Yesterday, we put out a quick "year in review" for 2009. Many are taking the opportunity to look back at the decade of 2000-2009 (even if technically the decade goes into 2010.)
It is striking to see how the conversation has evolved from ten years ago. In California, the health policy debates were focused on (and that Health Access was active in) was the establishment of the HMO Patients Bill of Rights (and the creation of the Department of Managed Health Care to enforce them), and the implementation of the new Healthy Families program for low-income children. Although in the case of Healthy Families, the issue back then was that the program was undersubscribed, and the state was not taking advantage of 2:1 federal matching funds, and so efforts were focused on boosting enrollment like simplifying the overlong application and training application assisters. (Governor Davis didn't run on health issues, but he highlighted both children's coverage and patients' rights as part of his re-election bid in 2002.)
These issues are still with us: * The Department of Managed Health Care recently implemented language access regulations and will officially put in place standards for timely access to care in a few weeks. They've begun a regulatory process on regualting so-called discount health plans. * Healthy Families has grown steadily and been a success story in reducing the number of uninsured children--although there are still hundreds of thousands of children without coverage that are even eligible but unenrolled. Yet as opposed to a time of budget surplus, the budget crisis has meant that simply keeping the program's doors open is a victory. State funding for those application assisters has been zeroed out, and the entire program was proposed to be eliminated last year.
The boom times allowed for incremental improvements in access to health care. What was not in the conversation was the major health reforms and expansions in the debate now--perhaps there was still a caution and a recovery from the failure to pass major health reform in the early Clinton years. The 2000 presidential election between Vice President Gore and Governor Bush did not focus on health care issues--and when it did, it was about issues like incremental expansions of children's health coverage and passing a national version of an HMO Patients' Bill of Rights. Both elements are parts of the much bigger reform package that is being discussed now.
At the beginning of the decade, California started an effort to invest and get federal money to expand our Healthy Families program to cover the parents of those children--but when we finally got federal permission, an economic downturn--along with 9/11 and the energy crisis--caused a budget crisis we have never really recovered from. Our budget crisis was not helped by the various reductions in revenues that were approved--from the vehicle license fee that Governor Schwarzenegger campaigned on to win the recall to the corporate tax giveaway in the last budget. So much of this decade has been about preserving existing health care public programs through tough budget times. And the last budget--that eliminates various Medi-Cal benefits and much more--is more of a blow because it is a defeat after a decade of defense.
But at the same time, California provided the template for the broader reforms we had now. In 2002, a health care options process generated some ideas on health reform. In 2003 saw the first reintroduction of a single-payer bill, SB921 by Senator Sheila Kuehl--and the passage of an employer mandate, SB2 by Senate President Pro Tem John Burton. That bill was signed by Governor Davis days before his recall in 2003, which set the stage for a referendum campaign in 2004. While unsuccessful, the close vote (49.2%) showed that health reform was achievable, which led to other efforts, like the successful passage and implementation of Healthy San Francisco. Governor Schwarzenegger opposed Prop 72, and vetoed both universal children's coverage (AB442 in 2005) and single-payer bills (SB840 in 2006), before putting forth his own reform proposal in 2007.
Whatever people thought of the details, the final proposal negotiated with Assembly Speaker Nunez was ambitious, and has similarities to what it now being discussed in Washington, from much bigger Medicaid expansions to insurance reforms including guaranteed issue. We have also seen, however, that a failure means that politicians can quickly move on to many other issues.
So ten years later, some things haven't changed, but a lot has. We have made some progress, in policy (like HMO consumer protections), and also in what is politically possible. The question is whether, despite the budget and other barriers, we can build on that base for the next ten years.
2009 YEAR IN REVIEW ON HEALTH ACCESS ISSUES * The Hope of Federal Health Reform: Further Than We've Been Before * California's Budget Blues: Medi-Cal Benefits Eliminated, Clinic Funding Zeroed * Some Progress on State Consumer Protections...
For health care in California, the year 2009 was the best of times, and the worst of times.
The year began with the hope and excitement of new Obama Administration—especially, for health advocates, for a new president that made health reform a central part of his campaign. The good news from Washington, DC, started quickly, with the reauthorization of the SCHIP program that covers low-income children, which had been vetoed in previous years.
But the California budget crisis loomed, with nothing more symbolically showing the disconnect between the federal possibilities and state problems than Governor Schwarzenegger’s budget proposal to eliminate the state’s SCHIP coverage for a million low-income children in its entirety—and actually have that program, Healthy Families, close enrollment and be a week away from sending out hundreds of thousands of disenrollment notices. That roller coaster continued as the same Governor and Legislature that approved steep cuts in the program earlier in the year then passed a fix to temporarily prevent kids from being kicked off coverage—and then wait with concern about federal approval. Given everything, it’s gratifying that at year’s end, Healthy Families’ waiting list has been cleared and children are being covered and enrolled—even if some families are now paying more, and future funding in uncertain.
The work started in 2009 is not yet finished, but here are some other highlights:
HEALTH REFORM: It’s not done, but comprehensive health reform has never made it so far in the legislative process, going through five policy committees and full floor votes in both the House of Representatives and the Senate. It’s not finished, but the final product is likely to provide more security and stability for people with health coverage, and include be the biggest expansion of health coverage (both public and private) ever, to around 30 million Americans—and nearly 4 million Californians.
Health advocates, including the state's Health Care for America Now! campaign, succeeded in having our two Senators be champions on key issues, and getting all Democratic Representatives from our 53-member House delegation—including all 7 “Blue Dogs”—to vote for the House version of reform. With the exception of the anti-abortion Stupak amendment, the House reform is a very strong bill that meets consumer advocacy principles, from affordability and employer responsibility to providing a public health insurance option. Californians took the lead in the House, and were in leadership positions—Chairmen Miller, Waxman, and Stark—in each of the three House committees of jurisdiction. From Speaker Pelosi to the chairs of the key Asian, Black, and Progressive caucuses, the House did its job and is looking to make final bill better than what passed the Senate, which needs improvement in key areas.
The work for health advocates now is to help our sizable California House and Senate members improve the final bill while passing it in early 2010, and then begin the longer effort to implement and improve it here at the state level, through legislation and regulation.
CALIFORNIA'S BUDGET CRISIS: In both February and July, the Legislature passed and the Governor signed two budget packages to solve a combined $60 billion deficit—with many cuts, including to health care—for the year-and-a-half period of January 2009-June 2010.
The first February package of $42 billion included significant health and human service cuts that were "triggered"—including the full elimination of ten benefits for three million adults with Medi-Cal coverage, including dental, vision, podiatry, speech therapy—as well as some temporary taxes. The package also placed six propositions on the May ballot, including a spending cap (and two others to divert funding away from mental health services and health and social services for young children). The only one that passed was to prevent increases legislator salaries in deficit years.
A July package was needed to address over $20 billion more in deficits, and that led to even steeper health and human services cuts, and no new revenue. The reductions in health included cuts to coverage, hospitals, AIDS and mental health programs, and the zeroing out of state funding for community clinics.
For 2010, a new $20 billion hole is projected for the next year-and-a-half. Health Access plans to release a report next week, “The Damage Already Done,” to start to document the effect of the cuts in just six months. This will be part of sustained coalition efforts this year to detail the impact of these budget choices on California families, on our health system, and on our economy.
As for state legislation that was considered, the budget did take up much of the attention and energy. Key legislation was passed and signed into law, attempting bring in more federal money for children’s coverage, hospital Medi-Cal reimbursement, and individual’s COBRA coverage.
Some consumer protection bills were vetoed, on issues like insurers rescinding coverage, and proposals to mandate key benefits, from maternity coverage to mental health parity. But a few good bills were passed and signed into law, including a prohibition on gender rating—which will stop insurers from charging men and women differently.
Since the Senate is seen as a more delicate compromise, some people think the final product would look much closer to the Senate version. While it is important to be realistic, I think there will be some significant improvements from the Senate. There are some compromises that have been made which were very contentious, and probably won't get reopened. But as the opponents tell us, it is a 2,000+ page bill, so there lots of opportunity for improvements in other areas. The House, which by passing their version earlier already exerted some influence on the Senate bill, has a political imperative to put its stamp on the final bill. Also, the House version didn't pass with lots of extra votes, and their members are all up for re-election next year, so they have as much reason to ask for adjustments.
* Affordability, Affordability, Affordability: Required insurance could still be too expensive for many. Both bills require many Americans to have insurance. In the Senate bill, the caps on how much we're expected to pay are too high, and the subsidies for working families are too low. Many are working to fix this, but it's going to be a significant fight.
* Employer responsibility: The Senate bill’s requirement on employers has major loopholes for large employers who don’t provide coverage to their workers. Also, this complex and confusing “free rider” provision has potentially negative workforce impacts, encouraging part-time rather than full-time work. The Senate also needs to apply basic benefit standards to all employers, including large ones. The House bill has simple standard for large employers, who would either provide coverage to their workers, or pay a flat percentage (sliding scale up to 8%).
* Progressive Financing: Though the House bill is financed through progressive options like a surcharge on wealth individuals and families, the Senate bill includes an excise tax on high-cost health plans. We advocate a variety of progressive revenue options to offset a repeal or narrowing of the excise tax.
* Immigrant inclusivity: While both bills prohibit the use of federal funds to fund coverage of undocumented workers, the Senate bill excludes undocumented workers from using their own wages and money from being able to buy coverage in the national insurance exchange. Another issue is that the bills continue a 5 year waiting period for recent legal residents who would otherwise be eligible for Medicaid. We are urging Senators to support an amendment being offered by NJ’s Senator Menendez to lift this restriction.
* Abortion: While both bills adopt the current law that federal funds not be used for abortion coverage, the House bill goes beyond that in restricting reproductive rights. The Stupak provision House bill virtually prohibits anyone purchasing insurance in the Exchange from buying a plan that covers abortion—even if paid for with their own money. The Senate leaves the issues to the states. We need to work against a rollback of reproductive rights.
* State consumer protections: The new Senate bill did remove the permission of "nationwide plans" that seriously threatened state-based consumer protections. However, both bills do allow "interstate compacts," where states can allow insurance plans from another state without having to abide by their consumer protection laws. We are advocating for this provision to be removed.
* Public health insurance option: While the House passed health care with a public option, the Senate does not include one. We need to continue to advocate for a public health insurance option. The public option would provide competition for private insurance—and we need to continue to support its inclusion, even after a bill is signed into law.
If you read this blog, you know the remarkable moment we are in, both in terms of the challenges and opportunities. We have much we can win, and much we can lose... and that's why we need your help.
We are on the cusp of history. Congress is poised to pass landmark legislation to provide more security and stability for those who have health coverage, and to dramatically extend access to affordable, comprehensive health care for those who don’t. It would prohibit insurers from denying coverage for pre-existing conditions, or placing arbitrary caps on coverage.
But there is so much more to do to fulfill the promise of reform in 2010. Health Access needs your help to make the promise a reality.
Health Access will continue to lead efforts in California—including the Health Care for America Now campaign in our state—to pass health reform, and the right reform. Across the state and in Washington, DC, Health Access provides information and analysis to elected leaders to help them understand the impact and implications of the reforms they are working on. We are continuing organizing and advocacy efforts to include the strongest possible provisions on everything from affordability to consumer protections. If you read this blog, you know we also educate the public about what these changes will mean for them individually, and why comprehensive reform is so important California and the nation. Hopefully, you've looked at our materials, and hopefully they have been helpful to you.
We need your help not just to help pass reform, but to do the all-important work afterwards. We will have major opportunities to implement and improve health reform to make sure it works well here in California--from putting in place the right regulations to protect patients from insurance company abuses, to pursuing a public health insurance option for California.
But with these opportunities come significant challenges. Under California’s budget deficit, Governor Schwarzenegger threatens to undermine our progress by proposing massive cuts to existing programs like Medi-Cal and Healthy Families. Health Access has been on the front lines of the fight to prevent these ugly cuts to the safety net and the health system on which we all rely; to offer alternatives to cuts; making sure that the real cost and impacts of these cuts are understood, and working with grassroots groups to make sure the voice of their constituents are heard.
Your year-end gift to Health Access Foundation will help us finish the work of passing the best possible health reform at the national level; start the work of fulfilling the promise of reform here in California; and guarding against significant setbacks of budget cuts that threaten to cripple our health system, our families, and our economy.
“I have long supported fixing our broken health care system with comprehensive reform. But, I still believe both the House and Senate bills fall short and need additional work. Congress must ensure states are not strapped with unfunded mandates and unfair costs that will only lead to larger budget deficits with unsustainable services. I remain committed to working with Congress and the President as the two houses move forward on reforms that are balanced and focus on slowing the growth in health care costs, improving the quality of care and providing health insurance coverage for the uninsured, while ensuring states can sustain the expansion of programs like Medicaid. This is a historic opportunity and I urge members of Congress and the Obama administration to come together and work through these issues to fix our broken system.”
The Governor took the opportunity of this health reform vote to refocus attention on his letter urging "flexibility to meet current obligations within the revenues available to states." In other words, he wants more money for California, and the ability to make cuts to health programs--seeking authority to make cuts to Medi-Cal and Healthy Families eligibility, benefits and reimbursements to providers.
We're not the only ones who think such actions are very unbecoming, especially at Christmas. Assemblyman Dave Jones, chair of the Assembly Health Committee, called him on the substance of the letter seeking cuts, and on the timing:
“It’s the day before Christmas and like Ebenezzer Scrooge, Governor Schwarzenegger wants to take poor Tiny Tim’s crutch away. And deny him any healthcare. Bah humbug, Governor!
The Governor has asked Congress to allow him to make cuts in healthcare for Californians.
Here we are in the worst recession since the Great Depression. Record numbers of Californians have lost their jobs outright or had their income cut. Record numbers of Californians are without health insurance. They are not able to see a doctor or get treatment for themselves or their loved ones. And the Governor’s response is to look for ways to deprive even more Californians of healthcare, so more Californians will get sick and die.
The Governor, in writing to Congress, is not speaking for Californians or California. California needs Congress to expand healthcare coverage and to increase payments to California to help pay for it. But the answer is not, as Governor Scrooge requests, to turn our backs on those who rely on California for medical care or to cut the already too low reimbursements to our doctors, nurses, hospitals and other medical providers who provide that care.
In a word, what the Governor proposes is worthy only of Scrooge. Lets hope that the Governor is visited by several ghosts tonite who will cause him to see the error of his proposal to cut healthcare for Californians.”
Today at 4:15AM California time, the United States Senate passed its health reform measure 60-39.
We watched live on C-SPAN while our colleague, Elizabeth Landsberg, advocate for Western Center on Law and Poverty, watched from the Senate gallery. She was a little late getting there because Vice President Biden was entering the Senate chamber to preside but she saw Majority Leader Reid' speech and the vote itself. This blog post incorporates her eye witness report.
California Senators Barbara Boxer and Diance Feinstein called out their Ayes loud and clear. Senator Byrd of West Virginia said he was voting Aye for his friend Ted Kennedy. And Majority Leader Reid accidentally voted No, and then corrected himself to the laughter of all assembled, including even the clerks at the desk.
Elizabeth reports that Senators seemed very happy that the measure had passed the Senate. We also observed the milling around the clerk's desk and what looked like very happy Democratic Senators.
Next--Merging the House and Senate Bills The next step is to merge the House and Senate bills. There are significant differences between the two bills--and we much prefer the House bill--but the big difference is between the status quo and either bill.
More to follow. posted by Beth Capell | Permalink | 6:14 AM
60, even though they didn't need it...
It was early morning Christmas Eve, 4am for those of watching from the West Coast. Vice President Joe Biden presided for the final vote of HR3590, the Senate's version of health reform. Senate Majority Leader Harry Reid gave appreciation to staff, and final arguments were given by both Republican Leader Mitch McConnell and Reid.
McConnell was defiant. He gave clear indication, that this fight is long fron over. "We will do everything in our power to stop it from becoming law."
Reid comments were touching, invoking Ted Kennedy and saying, perhaps hopefully, that "facts will always defeat fear." He asked the assembled to think of those who were just when Truman made his call to the U.S. Senate to pass health reform, and who because of inaction, became uninsured during their life. Those babies are now months away from Medicare. As Reid said, that's a gong time to wait, to get the commitment to provide health coverage.
To no surprise at this point, all Democratic and Independent Senators voted in support, including our California Senators @Barbara_Boxer and Dianne Feinstein. All Republicans in attendance (Sen. Bunning was not present) voting no. They only needed 50 votes (plus Vice President Biden) for this final vote but got the 60 that allowed the vote to take place. There was applause in the gallery, including from Senator Kennedy's widow, who was in attendance, and Congressman John Dingell--two figures who indicated the long legislative history of attempts in this area. Many Senators gathered afterwards with handshakes and hugs.
Readers of this blog probably already have links to the early morning commentary of Jon Cohn and Ezra Klein. But if not, they are worth reading. Talking Points Memo has other response from across the political spectrum. There wass lots of commentary on the blogs and on Twitter, even by allies in California like @CPEHN, @CALPIRG_mike, and others, sometimes with the whimsical hashtag #cspanatdawn
The most important responses, however, are those of the members of the House of Representatives that have to negotiate with the Senate for a final bill. The three chairmen of the three main House Committees, including Californians George Miller and Henry Waxman, released this statement that suggests their positioning, pointing to similarities and differences:
“We commend our colleagues in the Senate for this crucial vote, which brings health reform closer to reality than at any time in the past 70 years. While there are clear differences between the bills passed by the Senate and the House, both bills will bring peace of mind and fundamental health care coverage to millions of Americans who are currently uninsured.
“Both bills will slow the growth of out-of-control health care costs and reduce the deficit by over $100 billion in the first ten years – and by much more in the second decade. Both bills will make unprecedented reforms to the insurance industry to hold insurers accountable and protect consumers from delays or denials of care based on pre-existing conditions, from rescissions, and from exorbitant out-of-pocket expenses that bankrupt far too many Americans. Both bills will protect and expand peoples’ choices of doctors and health plans. And both bills will offer relief to small businesses getting crushed by spiraling health costs.
“Now that the Senate has cleared this critical legislation, we look forward to working with them and the White House to reconcile and further improve our bills. We are committed to producing a final bill that incorporates the best reforms for middle-class families, small businesses, seniors and our fiscal health, stays true to the values of our members and delivers on the changes the American people desperately need.”
Finally, here's yesterday's statement, from Politico, from two other California Congresswomen, Lynn Woolsey, the chair of the Congressional Progressive Caucus, and Barbara Lee, chair of the Congressional Black Caucus, on what they are seeking in the final negotiations.
"Now that the Senate is poised to pass its version of a health care reform bill, it is time to turn to reconciling it with the House legislation... For Congress to achieve true health care reform we must have a meaningful conference process that integrates both bills into the best possible piece of legislation for the American people."
They list top prioirities:
"A public option — If the bill requires people to buy health insurance, there must be a public option to bring down costs by providing lower-cost competition to private insurers and choice to consumers."
"Affordability protections — The legislation must protect lower and middle-income individuals by ensuring that subsidies make coverage affordable and that Medicaid patients have access to primary care physicians."
"Tighter market regulations — New regulations must keep premiums reasonable and end abusive practices. Insurance companies should no longer be exempt from anti-trust laws and any premium increases must be reviewed before they take effect."
“Employer mandates — If individuals are required to buy insurance, employers should be required to provide it."
“Tax surcharges — Health care reform should be financed by tax surcharges on the wealthy not excise taxes on health insurance plans offered to many workers and union members.
The final product will be better than the Senate bill, and I think by more than what the conventional wisdom suggests. For political and policy reasons, the House will not simply take what the Senate has passed. And while there are some specific areas where it will be hard to revisit hard-fought compromises, there's still leaves lots of room for refinement and improvement. The pressure will be the timetable to get this done quickly.
But California advocates are especially important here, to communicate and advocate and organize with our key Congressional delegation what our priorities are for the final negotiations. We can't disengage now--or at the very least, we need to get right back to work after the holiday break!
"With passage by the Senate, the nation has moved one big step closer to comprehensive health care reform. Health Care for America Now will work to get the strongest bill to the President's desk, one that provides good, affordable coverage to all and holds insurance companies accountable. To realize the promise of reform, we need to be sure that employers are required to help pay for good coverage for their workers, that premiums are affordable to families, that we do not tax benefits, that we enact tough insurance regulations, and that we offer the choice of a public health insurance option. We will urge President Obama to work with leaders in both houses of Congress to agree on legislation that meets these goals, guaranteeing good health coverage we can count on."
We have watched much but not all of the Senate floor debate on health reform. We enjoyed Roland Burris' version of the Night Before Christmas, which closed with "health care for all, even our friends on the right".
But I was most taken aback to hear Sen. John Ensign (R-Nevada) cite favorably a US Supreme Court case that overturned child labor laws as the constitutional basis for opposing health reform. This is like citing Plessy v. Ferguson, the case in which the Supreme Court upheld state laws on segregation, as a justification for opposing Medicaid and Medicare, saying that the states should be responsible for health care for the poor and seniors just as the Supreme Court allowed states to set their own standards for segregation.
Overturn child labor laws? Eliminate the minimum wage? Why? Because the federal government should not interfere in the rights of the states to regulate the right of children to work or minimum wage. This parallels one of the fundamental arguments that is made by the opposition to health reform: the federal government should stay out of health care--except of course for Medicare (which Chuck Grassley and John Ensign now claim to support).
Just as it seems presposterous to think that the federal government cannot prohibit child labor or set a minimum wage, it should be preposterous to think that the federal government cannot reform health insurance. After all, regulation of insurance is a right reserved to the states under federal law, now long uncontested, the McCarran Ferguson Act. And if the federal government gave states the right to regulate insurance, then Congress and the President can act to change that.
But it gives us a glimpse into the world that the opponents of health reform seek--a world where there are no child labor laws to kill jobs for children, where there is no minimum wage to deny low-wage workers the chance to compete for the lowest wage, where there is no guaranteed Social Security benefit so seniors and the disabled live on whatever their family can help with. Today this is the world of the uninsured who are entitled to just as much health care as they can afford out of their own pocket.
We have written lots (and will write more) about how the health reform proposals now pending in Congress can be improved but here's what we know: if we do health reform right, it is the equivalent of creating Social Security for retirement, the minimum wage for wages and yes, child labor laws to protect the most vulnerable among us.
And what we also know is that the fight still goes on to protect Social Security, to increase the minimum wage and yes, even more sadly but thank goodness more rarely, to protect children from being forced to work. Americans have a right to Social Security, they have a right to a minimum wage, and children have a right to go to school, not to work--and we should have a right to health care. So we agree with Senator Ensign that the fight for health reform is like the fight to outlaw child labor---but we think the federal government should outlaw child labor and he apparently does not.
More on the Governor's letter and budget threats...
This morning numerous media stories featured the threat by Governor Schwarzenegger to eliminate the IHSS program unless California is given "flexibility" to cut Medi-Cal eligibility from 106%FPL for parents to 70% (about $850 a month for a single mom with one child), to cut provider rates (already 51st in the nation), and to reduce other benefits.
The Governor blames restrictive federal rules and the cost of health reform. He alleges that the federal health reform will force California to spend $3 billion annually on Medi-Cal.
Creative arithmetic: The Governor says that federal health reform includes "required spending" that would increase Medi-Cal outpatient provider rates to 80% of Medicare. While Health Access supports improving Medi-Cal provider rates, nowhere in any of the federal proposals is California required to increase all outpatient rates to 80% of Medicare. The federal proposals do require an increase in reimbursement for primary care but provide enhanced federal reimbursement for that purpose.
The Governor also assumes that 100% of those eligible for Medi-Cal will sign up. In contrast, the Congressional Budget Office assumes that only half of those eligible for Medicaid will sign up. Health Access hopes we could get closer to 80% enrollment or take-up but that would take lots of changes in our Medi-Cal program (more on that over the next few months).
What happens when? The Governor is correct that both the House and Senate versions of health reform impose a "maintenance of effort" requirement on Medicaid/Medi-Cal and CHIP/Healthy Families. This "MOE" requirement would preclude California from reducing eligibility for these programs from now until full reform kicks.
But the Governor in his rhetoric ignores that the expansions of Medicaid do not occur until 2013 (the House) or 2014 (the Senate) and that for the first two or three years, the feds pick up the entire cost of the expansion.
And then in 2018 or 2019, California would be on the hook for 9% (yes nine percent) of the cost of the expansion (under the House bill) or 18% (the Senate bill). So instead of the 1:1 match we usually get, California would get either a 9:1 match or a 4:1 match for the newly eligible. And that would be almost a decade from now!
What did we find? Under the House bill, if half of those eligible for Medi-Cal enroll, then California actually saves $200 million and covers about 840,000 of the 2 million eligible for Medi-Cal under the House bill. Under the Senate bill, if 80% of those eligible enroll, then Californian needs to commit about $700 million to cover 1.3 million of the 1.7 eligible for Medi-Cal. And that is in 2019.
Better deal for California: We agree with the Governor that the existing federal matching formula for Medicaid, known as the FMAP, should be revised to reflect more accurately the need of Californians for an adequately funded Medicaid program that serves 7 million Californians and that should be expanded to serve more. However, we bet the Governor would get further with this idea if he was willing to step up and increase revenues to close California's budget gap instead of making the budget gap worse by sponsoring bond measure after bond measure that imposes additional debt obligations on the General Fund.
Governor Arnold Schwarzenegger used to be the champion of health reform. He supported a reform model on the basis of "shared responsibility"--the state would do its part, but he'll ask contributions from individuals, employers, providers, and local, state and federal governments, etc. He proposed raising revenues--both legislatively and going to the ballot--to expand programs like Medi-Cal and Healthy Families, as a way to get more of the 50/50 federal matching funds that were available to use, but we were not taking advantage of because of our lack of investment.
Things have changed radically. This past year, he proposed to cut Medi-Cal and eliminate Healthy Families. He refused to consider revenues to save these programs he appropriately sought to expand merely two years ago.
And now, he's been badmouthing health reform as a burden to states. For the last week, GOP Senators have invoked him in their opposition to health reform in floor speeches. For all practical purposes, he has emerged as an opponent to health reform, highlighting the cost to states.
Yesterday, the Governor sent a letter to the California Congressional delegation, circulating a $3 billion figure as the cost to the state of California. It's hard to account for how highly inflated that number is. It includes a Medi-Cal provider rate increase that is not required, an assumption that every single person eligible will sign up, and neglects that it will take nearly 8 years--a couple of Governors from now--for full implementation and any costs to materialize.
Here's the short version: the state gets savings of a couple hundred million dollars in the first several years. Even when the Medicaid expansion for 1.5 to 2 million low-income Californians takes into effect in 2013 or 2014, the federal government will pick up 100% of the cost of newly-eligibles for 2-3 years. Finally, there is a cost to the states--but not with the normal 50/50 split, but with either 82% or 91% of the bill being picked up by the feds. That's somewhere between a 4:1 to a 9:1 match--much more generous than the current matches in Medi-Cal (1:1) or Healthy Families (2:1).
For states, that's not a burden, that's a bargain.
So much for "shared responsibility." What really seems to get Governor Schwarzenegger is that he won't be able to make additional cuts on both Medi-Cal and SCHIP, because there would be "maintenance of effort" requirements that states continue what they have been doing. In his letter, he threatens the complete elimination of In-Home Support Services, CalWORKS and other programs.
I understand that every Governor wants to bring in more federal dollars. But misrepresenting our situation won't help. In order to get federal funds to solve our budget woes, he is ready to take hostages--whether that be IHSS or CalWORKS at the state level, or health reform at the federal.
That can't be the only or best way to get the added federal funds we agree we need.
As we have written previously, the manager's amendment to the Senate bill that was adopted earlier today makes a number of changes to the Senate bill.
Our California Senator Barbara Boxer, as well as Senator Dianne Feinstein, won a significant improvement for California as well as six or seven other states, including Idaho, North Carolina and Michigan.
It is easy to figure out that Nebraska (and Hawaii) got something in the Medicaid provisions because those two states are mentioned by name.
We guessed that California met the following: "If the State is not a low DSH State described in (5) (B) and has spent more than 99.90 percent of the DSH allotments for the State on average for the period of fiscal years 2004 through 2008, as of September 30, 2009, the applicable percentage is 35 percent."
What is that and why do we care? DSH or Disproportionate Share Hospital funding is a key part of Medicaid funding for hospitals. In some states, DSH helps to make up for low Medicaid reimbursement rates. In other states, including California, DSH helps to cover the cost of care by hospitals for the uninsured as well as improving low Medicaid rates.
DSH is a big deal in California both because we are 51st in Medicaid reimbursement and because we have such a high proportion of uninsured.
So what did our Senators win for us? The earlier version of the Senate bill cut DSH funding in half once the rate of uninsurance drops. The new version would cut DSH funding by only 35%.
This moves the Senate bill much closer to the House version in terms of the DSH cut, at least for California, Idaho, North Carolina, Michigan and several other states.
An end of the year bonus—and one that we really earned!
On Friday, December 18, 2009, Health Access received word that the timely access regulations will be final effective January 17, 2010.
We have worked on this issue for more than a decade. The original HMO Patient Bill of Rights, a package of more than twenty bills, included timely access inAB497 (Wildman). AB497 was vetoed in the face of bitter opposition from the HMOs and the Wilson Administration. The legislative staff for the Department of Corporations which was responsible for regulating at that time told us that whatever an HMO decided was timely access was the standard. That was not nearly good enough for Health Access.
AB497 set specific standards for timely access, standards that are remarkably similar to those that are now in effect. AB497 required that: * A telephone call be answered within four minutes * A non-urgent appointment be provided within ten days * A medically urgent appointment be provided within 48 hours
And what do we have in the regulations just finalized? * A physician, registered nurse or other appropriately licensed health care professional must provide telephone triage within 30 minutes * A non-urgent appointment must be provided within ten days * An urgent appointment must be provided within 48 hours Plus a variety of other standards for mental health services and dental care.
Well, maybe four minutes was a bit of a stretch but the notion that every consumer can get triage in time to get to an emergency room within the so-called golden hour, if needed, is now part of the requirements for all physicians who contract with DMHC plans, which is virtually every practicing doctor in California.
Timely access was not part of the package of legislation adopted in 1999 that we usually refer to as the HMO Patient Bill of Rights. Instead, timely access (AB2179 Cohn) and language access (SB853 Escutia) were adopted later along with standards of prescription drug coverage (SB842 Speier), all enacted in 2002 or 2003. And the strategy for both timely access and language access was the same: the law required the DMHC to adopt regulations that specify how HMOs and PPOs would meet the obligation to provide care in a timely manner and in the language spoken.
Language access regulations were completed prior to those for timely access but the timely access regulation ties down one key piece of language access: that the requirements for interpretive services run concurrent with the timely access requirement—that is, when you show up for the doctor’s appointment within ten days, they should be prepared to provide care in the language you speak.
We have worked on this issue for more than a dozen years. The enactment of the regulations are a major milestone. But our work is not done—now we will look to see whether HMOs and providers comply and how vigorously the regulations are enforced.
SENATE VOTES TO MOVE HEALTH REFORM THIS WEEK * "Manager's Amendment" Make Changes--Good and Bad--to Health Reform Bill * New Language Secures 60 Votes in Senate to Llimit Debate, Have Final Vote by Christmas Eve * Next Step: Negotation over Key Differences between House and Senate Bill * Public Hearing at NAIC, Updates on Twitter.....and other news for the week...
60!: Earlier around 1am East Coast time this morning, the U.S. Senate held a key vote, mustering the required 60 votes needed to cut off the debate and proceed to subsequent votes later this week to pass major health reform from the Senate floor. California Senators Barbara Boxer and Dianne Feinstein both joined all 60 Democratic and Independent Senators to vote for the motion; All 40 Republican Senators voted against it.
Further votes are expected Tuesday, Wednesday, and final passage Thursday, December 24th, Christmas Eve. That would then start negotiations to reconcile the Senate bill with the House health reform measure passed earlier in the year. The expectation is that those talks will go into January, but with a goal of a final agreement, and one final vote in the House and Senate, by the end of January.
The 60 votes were secured largely through changes made through a 380+ page "manager's amendment." The full text of the bill, and the amendment, is available at: http://www.democrats.senate.gov/reform/
The advocacy done in the next few weeks, especially with key California Congressional members, will help determine the final shape of the bill.
ADVOCATES CONTINUE TO PUSH ON HEALTH REFORM & THE RIGHT REFORM: Lat week, Health Care for America Now! events around the state mobilized hundreds in several locations to advance health reform, and to push to improve provisions that are pending as we speak. These efforts included actions at hospitals where workers and patients called their Senators, to visiting offices of key Congressional members. For more information about these events, contact Patrick Romano at email@example.com.
HUNDREDS MARCH IN SAN FRANCISCO: People for meaningful health reform took to the streets of San Francisco, carrying candles in a vigil to honor the 45,000 Americans who die each year for lack of health insurance. The procession of about 350 people, walking from Yerba Buena to Union Square, moved silently out of respect for the deceased. Health Access, as the lead California organization working on behalf of Health Care for America Now, joined in coordinating the march, which attracted the notice of radio, TV, and print media.
ADVOCATES ON ALERT: The upcoming holiday season differs from many others because of what's at stake for health reform -- in the U.S. Senate, the governor's upcoming state budget, and the state Department of Health Care Services' Medi-Cal waiver proposal to massively restructure the program that provides coverarge to nearly 7 million Californians. Health Access encourages you to keep in touch with each other -- and us -- through Twitter, our Facebook page, and our blog. Don't miss any opportunities to make calls, march or speak out on behalf of real reform!
MAKING THE CASE ON TELEMUNDO: The case for equitable health reform is being heard again and again on YouTube, as it was recently on Telemundo. The Spanish-language television network reported on how the needs of legal immigrants fit into the health care debate. One of the community advocates interviewed was Health Access' Nancy Gomez, an organizer in our Los Angeles office. Watch it here, on YouTube.
AND THEY CALLED IT A PUBLIC HEARING...: Two of Health Access' experienced policy experts attended a public forum in San Francisco recently of the National Association of Insurance Commissioners. Elizabeth Abbott and Beth Capell were in attendance to gather/share information and concerns about the huge changes in health care delivery our nation is about to embark upon-- the biggest shift since Medicare and Medicaid were enacted 45 years ago. They were concerned at what they found. Read about their watchdog reports on our blog.
With those changes, Senator Ben Nelson of Nebraska announced his support for the health reform proposal. This means that barring a surprise, the Senate Democrats have the 60 votes necessary to pass the bill off the floor and into conference committee. Given the wide ideological spectrum in the Democratic Party, this is a significant feat--and a bill that is necessarily a compromise.
Here's a list from Senator Reid's office of the components of the manager's amendment, with editorial comments from HCAN's Blog:
* Stronger medical loss ratios. Health insurers will be required to spend more of their premium revenues on clinical services and quality activities, with less going to administrative costs and profits - or else pay rebates to policyholders. These stricter limits will continue even after the Exchanges begin in 2011, and apply to all plans, including grandfathered plans. (Ed note: Reportedly, these require group insurance plans to pay 85% of premiums to health care, and individual plans to pay 80%. These would go into effect in 2011. In 2012, the ratios would be based on the average medical loss ratio in the Exchange.) * Accountability for excessive rate increases. A health insurer's participation in the Exchanges will depend on its performance. Insurers that jack up their premiums before the Exchanges begin will be excluded - a powerful incentive to keep premiums affordable. * Immediate ban on pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage of pre-existing conditions for children. Patient protections. Health insurers will have to abide by a set of patient protections that, for example, protect choice of doctors and ensure access to emergency care. * Ensuring access to needed care. The use of annual limits on benefits will be tightly restricted to ensure access to needed care immediately, and will be prohibited completely beginning in 2014. * Guaranteed opportunity to appeal coverage denials. All health insurers will be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable. * Multi-state option. Health insurance carriers will offer plans under the supervision of the Office of Personnel Management, the same entity that oversees health plans for Members of Congress. At least one plan must be non-profit, and the plans will be available nationwide. This will promote competition and choice. (Ed note: At least two plans will have to be offered, one of which must be non-profit. OPM can negotiate medical loss ratio, profits, premiums and other terms.) * Free choice vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an exchange plan. * Children's health. Support will be extended for the Children's Health Insurance Program and the adoption tax credit. Foster care children aging out of Medicaid will be able to retain its comprehensive coverage. * Rural and underserved communities. Access will be expanded through funding for rural health care providers and training programs for physician and other types of health care providers. * Revised abortion language, including state opt-out of abortion coverage (Ed note: details here)
How will health reform prevent the insurance companies from unjustified rate increases and consumer abuses?
That was one of the main rationale for the public health insurance option, which is still in the House bill and not in the Senate version of health reform. It's not the only mechanism with this goal. Noam Levey at the Los Angeles Times has a good story today focusing on the regulation of insurers in the bills.
It's a topic that has gotten little attention in the media, and so people assume there's little of it in the bill. But the list of new consumer protections is long, both of ones that people have heard of, and ones that people haven't. A partial list of new or improved insurance regulations (compared with the status quo in California) includes:
* Rescissions prohibited on day one. (Thousands rescinded in CA; Settlements with insurers have been negotiated but regulations and legislation stalled.) * No denials or discriminatory pricing based on pre-existing conditions. (Hundreds of thousands denied in CA now.) * No denials or discriminiatory pricing based on gender. (Just banned in CA to go into effect next year.) * A limit of any pricing difference based on age of 3:1 from the oldest to the youngest on a 3:1 basis. (No limit in CA now; practially the pricing difference on age is 9:1) * The establishment of a basic benefit package for all health coverage (Some mandated benefits in CA now, but not even all the basics in Department of Insurance plans: there's not even a requirement in CA that coverage include both doctor and hospitals) * A minimum actuarial value for all plans, and labeling of products based on their comprehensiveness. (No minimum in CA, and lots of "junk" plans that pay out very little are sold in CA) * Standardized definitions between plans of product services (CA health plans are not consistent even within a company over what counts for a "deductible," for example.) * No arbitrary annual caps on coverage (No limits in CA on Dept. of Insurance plans.) * A maximum cap on out-of-pocket costs of $5000 or $6000--and less for lower-income families--so even a plan with higher cost-sharing will at least prevent bankruptcy (No limits in CA on Dept of Insurance plans.) * No cost-sharing for preventative services. (No regulations in CA.) * Minimum medical loss ratio so that money goes patient care rather than administration and profit. (Existing MLRs exist at DMHC and DOI, defined differently. Legislative efforts in CA to increase the MLR have stalled.) * Regulatory review of insurance rate increases. (No process now; CA legislation stalled.)
The article describes the predicament of how to describe what's in the bill. At one level, we appreciate the significant insurance oversight in the bills that goes well beyond our current framework, but will it be sufficient?
Here's two lines from the article that sum it up:
"In any other year, these changes would be cause for a White House signing ceremony with bands and fireworks," said William Vaughan, health policy analyst for Consumers Union.
Like any regulatory framework, however, this one has holes.
Some of the holes are specific and have been identified. As Brian Leubitz of Calitics reports, a majority of the California Congressional delegation--led by Reps. Jackie Speier and Susan Davis, former state legislators that sponsored state consumer protections that Health Access sponsored and/or supported back when--wrote to their leadership to fix a concern about provisions that would make it easier for plans to be sold in one state from states with weaker patients' rights law.
Other holes are one about degree--is it enough? And that's why we need to push hard in conference committee to make it better.
For example, California's Senator Dianne Feinstein has been championing a “rate authority” amendment that would beef up the rate review sections of the bill. Health Access California joined several groups in support of her proposal. We'll see how that effort fares.
We hear Senator Majority Reid's "Manager's Amendment" will include a higher medical loss ratio, incorporating a popular amendment by Senator Al Franken.
But that suggests an issue in other provisions: what is enough? I am pretty sure that the minimum actuarial values proposed in the bills are too low, especially in the Senate. There are those who defend a lower actuarial value, as providing consumers a choice of a lower premium product, even if it provides a lower value. I would argue that a product that ends up only covering on average only 60% of a patient's health expenses shouldn't be called coverage--as a someone said on Twitter, that's just splitting the bill.
But even the mere fact of having a standard on actuarial value, on out-of-pocket costs, on other issues, is a major reform. Would it have been worth it to pass a minimum wage, even if the wage were to be set lower than was really needed? Or does it provide some protection to get rid of the worst abuses, and provide a policy construct for the future? Or it the standard that is set so low as to be meaningless?
Either way, we need to continue to press for strengthened insurance oversight.
Final thoughts: When focusing on a public option and on regulatory oversight, the LA Times article neglects a third strategy regarding insurer accountability regarding insurance company abuses and unjustified rate increases, by using government as a regulator, a negotiator, and a competitor. Without the competitor of a public health insurance option, there needs to renewed focus on the other two strategies.
The strategy of negotiation should merit attention. The new health insurance exchanges are seen as a way to bring individuals and small businesses together, to get both the efficiencies and group purchasing power of large purchasers. The combined Senate bill includes Senator Kerry’s “active purchaser” language--which is similar to the House—to allow the exchange to negotiate with health insurers for the best possible price. Large employers and purchasers typically get better rates and insurers have less overhead and profit. The House is even stronger in this regard, and that’s what we hope can come out of conference committee. It’s another piece of the effort to control costs.
The key point is that these accountability strategies are not either/or. Given that no consumer protection is airtight, there is a need to try multiple efforts to provide the security that families so desperately need. That's why, in addition to the provisions in the bills, and the improvements being attempted, we need to continue to work for a public health insurance option, even if we doesn't get included in this package.
Word has come that the federal government will permit, for a limited time, California to take advantage existing federal rules to implement AB1422 (Bass) which would help to fund the Healthy Families program.
This is a great relief. Until now, we heard very discouraging words from those in DC about the prospects for approval of federal matching funds through the extension of the gross premiums tax to Medi-Cal managed care plans.
As you may recall, the health coverage of almost a million children was put at risk as a result of the budget adopted by the Legislature and the further line item vetoes by the Governor back in July. AB1422 was a last ditch effort supported by both the insurers and the advocates to find a way to end the waiting lists and avoid disenrollment of hundreds of thousands of children in the midst of the great economic downturn.
When we learned of the difficulties at the federal level, in a matter of days, an impressive coalition of 20 California groups signed a letter of support for the implementation of AB1422 for Obama Administration.
The federal Centers for Medicare and Medicaid Services will pursue a formal rule making process that is likely completed in June 2011 or later.
Nobody wants a lump of coal in their stocking, least of all the children of California---and in the land of sunshine and oranges, every kid should have health care—and now a million of them will have that chance.
Two years ago today, December 17, 2007, there was an Assembly vote on a comprehensive health reform in California, the result of a year-long negotiation between then-Assembly Speaker Nunez and Governor Schwarzenegger. The bill went on to defeat in the state Senate.
There was a debate about whether the bill was worthy of support. Many consumer and constituency groups supported it, but some didn't.
The political situation before us is both strikingly similar, and radically different. Same goes for the policy proposal itself.
One big difference is that the bill in 2007 was a final product, in more ways than one. A companion ballot measure had been filed, and so the Senate was being asked to ratify it without changes. Were the ballot measure to pass, key parts would not be easily changeable.
The situation now is different--the bill is still in flux, and there are things to win, and to lose: the next week the Senate is considering to move an amended health reform bill, to go to a conference committee. It will need to be melded with a House bill, which is a very good bill, before final votes in the House and Senate in January. Even after passage, there will be opportunities to improve the bill in the years ahead, at both the federal and state level.
My take: we only lose when we give up. And we shouldn't give up. Others who have concerns with the Senate bill are echoing similar themes.
So I am concerned that some seem to be giving up on the current process. There's been a back-and-forth on the positioning of the Senate health reform bill, where Nate Silver of FiveThirtyEight has asked "20 Questions" for those who would kill the Senate health reform proposal; bloggers at DailyKos and FireDogLake have responded; and FiveThirty Eight followed up.
New facts about why health reform is needed in CA...
Under all versions of health reform currently pending in Congress, millions of Californians would get significant help in affording their coverage and/or in improving the comprehensiveness of their coverage, according to three new studies just released by UC-Berkeley and the University of Chicago. The studies also indicate the important differences between the House and Senate versions, as they head into conference committee.
The data puts into context the millions of Californians who would get help under health reform--and not just the uninsured. Many who have coverage would get more stability and security.
Here are some of the key findings from these three important studies that have been just released about the impact of health reform on California.
* Californians' Access to Coverage under the Health Reform Proposals This data brief finds that nearly 4 million Californians who are without health insurance, covered in the individual market or enrolled in unaffordable job-based coverage, would be eligible for Medicaid or subsidized coverage under the national health reform proposals. The brief analyzes both the House and Senate legislation to compare how they differ in their impacts on Californians. * Close to 2 million Californians who were uninsured, in the individual market or had unaffordable employer sponsored insurance in 2007 would qualify for Medicaid under the House bill, compared to 1.74 million under the Senate bill. * 1.93 million Californians would be eligible for subsidies in the exchange under the House bill and 2.19 million in the Senate. * 95 percent of California businesses, employing 44 percent of all workers would be eligible to purchase coverage through an exchange by 2015. * One out of five businesses would be eligible for tax credits towards the purchase of that coverage.
* National Health Reform Requirements and California Employers This issue brief analyzes the impact that the House and Senate health reform proposals would have on the 18.4 million Californians who are enrolled in employer-based insurance. While the vast majority of employees work for firms that currently comply with most of the new requirements for employer-based insurance included in the bills, reform legislation, if passed, would increase protection for many insured workers and their families in California. Many workers would have their coverage improved under these bills. They include those who's coverage now is less than comprehensive: * 23 percent of workers with employer-based insurance are enrolled in a plan either without an out-of-pocket limit or a limit exceeding $5,000. * Over 40 percent of insured employees are enrolled in a plan with a lifetime limit. * About 10 percent of California insured workers are enrolled in a plan where preventive benefits are subject to a deductible.
* How Would Health Care Reforms Change the Spending of California Families Without an Employer Plan? This report uses simulated claims data to project out of pocket costs at different cost sharing subsidy levels for the House and Senate bills, and provide a comparison to costs in the current individual market in California. Among the findings: * Californians with an income of $16,245 a year would save $5,053 on average on premiums and out-of-pocket costs under the House bill compared to what they would spend in the current individual market; they would save $4,116 under the Senate bill. * Those with an income of $43,320 a year would save $838 a year under both plans compared to what they would spend in the current individual market. * California families of three with typical health care use earning less than $59,000 would spend significantly less under the House bill than the Senate bill, while those earning between $59,000 and $73,240 would spend less under the Senate bill.
We have worked with Ana for years, from when she staffed for Senator Deborah Ortiz on one of the first bills to prevent hospital overcharging, to her time staffing health legislation working for the Governor's office. She emerged as a smart and tough-minded negotiator for the Governor in the final efforts in late 2007-08 to pass a state health reform measure.
She has served this Governor loyally; no one should mistake her appointment as a signal of the content of the budget, despite the facts that she is the first Latina to hold the post, her Democratic beginnings or familiarity with health and human services. All indications are she will be a familiar face for a truly awful budget, given not just the severity of the budget situation, but the direction that the Governor has taken in the last year against the additional revenues needed to prevent cuts, even proposing to eliminate Healthy Families, CalWORKS, and other key health and human services.
What might be in the next budget that the Governor will announce sometime before January 10? We will likely revisit and even go beyond the cuts that were rejected last year as too severe--and given the cuts that were made, that's saying something. Some of those cuts had literally life-and-death consequences.
Much more on the budget to come...but for the moment, congratulations and condolences to Ms. Matosantos.
I am perplexed by the line among some in the blogosphere, where some, including Howard Dean, are arguing to stop the Senate health reform bill.
But it's clear we still have an opportunity to make it better, as it goes to the House of Representatives--especially on issues like affordability, employer responsibility, and insurance regulation. We here in California have an important voice to tell the leadership and the rank-and-file to stand strong on the range of issues.
If there's a moment to make a final assessment of a final product--to assess the positives and negatives and make a final decision--this isn't it, not when we still have the opportunity and obligation to fix it.
Senator Jay Rockefeller, who has been a champion on health reform for decades, rebuffed Dean's argument below. He also makes a point that once we pass the framework, there is opportunity for improvement in subsequent years as well. If health reform fails, then we are stuck with the old system and politicians will run from the issue for a generation. If we pass a framework, there will be opportunities and efforts to make changes every single year. As the health policy enthusiast he is, he exclaims, "I love that."
Today, there was a rally and "die-in" in Washington, DC by "tea party" opponents of health reform, chanting "kill the bill." One of the speakers was Rick Scott, the disgraced former CEO of Columbia/HCA and now head of Conservatives for Patients Rights. Other speakers were talk radio hosts, Dick Armey, the former Republican Majority Leader of the U.S. House, and current elected officeholders like Representative Michele Bachmann and Senator Jim DeMint.
Judging from watching the rally on C-SPAN, the news of the removal of the public health insurance option in the current Senate bill may have gotten a few Senators votes, but did nothing to minimize opposition from these speakers.
Maybe because they recognize that there is more at stake than the public health insurance option.
For those of us who think the public health insurance option is important, we need to continue to advocate for it--there's still conference committee, and there will be opportunities in implementation, both in DC and here in California.
But a public health insurance option as envisioned really only works if it is in the context of a broader framework like proposed in this bill. A public health insurance option, to be successful, needs to operate by the same rules as the private insurers it competes with. So if insurers are allowed to deny patients for pre-existing conditions, the public health insurance option will have to follow suit. It's only in the context of a framework of a regulated exchange with guaranteed issue and modified community rating, like the current health reforms provide, that a public health insurance option can both thrive on its own, and be a competitor for insurers rather than a dumping ground.
It's an entire framework that would change the health system we have. One that would: * Makes almost 4 million uninsured Californians eligible for coverage * Means that when you lose your job or get divorced, you don’t lose your health insurance * Requires insurance companies to take everyone * Prevents insurance companies from dropping you when you get sick * Makes health insurance more affordable for millions of Californians * Begins to reduce health care spending overall * Imposes rate review on insurers * Says the insurers must spend at least 80 cents out of every premium dollar on health care * And provides for the largest expansion of public programs (still) since Medicare and Medicaid were created.
But there are other aspects of the framework that the Senate bill is deficient, in some cases seriously so. How much do we ask of low- and moderate income families in terms of getting affordable coverage? What is the minimum level of coverage that a health plan should provide? Should all large employers contribute into the health care system? How is this financed? Are we going to impose cumbersome verification procedures for people to buy coverage that make it harder for people to get coverage?
As evidenced by the opposition rally today, the opponents of health reform aren't done in there efforts to either stop the process or make the bill worse.
We can't let up. Our task is to continue to work to both move the process forward, and to make it better.
Ezra Klein of the Washinton Post has a post that details the situation, and especially the timing moving forward: Votes starting as soon as Thursday lead to a timetable that extends to Christmas just to report the bill off the Senate floor.
And then there's conference committee, with a House bill that is superior in many ways.
That's the one thing I want to emphasize tonight. This is not the time for the final evaluation of the bill, for taking a step back, for either giving up or going along. There's still work to do! The health reform fight isn't over..
There's lots of fights on very important provisions still left to be won or lost in Senate and in conference committee. We need to continue to advocate on the very crucial issue of affordability, and on issues like employer responsibility, insurer regulations and oversight, inclusivity, financing, as well as continuing to look for opportunities to include public health insurance options.
The fight isn't over to make it the best bill it can be--or to prevent it from getting worse. We still have work to do.
The other night on the PBS Newshour, our colleague Jacob Hacker, who was briefly at UC Berkeley and has now returned to Yale, said that the Senate compromise on the public option was a bit Dickensian, a tale of two public options, the best of times and the worst of times---that is a public option that was an expansion of Medicare to a new population, those aged 55 to 64 was the best of the public option while he was disappointed by the trigger on a public option available in the exchange. (He's also not impressed with another part of the deal, national nonprofit plans offered by the Office of Personnel Management.)
What would a Medicare buy-in mean for California? Courtesy of www.chis.ucla.edu, we took a look at how many Californians might benefit. Of the 3.7 million Californians ages 55-64, almost 12% are uninsured and another 7% buy their own insurance. That means that almost 20% of Californians aged 55-64 might benefit from a Medicare buy-in, especially if (or when) affordability credits are made available to help them afford that coverage.
This is a very big deal for those aged 55-64. In the current individual insurance market, these are exactly the people that are all too often uninsurable—precisely because by that age, most people have one chronic condition or another or have had an illness or surgery that made them uninsurable. And while 65% of those aged 55-64 have employment-based coverage, losing that coverage is a devastating life event at an age when most people expect to need health care. The Medicare buy-in would eliminate that fear.
We are somewhat bemused by the reaction of doctors and hospitals to the expansion of Medicare. The 4 million Californians who rely on Medicare today seem to have ready access to doctors and hospitals. Would an increase from 4.1 million Californians with Medicare coverage to 4.8 million undermine the ability of doctors and hospitals to provide care? The protests seem especially odd to us when a majority of those who might benefit from a Medicare buy-in are uninsured.
Health Access California congratulates John Perez on winning the unanimous support of the Democratic caucus to become the next Speaker of the California Assembly.
John Perez has been known to us for many years. While the many media accounts took note of his roots in the labor movement, we first met John when he was appointed by Senate President Pro Tem Bill Lockyer in 1997 to serve as a consumer representative on the Managed Care Advisory Task Force. Then-Governor Pete Wilson created the Managed Care task force as a means of thwarting the campaign for the HMO Patient Bill of Rights, sponsored by Health Access California.
John Perez was a forceful voice for consumers during the months of meetings of the managed care taskforce. We are pleased to note that when Governor Gray Davis signed the HMO Patient Bill of Rights in 1999, it was an even stronger package than the original proposal---in part because of the willingness of a broad range of consumer advocates to speak up for even stronger reforms of HMOs.
We also know John Perez because he led the Stonewall Democratic Club in Los Angeles along with Anne Marie Staas Niedorf. Health Access California was one of the many beneficiaries of Anne Marie’s long history of activism: she hosted more than one house party devoted to health care, including the HMO Patient Bill of Rights. We are saddened to report that Anne Marie finally lost her long battle with her various ailments last month. May she rest in peace.
John Perez has also served on the President’s Council on HIV and AIDS as well as on the board of AIDS Project Los Angeles, giving him insight into a key health issue that shows many of the flaws in our health care system.
And we would be remiss if we did not note that John was political director of UFCW during the very difficult grocery workers strike in Los Angeles in 2003, a strike over health benefits that helped to set the political context for the fight for an employer mandate in SB2(Burton)/Proposition 72 of 2003 and 2004--which in turn led to the passage of Healthy San Francisco and the employer reponsibility elements of proposed state and national health reforms. Health Access California is proud to have worked with the California Labor Federation and the California Medical Association on that pivotal campaign that restarted the health reform conversation in our state, and eventually nationally.
We greatly look forward to working with Speaker-elect Perez in his new role, which will include the massive amount of work to implement federal health reform at the California level.
Speaking of Twitter, if you aren't on it, you should be! For why and how, read this piece in the California Pan-Ethnic Health Network's online newsletter, which I co-wrote with the prodigious Rachel Larson of CPEHN. It answers such burning questions as: * Why Tweet? * What Is Twitter? * How Do I Get Started? * How Do I Find People to Follow? * How Do I Get People to Follow Me? * What Are All of the Symbols I See in Other People's Tweets? * How Do I Keep Up with Twitter?
This technology enhances in-person communications, but doesn't replace it. We are happy to be having our holiday party at Max's in Oakland this evening with our colleagues at CPEHN and elsewhere. But if we don't see you there, we look forward to tweeting with you!
My colleague, Beth Capell, has already posted her impressions from the National Association of Insurance Commissioners (NAIC) meeting that we attended last week in San Francisco. It was so not what I expected that I thought I would add my reaction as well.
During my federal career at The Centers for Medicare and Medicaid Services and the Social Security Administration, I was responsible for holding public hearings on public policy issues according to federal requirements. The NAIC meeting had no resemblance to any official public hearing that I've ever attended. The entire premise is that a public hearing is designed to be a venue for informed expert testimony, but also a forum for probing follow-up questions of the policy experts by the Commisioners and an opportunity for public comment. A federal hearing must meet several criteria:
The hearing must be announced 3 weeks in advance in The Congressional Record and must be held in a public setting with access for persons with disabilities
There should be no admission charge whatsoever, offer free/reduced rate parking, and the location be accessible by public transportation
The sponsoring organization must transcribe the entire hearing and distribute it to all Commissioners and also take meticulous notes that are made available to the public
They must hold the hearing for a sufficient duration of time to allow for questions from the audience for the experts giving testimony and for the Commissioners
. . .And more
You get the picture. Although the NAIC "public hearing" met some of the above criteria, it was by no means free ($650 fee for each of us to attend just this one session, although they allowed how they would not charge us if we returned our badges.) I thought it had the closest resemblance to a "show hearing" (where they could say they held hearings outside of Washington, DC, but it did not provide any opportunity for new information or a dialogue between the panels of experts, the audience, and the Commissioners.
I was struck by the time constraints of the hearing. In a world where the health care dialogue occupies such a significant amount of time and includes many complicated policy issues, this felt very abbreviated. Out of a week-long conference, it allowed for 3 hours for panels to give testimony (and pretty much stuck to that.) I guess it is easier to shoehorn testimony into that block of time if you don't have to make allowances for pesky questions from the audience--or much engagement from the Commissioners themselves. Three hours for a fulsome discussion of the most significant changes to health care delivery in 45 years--since the enactment of Medicare and Medicaid--seems way not enough time. This is particularly true when by many versions of health care reform legislation under consideration, significant policy pieces will be developed by NAIC and or be delegated to them to enforce. And what about consideration of whether and how is it effective to delegate regulatory functions to a non-governmental entity like NAIC? This was not discussed at all.
Two consumer organizations gave testimony at the hearing and raised some significant issues for consideration, including AARP and Consumers Union, the publisher of Consumer Reports. (The third "consumer voice" at the table was represented by The Hemophilia Association, but their spokesperson was the former Insurance Commissioner from Indiana, so I'm not exactly sure that counts.) In addition, each of the consumer organizations were asked to truncate their testimony because of time constraints (although no similar request was made of other testifiers, such as the doctor speaking on behalf of the American Medical Association. He was able to expound at length about how underpaid doctors are.) I found it curious that although some of the consumer testimony ran counter to accepted orthodoxy at NAIC, it did not generate substantive questions of the consumer panel or an engagement by the Commissioners in any meaningful dialogue.
And, you may ask, how about the showing of California's contingent at this NAIC meeting on our home turf? What probing questions did our Insurance Commissioner ask? What leadership did he demonstrate among his peers after California's recent foray into enacting health care reform here? Mr. Poizner was not in attendance. Although he may have directed some of his staff to attend, they were in no way visible at this hearing. There were insurance commissioners from other states in attendance who raised issues from a protection-of-consumers perspective or discussed challenges they had faced in their states. Honorable mention goes to the insurance commissioners from PA, OK, and RI who added to the content of the hearing.
There was one distinct highlight of this hearing--that I would say could have taken the place of several so-called experts who were given equal time. That was Jon Kingsdale, who is the Director of the Massachusetts Connector and has the closest thing to real experience in what may be part of our new health care reality. He talked about the technology challenges he faced, how he staffed the health care exchange with real talent from public service and the private sector, how they rank on the report card from Bay Staters, and how he publicized the individual responsibility with the cooperation of the Boston Red Sox and CVS Pharmacy and got 98.9% compliance (and, as he acknowledged, that he "just didn't send all of the outlaws to New Hampshire!")
So, on balance, it was worth attending, and it was educational for us, but I have to admit it was a particularly mediocre cookie for my (hope I don't really have to pay) $650.
Steps forward and back on the most contentious issues...
Tuesday, December 08, 2009
Earlier today, California Senators Diane Feinstein and Barbara Boxer joined the majority of their colleagues to table an anti-abortion Nelson/Hatch amendment, 54-45. They argued the amendment, which mirrored the Stupak amendment in the House bill, would go beyond the three decade-old Hyde amendment that prohibits federal funds to be used for abortions, which continues to be encoded in the main Senate bill. The amendment was opposed by most Democrats and the two female Republican Senators from Maine, Snowe and Collins.
They made the case that the amendment would prohibit women from using their own dollars to have private plans that cover abortion services. While Senator Boxer, who managed debate for the opposition, was successful, the issue continues. Senate Nelson of Nebraska, whose vote is crucial, may require other changes. And there remains a negotiation with the House bill, which does include the Stupak amendment.
In other news... ten Senators, five progressives and five moderates & conservatives, have come up with a potential deal on the "public option." What is it? No one knows for sure.
“This has been a long journey. We have confronted many hurdles, and tonight I believe we have overcome yet another one.
I asked Senators Schumer and Pryor to work with some of the most moderate and most progressive members of our diverse caucus, and tonight they have come to a consensus.
It is a consensus that includes a public option and will help ensure the American people win in two ways: one, insurance companies will face more competition, and two, the American people will have more choices.
I know not all 10 Senators in the room agree on every single detail of this, nor will all 60 members of my caucus. But I know we all appreciate the hard work that these progressives and moderates have done to move this historic debate forward.
I want to thank Senators Schumer, Pryor, Brown, Carper, Feingold, Harkin, Landrieu, Lincoln, Nelson and Rockefeller for working together for the greater good and never losing sight of our shared goal: making it possible for every American to afford to live a healthy life.
As is long-standing practice, we do not disclose details of any proposal before the Congressional Budget Office has a chance to evaluate it. We will wait for that to happen, but in the meantime, tonight we are confident.
Stinking badges: Pseudo-public meetings at the NAIC
Monday, December 07, 2009
On Friday, two intrepid Health Access staffers took a field trip to San Francisco to venture into the wilds of the National Association of Insurance Commissioners which was holding a “public” forum on health care reform, as part of their regular quarterly conference that moves around the country.
We thought this was important to do since the Senate version of federal reform gives the NAIC considerable responsibility in implementing health reform. We joined colleagues from AARP and Consumers Union, organizations that have worked closely with NAIC over the years on the regulation of Medi-Gap and Medicare Advantage policies.
So what did Health Access observe?
First, to get into the “public” forum, each of us was required to put $650 on our credit cards: the staff promised that this would be refunded if we dropped off our “official” badges. We put our badges in a drop box after 5pm on Friday. We will let you know if we get charged or not.
What kind of public meeting is that requires consumer advocates to present their credit cards to get in? Well, it’s not a public meeting. It's a private trade association advantaging the insurance industry it purports to regulate.
Second, we picked up the list of attendees: no surprise: page after page of insurance company representatives, at least one Pharma representative, lots of lawyers (presumably for insurers), and brokers.
Third, the attorney who presented an “impartial” analysis to the Insurance Commissioners called the Obama health care team the “Taliban”—and no one but no one challenged this characterization or even seemed to take it amiss—except of course for the Health Access team and our other consumer colleagues.
Fourth, our colleagues from AARP and Consumers Union, who were invited speakers, asked for “transparency” and public process. What was plain is that lots of the work of NAIC is done in conference calls in between quarterly face to face convenings that move around the country. Some of the commissioners or their staff said that they would try to provide notice so that there could be public input.
Good grief! In California, when important regulations are under development, there is plain statute requiring notice, the opportunity for the public to participate, an obligation for regulators to respond to comments, and a cop on the beat to enforce these requirements: the Office of Administrative Law. For instance, when the Department of Managed Health Care substantially rewrote the timely access regulations in late 2006 and gave only 15 days (over Christmas) for the public to respond, the Office of Administrative Law tossed out the regulations and forced DMHC to start over again.
But at NAIC, consumers are apparently at the mercy of whatever the Commissioners determine constitutes adequate notice and adequate public process.
When considering health reform, the NAIC should consider some reforms of itself.
SENATE FLOOR DEBATE STARTS ON HEALTH REFORM * Also: Giving Thanks for the Votes; * COBRA Subsidy Comes to a Close for Some; * Join Thursday's Health Reform Candlelight Procession in San Francisco; * Hang with Health Access & CPEHN at our Holiday Party: Wed, Dec 9th, in Oakland ...and other news for the week...
SENATORS TAKE FIRST FLOOR VOTE ON HEALTH REFORM: The U.S. Senate took a historic first floor vote on the health care reform bill, adopting a crucial amendment to help make health care more affordable for women. Last week, Sen. Dianne Feinstein gave the amendment needed momentum with her remarks about women unfairly having to bear extra cost burdens simply because of their reproductive roles. Speaking earlier today, Sen. Barbara Boxer rallied opposition to another amendment that is similar to the anti-abotion Stupak amendment. Emotion and optimism marked the first week of floor action on the legislation, with Sen. Harkin predicting swift passage: "This bill will pass the US Senate...we'll have it on the President's desk by early next year." Follow us on Twitter for real-time updates on Senate debate.
THANKS-GIVING CONTINUES INTO DECEMBER: Health care reform advocates throughout California continue to express thanks to the members of California's congressional delegation who've voted in support of health reform. Advocates are visiting the offices of each and every representative -- as well as the regional offices of Sen. Barbara Boxer and Sen. Dianne Feinstein -- to express gratitude. For more information, contact Patrick Romano, who leads the Health Care for America Now! campaign in California, at firstname.lastname@example.org.
HOLD A CANDLE TO HEALTH REFORM: Some of the same folks will meet up in the Bay Area on Thursday, December 10, for a candlelight procession through the streets of San Francisco. Hundreds of people are expected to march from Yerba Buena Gardens to Union Square in a procession honoring the 45,000 Americans who died this year waiting for health care reform. For more info, visit our Facebook page.
COBRA SUBSIDY'S END STINGS: This week, Families USA released a report in conjunction with Health Access California calling attention to the approaching end of the COBRA subsidy for those who lost their job-based insurance along with their employment in the recession. Read about it on our blog. The nine-month subsidy, arranged through the ARRA stimulus package, made a huge difference in how many families and individuals were able to keep insurance after job loss, but now those who picked it up immediately are seeing it expire. It is yet another sign of the importance of reform, which would prevent many families from losing coverage when they lose employment.
STILL TIME TO JOIN THE PARTY: There's lots going on during December, but if you are in the Bay Area, take the time to join Health Access California and the California Pan-Ethnic Health Network for a holiday celebration. Health Access and CPEHN are hosting our annual holiday gathering in Oakland on Wednesday, December 9.
The location is Max's of Oakland, 500 12th Street, at the Oakland City Center. (12th Street BART). Here's a map. It'll be from 4 p.m. to 7 p.m. Please RSVP to Pam Flood at email@example.com. Hope to see you there!
Any suggestions about the new update format, or questions about its content, should be directed to Cynthia Craft at Health Access, at firstname.lastname@example.org.
Over the weekend and today, CA Senators Boxer and Feinstein voted with the majority when amendments came up for a vote: * for a Stabenow amendment to assure that Medicare Advantage plans continue to include core Medicare benefits; * for a Kerry amendment on home care; * against Johanns amendment to send the bill back to committee; * for a Lincoln amendment to limit tax break for insurance CEO compensation; * against an Ensign amendment to limit the lawyer fees of medical malpractice victims; * for a Pryor amendment to survey patients in the exchange about their satisfaction; and * against a Gregg amendment to prohibit program expansions funded by Medicare savings.
Only the Kerry and Pryor amendments got the needed 60 votes for passage; the rest failed.
Debates are continuing as we speak, including on an amendment by Senator Ben Nelson to include the anti-abortion language similar to the Stupak amendment in the House bill. The debate continues...
The U.S. Senate is in full debate on health reform, and they started voting on some amendments in the last few days, despite various efforts by the GOP opposition to slow the debate down even more.
I've been in DC this week, and so have not been posting as much. Despite all the negotiations about amendments, you do get a sense that we are nearing a major advance. Beyond my Hill visits, my hope is to go see a little of the Senate floor debate in person, to say I saw a piece of history.
California's two Senators are actively participating in the floor debate as well. Here's some clips to give you a sense of what they are saying. Here is Senator Barbara Boxer, on women's health issues, from just a few days ago:
Here's a longer clip from Senator Feinstein from about a month ago, about the history of health insurance in this country:
The report, by the consumer health organization Families USA and co-released by the statewide health consumer coalition Health Access California, states that the subsidies – which were started last March by the American Recovery and Reinvestment Act (ARRA), but were made available for only nine months – have enabled millions of laid-off workers and dependents to afford so-called “COBRA” premiums needed to continue health coverage from their previous employer.
Under the ARRA, the federal subsidies pay 65 percent of the cost of COBRA premiums. In California, the federal subsidies for COBRA family coverage average $720 per month.
Without subsidies, the report finds, COBRA premiums for family health coverage will cost laid-off California workers, on average, $1,107 per month – 82.1 percent of the average ($1,349) monthly Unemployment Insurance checks they receive.
For the first recipients, who began receiving subsidies in March, the subsidies will expire on November 30. For those who started receiving subsidies after March, the expiration will be nine months after their start-up date.
For millions of laid-off workers and their families, the federal COBRA subsidies have been described as a health-coverage lifeline. Health advocates are arguing that new jobs legislation extends those subsidies.
Health and consumer advocates noted that pending health reform legislation would provide a permanent source of help to laid off workers. The health reform bills pending in Congress would enable laid-off workers and their families to obtain health coverage through a newly created marketplace, called an “exchange,” and families with low incomes would receive tax-credit subsidies to help pay the premiums.
Health advocates are urging Congress to extend the COBRA subsidy as a much-needed measure in the present to protect recently laid-off workers and their families. But, they say, this issue shows the dire need for health reform moving forward, so nobody loses health coverage when he or she switches jobs or becomes unemployed looking for work.
The Congressional Budget Office and Joint Tax Committee estimated that approximately 7 million adults and dependent children would receive the COBRA subsidy in 2009. The Treasury Department is compiling data about how many workers received the subsidy, but a count of the people benefiting from the subsidy is not yet available.
The data for the Families USA report were derived from federal sources in the Departments of Labor and Health and Human Services. A more detailed description of the sources of the data is set forth in the report’s methodology section.