have their voice heard in this debate. In the House of Representatives, California is well represented in this debate, from Speaker Nancy Pelosi, to key members of leadership like Representative Xavier Becerra, on down.
Each of the three committees of jurisdiction for health reform has a senior Californian in a top leadership position: Rep. Henry Waxman chairs the Energy & Commerce Committee; Rep. George Miller chairs the Education & Labor Committee, Representative Pete Stark is the second senior member of the House Ways & Means Committee, and the chairman of the health subcommittee. Given this leadership and authorship, H.R.3200 can be seen as “made in California.”
Californians were also integrally involved in the back-and-forth that led to the final agreement allowing passage from the final committee in the House.
California also has the largest contingent of “Blue Dogs” Democrats, who are self-described as more conservative, and who have been advocating concerns and changes to the health care legislation. However, of the seven California Blue Dogs, five have generally been supportive of health reform. By the beginning of the year, California Representatives Joe Baca, Mike Thompson, Jane Harman, Loretta Sanchez, and Adam Schiff signed on in support of Health Care for America Now! principles, and have been supportive of health reform in general and of the public health insurance option in specific. These five members declined to sign a “Blue Dog” letter that opposed health reform without specific changes.
The two other California “Blue Dogs” are Representatives Jim Costa and Dennis Cardoza, both of the Central Valley , and both signed onto that letter urging changes to the health reform. While neither was on a relevant committee, the signing of the letter gave support to the group that did negotiate for a delay in the house floor vote and that got amendments to the bill, including on the public health insurance option and reducing affordability subsidies. Ultimately, a compromise was reached where some (but not all) of the “Blue Dogs” on the Ways and Means Committee agreed to support the bill.
That compromise was a concern to progressive members, including many Californians. A letter signed by 57 members (14 from California ) of the Progressive Caucus and the Tri-Caucus circulated in the last week gave strong support to health reform but warned “we will not support a weakened public option.” In addition to the leadership of Progressive Caucus Chair Lynn Woolsey, Black Caucus Chair Barbara Lee, and Asian Pacific American Caucus Mike Honda, other California Representatives who signed the letter included Lucille Roybal-Allard, Laura Richardson, Maxine Waters, Judy Chu, Diane Watson, Jackie Speier, Bob Filner, Linda Sanchez, Grace Napolitano, Sam Farr as well as Pete Stark.
Further negotiations ensued between Chairman Waxman, Blue Dogs, and Progressives who were concerned with the Blue Dog compromise, leading to additional “unity amendments” to the bill that sought to bridge the differences, most notably to find savings to maintain the affordability subsidies for low- and moderate-income families.
ACTIONS: Health and consumer advocates, including Health Access California and Health Care for America Now!, are urging Californians to CALL, WRITE, AND VISIT their Congressional representatives this week and through August in support of health reform. Opponents are mobilizing to chip away at the support for health reform, and we need to be clear about the urgency, the need, and the popularity of reform.
* In particular, Californians should THANK the members of the various committees that voted for H.R.3200, including: Henry Waxman, George Miller, Pete Stark, Xavier Becerra, Anna Eshoo, Doris Matsui, Jane Harman, Lois Capps, Jerry McNerney. Lynn Woolsey, Susan Davis, Judy Chu, Mike Thompson, and Linda Sanchez.
* Californians should THANK the Progressive members that are advocating strongly for a robust public health insurance option and for affordability subsidies for low- and moderate-income Californians, including: Lynn Woolsey, Barbara Lee, Mike Honda, Lucille Roybal-Allard, Laura Richardson, Maxine Waters, Judy Chu, Diane Watson, Jackie Speier, Bob Filner, Linda Sanchez, Grace Napolitano, Sam Farr and Pete Stark.
* Californians should THANK the “Blue Dogs” that have distanced themselves from that caucus to be supportive of health reform, of the Health Care for America Now! principles, and of the public health insurance option, including Joe Baca, Mike Thompson, Jane Harman, Loretta Sanchez, and Adam Schiff.
* Finally, and most importantly, Californians should URGE California Representatives Jim Costa (D-Fresno/Bakersfield) and Dennis Cardoza (D-Merced/Modesto) to come out in support of health reform and H.R.3200. The Blue Dogs got key amendments that should address their concerns, and nowhere in the state or nation is in more need of health reform than the Central Valley of California.
* While you are at it, call California Senators Barbara Boxer and Diane Feinstein in support of health reform as well.
One person who has taken on that tough job is journalist Joe Matthews, who recently had a post on a conservative website pretending to reveal what's going on in "Arnold's Brain." This isn't as much of a conceit as it may seem: as someone who has literally written a book on Schwarzenegger, many of Matthews' musings seem to come from the Governor, or at least his inner circle. Beyond his sources, he also seems sympathetic to Schwarzenegger, trying to give the Governor the benefit of the doubt. Earlier this year, he was on a radio program suggesting that the Governor's proposals to eliminate major programs like Healthy Families was simply a way to build the case for revenues--something that certainly never panned out. His recent entry, in the voice of Arnold, also seeks to put a positive spin to defend the indefensible cuts he has made:
My personality and celebrity is so big that the media, or what’s left of it, is missing the real story.
Here’s the tale in a nutshell: I tried to give Democrats what they say they want–universal health care and higher taxes. I did this at huge political cost to myself. And they said no...
You’ll forgive me for not committing political suicide a third time. The foreheads say I went back to the right in the last two months. Excuse me, but what other choice did they leave me?
And so now, when we get this terrible budget, full of health cuts that I hate (remember: I’m the guy who put my neck on the line for universal coverage), this is somehow my fault? You want someone to blame, foreheads? Try a f-----g mirror.
According to this take, the Governor really wants to do good and is really opposed to cutting children's coverage, he's just misunderstood. Matthews uses two examples that Health Access California was intimately familiar with: health reform in 2007 (which we ultimately were in support of the Governor's effort with AB x1 1), and Proposition 1A in the May 19th special election (which we were in early opposition).
The broad brush that this voice of "Arnold" uses for "liberals" makes little sense, since there was a diverse response on both issues: I know that for both issues, our Health Access California coalition vote was not unanimous, and we had good friends and allies on both sides of both issues. This is true of legislators as well: much to our chagrin, the Senate Democrats that helped kill health reform in 2007 were his strongest supporters for Proposition 1A in 2009. But this voice of "Arnold" seems to forget some things as well:
* As someone who supported AB x1 1, I agree with the assessment that California lost an opportunity when health reform stalled here, not just to raise revenues for expanded health coverage, but also to influence the national debate in a positive direction. But the Governor does bear some responsibility of his own, for example by delaying negotiations until key initiative and legislative deadlines passed. And by driving such a hard bargain on key affordability issues, he splintered the coalition that was needed to win in the legislature and on the ballot. He deserves some credit for coming to the issue, but shouldn't escape all blame.
* Proposition 1A presented health and human service advocates with the option of temporary taxes and revenues for only two additional years, but at the price of a permanent spending cap. Some proponents may have characterized it as a "soft" spending cap, but many others had different analyses--as is shown by the current debate over whether the Governor had authority to make additional cuts last week. Prop 1A was much less about increasing revenues than his second attempt at the legacy of a spending cap, in the rhetoric of "live within your means."
The main problem with Matthews' piece is he uses only two data points. As the San Jose Mercury News editorial board pointed out, the Governor's history on the issue of children's coverage--to take just one example--is far more spotty. "What other choice did I have?" can be answered with a long litany of his actions or inactions, from his very first budget proposal to a veto of AB772(Chan/Escutia) in 2005, a universal children's coverage bill, to his stance on Proposition 86--which was within 2 percentage points of passing:
Schwarzenegger came into office promising to make universal coverage for children a priority. Instead, he tried to cap Healthy Families in his first year in Sacramento and opposed Proposition 86 in 2006, which would have insured children through an increase in the tobacco tax...
Matthews' piece seems ill-timed, since it was only a few days before another, devastating data point: the Governor chose to unilaterally take another $50 million out of Healthy Families, on top of another $144 million cut he insisted on. So he has been far more consistent in seeking to cut children's coverage, and opposing taxes and revenues that would sustain such cuts.
What's the explanation for the latest cut? Willie Brown wrote in the San Francisco Chronicle, "I suspect his final cuts to children's health care and AIDS programs were made more out of anger at Democrats than sound thinking. They will haunt him for the remainder of his term."
Steve Harmon and Mike Zapler of MediaNews (such as the Oakland Tribune) notes that he seems to enjoy his role of budget slasher: "Gov. Arnold Schwarzenegger seemed to relish the task of reining in government spending, almost as if it was another cinematic role in which to star. With gusto, he launched blistering attacks against fraud in the welfare system, demanding that those abusing the system be kicked out. He unwaveringly stood his ground on taxes, never allowing Democrats to seriously consider including them in negotiations...." Let's not even get into the whole thing with him waving around a knife.
As the Los Angeles Times editorial board puts it, "Funny, isn't it, that when the governor scours the state budget for waste, fraud and abuse, he only seems to find it in programs for the old, the young, the poor and others unable to raise campaign funds or muster political opposition."
Matthews attempted to find a unified theory of Schwarzenegger, but there's an easier narrative available: as a down-the-line corporate conservative who has consistently gotten high marks vetoing proposals the Chamber of Commerce doesn't like throughout his service, but who had a moderate moment right before and after his re-election campaign. He toned down his rhetoric after being pushed back by the legislature from budget proposals to cut everything from the Lanternman Act to Healthy Families, and then after being rejected by the electorate on a budget spending cap and other efforts in a special election. After accolades for his 2006 pre-election concessions on global warming, minimum wage, and prescription drugs (that last reform for which we applauded him for signing and yet has never been implemented), the Governor sought a continuation of that national attention, and health reform was merely the means to that end. The budget crisis has allowed him cover to impose the conservative agenda that in any other time would be politically impossible.
I have no idea if that's a correct analysis of the Governor. But at some level, it doesn't matter. What the Governor thinks in his brain or feels in his heart doesn't matter. It is what he does and doesn't do.
And right now, his Administration is beginning to deny hundreds of thousands of children health coverage, among many other things. He had other options and choices from day one to the present. He still does, and maybe we'll see yet another version of our Governor in his remaining time. For the sake of California, I hope so.
One of the scary things about health reform bills is that you forget how bad the status quo really is... But then I read parts of the legislation and remember how many problems in our health system aren't the exceptions, but the rules themselves, as they exist today. It's amazing how much of health reform bills like H.R. 3200 are putting in place rules than seem so common sense that you wonder why they aren't in place already.
There was a time when Governor Arnold Schwarzenegger had significant national attention and credibility on health care issues, as a Republican leader who had proposed a serious health reform proposal. But he showed little ability to bring Republicans along with him in California, so it was unclear how he would fare in DC.
And that was before he cut Medi-Cal benefits and savaged the Healthy Families program, denying coverage to hundreds of thousands of children. The notion that he is the "health care governor" now seems a cruel joke.
Here's the Governor's letter in full in italics... and some annotation and commentary exploring the full contradictions of the Governor, where he can be absolutely right on and amazingly wrong-headed in the same breadth.
July 31, 2009
Dear Senator Reid, Senator McConnell, Madam Speaker and Mr. Boehner,
I appreciate your commitment and hard work toward reforming the nation’s health care system. I think we can all agree that the current system is not working as it should, and I have long supported a significant overhaul. Costs continue to explode, while tens of millions remain uninsured or underinsured. Many families are one illness away from financial ruin - even if they do have insurance. We have the greatest medical technology in the world at our fingertips, yet Americans’ health status lags behind many countries that spend less than half what we do per capita. Any successful health care reform proposal must be comprehensive and built around the core principles of cost containment and affordability; prevention, wellness and health quality; and coverage for all.
Here, the Governor makes an impressive and important case for health reform, as he did in 2007, and reiterates the same talking points as he did back then. It's like its 2007 all over again.
Cost Containment and Affordability
Cost containment and affordability are essential not only for families, individuals and businesses, but also for state governments. Congress is proposing significant expansions of Medicaid to help reduce the number of uninsured and to increase provider reimbursement. Today, California administers one of the most efficient Medicaid programs in the country, and still the state cannot afford its Medicaid program as currently structured and governed by federal rules and regulations. The House originally proposed fully funding the expansion with federal dollars, but due to cost concerns, members decided to shift a portion of these expansion costs to states. I will be clear on this particular proposal: if Congress thinks the Medicaid expansion is too expensive for the federal government, it is absolutely unaffordable for states. Proposals in the Senate envision passing on more than $8 billion in new costs to California annually - crowding out other priority or constitutionally required state spending and presenting a false choice for all of us. I cannot and will not support federal health care reform proposals that impose billions of dollars in new costs on California each year.
In the sharpest part of the letter--and perhaps the real point--the Governor is reacting to a change in the House bill demanded by the "Blue Dogs" to lower the cost of the health reform bill, by having the states' pick up a small percentage of the Medicaid expansion, rather than take on the full cost of that expansion.
The Governor has a valid point on the policy: it is preferable for the federal government to fund the cost of health expansions in Medicaid, even though most of the program now is a state-federal partnership. The federal government has the funding flexibility that states do not have, especially during tough economic times when state revenues are down but the need for such safety-net services increase. States who had to put up even a portion of the match may simply not do the expansion.
That said, the figure that the Senate bill might impose $8 billion in new annual costs seems wildly inflated. And this is a Governor who, a mere 18 months ago, was willing to support billions of dollars in increased taxes and revenues for his own health reform... but now he seems to say he would oppose anything that would require the state to raise a fraction of such revenues to implement a federal health reform that is relatively similar but does not have his name?
I know it only reflects the same inconsistency of the Governor in supporting revenues to expand Medi-Cal and SCHIP in health reform, but opposing revenues in the budget process to prevent steep cuts in those very same programs.
It's not a surprise that this or any Governor would advocate for the California budget. But he missed the opportunity--and responsibility--to advocate for the California consumer. The "Blue Dog" amendments in the House also sought to reduce affordability subsidies to low- and moderate-income families. The Governor refrained from making a comment--even though Californians would be most negatively impacted:
* California has a disproportionately high percentage of low-wage workers that would need and benefit from such affordability subsidies. * And since California has one of the highest costs of living in the nation, having meaningful subsidies go up the income scale to 400% of the federal poverty level is incredibly important.
One would hope that the Governor of our state would make the case not just for the budget, but for his constituents. California was lucky to have the Progressive Caucus, Black Caucus, Asian CaucOne us--led by California Representatives Lynn Woolsey, Barbara Lee, and Mike Honda, respectively--as well as the Hispanic Caucus, fight for those affordability subsidies.
The inclusion of maintenance of effort restrictions on existing state Medicaid programs only compounds any cost shift to states. We simply cannot be locked into a cost structure that is unsustainable. Governors have three primary ways to control Medicaid costs: they can adjust eligibility, benefits and/or reimbursement rates. Maintenance of effort requirements linked to existing Medicaid eligibility standards and procedures will effectively force state legislatures into autopilot spending and lead to chronic budget shortfalls.
Here, the Governor actually argues against the health and welfare of Californians. He wants the ability to limit eligibility, drop reimbursement rates, and scale back benefits--even in the context of a universal health system with an individual mandate.
With a requirement for individuals to take up coverage, there needs to be a resulting requirement that government--at the state and federal level--will provide the necessary assistance to get quality, affordable coverage. It was the Governor's lack of understanding about the need for that commitment that made negotiations on health reform so frustrating... and that prevented a broader coalition from coming around in support of the final proposal in California.
The federal government must help states reduce their Medicaid financing burden, not increase it. A major factor contributing to Medicaid’s fiscal instability, before any proposed expansion, is that the program effectively remains the sole source of financing for long-term care services. Therefore, I am encouraged by congressional proposals that create new financing models for long-term care services. Proposals that expand the availability and affordability of long-term care insurance are steps in the right direction, but they must be implemented in a fiscally sustainable way. More fundamentally, however, the federal government must take full responsibility for financing and coordinating the care of the dually eligible in order to appreciably reduce the cost trend for this group. This realignment of responsibilities is absolutely essential to controlling costs for this population, while ensuring that state governments will be better positioned to fill in any gaps that will undoubtedly arise from federal health care reform efforts.
I also encourage Congress to incorporate other strategies to help stabilize Medicaid costs for states. Delaying the scheduled phase-out of Medicaid managed care provider taxes pending enactment of new Medicaid rates, reimbursement for Medicaid claims owed to states associated with the federal government’s improper classification of certain permanent disability cases, and federal support for legal immigrant Medicaid costs are examples of federal efforts that could provide more stability to state Medicaid programs. Moreover, given the fiscal crisis that many states, including California, are experiencing, I strongly urge Congress to extend the temporary increase in the federal matching ratio to preserve the ability of state Medicaid programs to continue to provide essential services to low-income residents pending full implementation of national health reform.
The Governor here makes the pitch for more federal resources for California and the states in general. He actually brings up issues that are currently in discussion--the budget signed last week includes $1 billion in Medi-Cal savings from negotiating with the federal government over some of these disputed issues.
The Governor missed another opportunity in advocating for Medicaid savings--a robust employer requirement. The more that employers continue to provide coverage to their workers, the less likely they are to fall onto state programs like Medicaid. The proposal in the House (which is closer to what Governor Schwarzenegger agreed to at the end) is much more likely to provide state savings, than the relatively weak employer contribution in the Senate, which might actually increase Medicaid enrollment for currently eligible categories. He had a chance, consistent with his health reform proposal, to make the case for employer responsibility in an area where he could have made a difference, where there is real fluidity in the national discussion.
The Governor also makes the case for continuing the increased federal-state matching rate that California is getting from the stimulus, that has provided nearly $10 billion in federal funds, but that will expire at the end of 2010. Given that California is not likely going to be out of this fiscal hole that soon, such a request is necessary--however, it's probably more likely to come not under health reform, but in a second stimulus or more targeted package of aid to states.
Prevention, Wellness and Health Quality
Prevention, wellness and health promotion, along with chronic disease management, can help to lower the cost curve over the long run and improve health outcomes in the near term. This was one of the cornerstone pieces of my health care reform proposal in California, and I continue to believe it should be a key piece of the federal efforts. Prevention, wellness and chronic disease management programs should include both the individual and wider population levels.
At the individual level, proposals to provide refunds or other incentives to Medicare, Medicaid and private plan enrollees who successfully complete behavior modification programs, such as smoking cessation or weight loss, are critical reforms. To ensure they are widely used, individual prevention and wellness benefits should not be subject to beneficiary cost sharing. Because individuals’ behaviors are influenced by their environments, health reform must place a high priority on promoting healthy communities that make it easier for people to make healthy choices. California has demonstrated through its nationally recognized tobacco control efforts that population-based strategies can be effective and dramatically change the way the people think and act about unhealthy behaviors, such as tobacco use. A similar model, community transformation grants, has been advanced in the Senate Committee on Health, Education, Labor, and Pension legislation, and it should be included to support policy, environmental, programmatic and infrastructure changes that address chronic disease risk factors, promote healthy living and decrease health disparities.
Quality improvement measures are also critical to health reform. The House proposal for a Center for Quality Improvement to improve patient safety, reduce healthcare-associated infections and improve patient outcomes and satisfaction is a positive step. Coordinated chronic disease management is necessary to improve outcomes for chronically ill people. Systematic use of health information technology and health information exchange, including access for public health agencies, is vital to providing the necessary tools to measure the success of quality improvement efforts. Finally, investments in core public health infrastructure can be facilitated through the creation of the proposed Prevention and Wellness Trust.
These are important elements--and we wish the Governor's policies and actions met the rhetoric. He opposed a tobacco tax (Prop 86) on the ballot in 2006, and refused to consider another during this awful budget crisis.
However, this emphasis on focusing on healthy environments and communities--not just personal responsibility for better health--is much needed. His endorsement of "community transformation" and better public health infrastructure are all welcome and should be heeded by the DC policymakers. Unfortunately, some of these items have come under scorn, and maybe he can help defend them from attack.
Coverage for All
Coverage for all is also an essential element of health care reform and I believe an enforceable and effective individual mandate, combined with guaranteed issuance of insurance, is the best way to accomplish this goal. The individual mandate must provide effective incentives to help prevent adverse selection that could occur if the mandate is too weak. Creating transparent and user-friendly health insurance exchanges to help consumers compare insurance options will also help facilitate participation. States should maintain a strong role in regulating the insurance market and have the ability to maintain and operate their own exchanges, with the understanding that some national standards will need to be established. California has a long history of protecting consumers through our two separate insurance regulators, one covering health maintenance organizations and the other monitoring all other insurance products. Maintaining a strong regulatory role at the state level is in the best interest of consumers, and I urge Congress to maintain this longstanding and effective relationship as you design these new market structures.
There's a common understanding that the individual insurance market is broken, from the allowance of insurers to deny coverage for "pre-existing conditions," to the utter complexity and confusion to understand benefit packages or make apples-to-apples comparisons. The new "exchange" would place new oversight over insurers and fix many of these issues, while preserving a wide range of choices for consumers.
In this section, Governor Schwarzenegger argues for the continued role of state regulators. This is an area where a federal floor would be welcome, but also the ability for states to set higher standards where needed. California's insurance market has often been compared to the wild, wild West, in deperate need of taming--on issues from rescissions to the lack of minimum benefits--so a federal presence would be welcome. But there are areas where California has lead the way in consumer protection, such as with our HMO Patients' Bill of Rights, independent medical review, and advances on issues like timely access and language access. We wouldn't want to lose our ability to continue to improve consumer protections.
I hope our experience in California working toward comprehensive health care reform has informed the debate in Washington. There will be many short-term triumphs and seemingly insurmountable roadblocks for Congress and the nation on the road to comprehensive health care reform. We must all remain focused on the goal of fixing our health care system and remember that we all have something to gain from the reforms, and we all have a shared responsibility to achieve them. I look forward to working with you as you move forward on this desperately needed legislation.
The letter seems disjointed, wanting to continue the Governor's rhetoric from last year as a health reformer, but the main thrust--as most media reported it--was to send a signal of opposition, particularly about state costs. Unfortunately, in making that case, especially on any maintenance of effort requirement, he shamefully argues for the state at the expense of its residents. And he
When reading this, our Congressional delegation, who after all represents the same constituency, will reject the self-serving arguments, but also recognize the good points in the letter. There's some common ground for our delegation in supporting more resources for California, prevention-oriented policies, and the ability for state regulators to craft key consumer protections.
With most Republicans attacking health reform, it's just a shame--in more ways than one--that the Governor has lost his pro-reform voice and credibility on the issue with his recent actions. The letter only serves to continue his many contradictions.