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More on Hawaiian health care...

Friday, February 12, 2010
We've already written about Rush Limbaugh's hypocrisy in describing Hawaiian health care, which has long had health reform, in particular with a more robust employer mandate than anything envisioned in federeal health reform bills.

The Daily Show with Jon Stewart picks up the meme, with correspodent John Oliver using the Republican National Committee's winter meeting in Hawaii as the hook. It's worth watching.

The Daily Show With Jon StewartMon - Thurs 11p / 10c
The Apparent Trap
Daily Show
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posted by Anthony Wright | Permalink | 1:15 PM


HCAN on moving forward...

Wednesday, January 20, 2010
Here's a statement by Richard Kirsch, National Campaign Manager, Health Care for America Now:
“Health Care for America Now is committed to winning a guarantee of good, affordable health care we all can count on, and we will continue to push aggressively to get the best health care reform bill possible to the President’s desk for his signature as quickly as possible.

Tuesday’s vote was not a referendum on health care reform. It was a referendum on a particular candidate in a climate in which people, hard pressed by the economy, are impatient for change. When it comes to the need to make good health care affordable, nothing is different today than it was yesterday. Congress must keep going and finish reform right.

Fixing health care now is vital to fixing our economy. In survey after survey, voters continue to voice strong support for forcing health insurers to stop excluding people with pre-existing conditions, guaranteeing everyone has access to good, affordable coverage, and requiring health plans to spend premiums on medical care, not profits.

The people of Massachusetts already have benefit from health care reform. It’s time the rest of the country had the same access to good, affordable care.

We are on track to pass a strong bill, and we will stay focused on that until the President signs the bill into law.”

I would add that we at Health Access are pleased by Speaker Pelosi's continued leadership on this issue. And maybe that comes from the fundamentals: After all, the need and urgency for health reform from last year and last week didn't change this week and this year, because of a single result of a special election in a specific state. The election in question was in the state where health reform least mattered--as opposed to California, where it matters possibly most of all, given our large percentages of uninsured, lower-wage workers, people at risk of being denied for pre-existing conditions, etc. Even in Massachusetts, the candidate in opposition to national health reform did not dare oppose the identical state reforms already in place.

And that's the lesson. Pass a bill--a good bill--and health reform won't be the political issue it is now.

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posted by Anthony Wright | Permalink | 2:13 AM


Another view from Massachusetts...

Tuesday, January 19, 2010
Can we hear from folks in Massachusetts?

First of all, it isn't news that Bay State voters have the ability to pull the lever for the GOP. Before the current Governor, the last Democrat in the statehouse in Boston was Michael Dukakis, when I entered college at Amherst a generation ago. Since then, Republicans have run the state for the last 17 of 20 years.

So here's a perspective from our friends at Health Care for All-Massachusetts, who report that hardly any of the ads focus on health reform, and there was a lot more going on.

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posted by Anthony Wright | Permalink | 10:56 PM


Two cents on the MA election...

Darn Red Sox fans.

The Massachusetts Senate election has now been won by an opponent of health reform.

But was health reform what the election was about? Yes, in part. It was also about the economy, bank bailouts, unemployment, the conviction record of that state's attorney general, and (strangely) what team Curt Shilling roots for.

Don't get me wrong, it was also about health reform, although it was in the state where the bill least mattered, since they had already put in place some (though not all) of the reforms, from regulating insurers so there are no denials for pre-existing conditions, to affordability subsidies so low- and moderate-income people can better afford coverage.

Let's remember that the rest of the country voted for President Obama, who explicitly ran on health reform; the rest of the country voted for the remaining 59 health reform-supporting Senators; the rest of the country voted for the majority of the House of Representatives.

There were no exit polls today. But according to Rasmussen polling tonight (which tends rightward), 53% of MA electorate today approves of Obama, 38% disapproved. President Obama polled well ahead of the candidate in Massachusetts.

The need for health reform was real and urgent last week, and those same factors make it necessary and urgent next week. It's momentum and urgency was not based on how popular or easy it was--although it was popular, and likely will be again. That's the case with past programs and reforms--but only once they pass and their benefits are known.

There are options for moving forward. The House can pass the Senate version, putting in place a framework that then can be improved in the future--especially through the budget process, which takes a simply majority of 51 votes rather than 60. And it can be improved not just at the federal, but at the state level as well.

It will take those who voted for health reform to have the courage of their convictions, and to push reform forward not just because it is the right thing to do, but because those who voted for reform have a better case to make when they run on something rather than nothing. And that after listening to voters, there are improvements to make.

Now it is up to Speaker Pelosi to make that case to her members, that the Senate bill isn't the end of the effort, but the beginning... and that there is political reward in the continuing campaign to make it better.

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posted by Anthony Wright | Permalink | 7:14 PM


All eyes on Massachusetts...

Monday, January 18, 2010
What is it about the Bay State?

It was there that a 2006 reform got people talking again about health reform in a big way. (Maine and California got some attention in 2003 for reforms, but not as much.) The Massachusetts law was widely scrutinized (including by us at Health Access), either as a reform to emulate or to indicate what was missing.

So it is strange that the election in that state tomorrow for U.S. Senate matters so much. After all, Massachusetts voters already have had a very similar health reform for a couple of years, and have shown no sign of seeking to repeal it.

The concern is that if the Democrat loses, then supporters of health reform only have 59, rather than the needed supermajority of 60 votes. There may be other options, from trying to pass something before a new Senator is seated (there's been lots of lame duck sessions over the years), to simply having the House adopt the Senate bill as is (as Jon Cohn describes here). As Ezra Klein writes, there should be no question that the health reform push needs to go on, regardless of what happens.

As tweeted at @healthaccess and @sovernnation, Speaker Nancy Pelosi told KCBS today that she was not worried about Massachusetts Senate race, she was confident Coakley will win... and that they will pass health care "one way or another."

We'll see what way, in just a day...

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posted by Anthony Wright | Permalink | 6:33 PM


The Worst $650 Cookie Ever!

Wednesday, December 09, 2009
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.

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posted by Elizabeth C Abbott | Permalink | 10:12 AM


A Cautionary Tale for California...

Wednesday, October 21, 2009
Indiana's generally well-regarded Republican governor who formerly served as President George Bush's Director of Management and Budget, pulled the plug on October 16 on their effort to "modernize" the state's system of delivering welfare services. This was a similar result in Indiana to an effort to privatize welfare in the state of Texas which was a failure, and was cancelled in 2007 after a huge expenditure of Texas state funds.

The Indiana governor acknowledged that he continued to favor privatization of some state government functions. However, the systems changes he implemented resulted in too many errors and left too many deserving people waiting for too long for help they desperately needed. State legislators were inundated with complaints from their constituents. Eligible applicants suffered nightmarish consequences that affected their health coverage and their health status. In fact, Indiana is facing increased criticism and oversight from the federal government over their error rate. State hearings on this debacle are under consideration by the Indiana legislature.

Indiana expected significant cost savings by directing applicants to apply for benefits by calling customer service centers staffed by contractor employees or by having the public file for benefits using a computer. Now that the governor has cancelled the $1.34 billion contract, applicants will return to applying for public services as part of face-to-face interviews with state workers in local county offices. The governor admitted in his public statements that it wasn't the resources the state devoted to this endeavor or the amount of effort, but that it was "a flawed concept that simply did not work out in practice."

So, why are these experiences in Texas and Indiana so relevant to California? As my mother would say: "It is a cautionary tale." The California legislature passed, and the governor signed, AB 7 Centralized Enrollment for Public Social Services that purports to streamline and automate the process for applying for public social services like Medi-Cal, food stamps, and CalWORKS. The benefits of this law are reputed to be greater access to benefits by having the public apply over a computer, greater consistency in eligibility determinations from county to county, and significantly lower administrative costs for the state.

As the state prepares to implement this law in the coming months, it will face many of the same problems and criticisms experienced by these other states. California will doubtless incur tremendous costs (and will be unlikely to realize any savings) while exposing eligible Californians to significant delays and real adverse health consequences from what other states are calling "a failure."

The question to ask is: Can we learn from their mistakes?

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posted by Elizabeth C Abbott | Permalink | 3:01 PM


Healthier from health reform?

Saturday, September 05, 2009
Does expanding health coverage actuall improve people's health?

This is not as obvious an answer as you might think. Frankly, health reform is more about improving our economic health, rather than their personal health. Health care and coverage often comes after people are sick... it ensures that people get care but also that they don't fall into medical debt or bankruptcy for seeking such care. The focus of H.R.3200 and other health reform proposals is to provide economic security to families.

That said, the Wall Street Journal Health Blog had a revealing post a few weeks ago that does give a few concrete examples of how these health reforms can actually help our health. They interviewed John Auerbach, the commissioner of Massachusetts’s Department of Public Health. He gave a few indicators he's watching.
In particular, he cites three pieces of data as short-term indicators:

1) Smoking rates: In the first year of the effort that started in 2006 to get all residents insured, there was a surge in people covered by Medicaid, which pays for smoking cessation patches and counseling. Some 11% of smokers on Medicaid choose to take advantage of cessation tools that year. In 2007, Massachusetts saw an 8% drop in adult smokers, its largest dip in 10 years. In addition to having the patches paid for, Auerbach believes that a number of recently insured adults received a physical in that year and discussed smoking cessation with their docs.

2) Colonoscopies: There was a statistically significant increase in age-appropriate colonscopies in the state. “If you’re uninsured, you’re not going to get a colonscopy,” Auerbach said.

3) Flu vaccines: The percentage of adults who received a flu vaccine increased above and beyond the increases the state had been seeing in recent years. The largest percentage of vaccines are given in private doctors’ offices, so it makes sense that if more people are going to their primary care docs, the more likely they would be to receive a flu shot, according to Auerbach.

I have a sense there are many more health benefits to health reform--on top of the economic benefits--especially as time goes on. (And the two are intertwined--in people have less economic anxiety, and are not driven into poverty because of medical costs, that will have health benefits as well.) But those are good initial indicators about why this effort is so important.

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posted by Anthony Wright | Permalink | 10:02 AM


On another ballot....

Sunday, November 02, 2008
There's lots of important ballot measures on the California ballot, but one for health advocates to watch is in Arizona.

In Arizona, there's Proposition 101, which would block future universal health coverage efforts in that state, according to Jacob Goldstein of the Wall Street Journal Health Blog.

The initiative, as a constitutional amendment, states that it would:
"Prohibits laws that: restrict person's choice of private health care systems or private plans; interfere with person's or entity's right to pay directly for lawful medical services; impose a penalty or fine for choosing to obtain or decline health care coverage or for participating in any health care system or plan."
While phrased as "choice," in actuality it would prohibit even basic regulation of private insurers, including most efforts to control costs in the health care system. The proponents are candid in their desire to have this amendment in order to prevent various broad health reforms, from the creation of a single-payer proposal, a "pay-or-play" policy, an individual mandate, or other ideas.

Supporting are conservative doctors and anti-tax groups, while there's an interesting coalition in opposition from health advocates to chambers of commerce to hospitals and health providers to childrens and senior groups to Gov. Janet Napolitano.

The proponents talk about "choice," but actually don't acknowledge that the current health system is what restricts choice: people don't get coverage because they are denied for pre-existing conditions, or are denied because it is unaffordable. The point of reform is to provide those new choices, including public--not just private--coverage options, that many don't have now.

Regardless, Proposition 101 is one of many monkey wrenches that will be thrown at health reformers in the next few years. Let's see how Arizona deals with it this week.

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posted by Anthony Wright | Permalink | 9:29 PM


Coast to coast consumer protections...

Tuesday, August 12, 2008
Congratulations to New Jersey Governor Jon Corzine, who just signed a law to prevent hospitals overcharging the uninsured. Previously in 2006, both California and New York passed comprehensive legislation to prohibit hospitals from overcharging those who don't have an insurer or government program to negotiate for them, and as a result, get charged more 3-4 times or more of what insurance companies or public program pay for the exact same service.

The New Jersey bill, described by ace health reporter Lindy Washburn of the Bergen Record, would limit charges to 15% above Medicare rates.

More information about the California law--AB774 (Chan)--is on the Health Access website. We continue to be active in making sure the law is enforced, that patients know about their rights, and to work in the policy arena against overcharging and medical debt. (Watch for more announcements this fall.) It's good to see New Jersey and other states looking at this issue, so that the consumer protections can be more widespread.

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posted by Anthony Wright | Permalink | 3:30 PM


Mega problems with mini-coverage...

Tuesday, July 29, 2008
Last week had a startling article by Julie Appleby at the USA Today about the result of a 36-state investigation of HealthMarkets, resulting in a $20 million settlement, for duping lots of health care consumers into buying substandard health coverage.
The investigation, prompted by numerous complaints, found that insurer HealthMarkets failed to properly train its sales agents, who didn't always fully disclose the limits of its health policies to consumers and sometimes did not pay for medical services promptly.

HealthMarkets, owned by three private-equity firms including the Blackstone Group, has about 612,000 policyholders in 44 states through its subsidiaries: Mega Life and Health Insurance, Mid-West National Life Insurance and Chesapeake Life Insurance.

The company sells an array of plans, many of which pay only limited amounts toward medical care. The settlement follows the January release of the investigators' findings, which covered company practices from 2000 to 2005.

"The severity of their actions certainly warranted that level of penalty. They hurt a lot of people," says Washington Insurance Commissioner Mike Kreidler, whose state and Alaska led the investigation. Since 2002, HealthMarkets has been fined by at least seven states and faced lawsuits from dozens of policyholders.

There has been lots of commentary on the web about these practices, and these products--at sites like Managed Care Matters, and The Health Care Blog which includes a report that these insurers and issues are active in California.

Recently, the Sacramento Bee profiled a story of a couple that got snookered into buying "junk insurance" by one of the companies listed above. That article, spotlighted the pending SB1522(Steinberg), sponsored by Health Access California, as a legislative remedy, to begin to address this troubling issue.

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posted by Anthony Wright | Permalink | 12:50 AM


Progress report

Wednesday, July 02, 2008
Ezra Klein has a good update on what's going on with the Massachusetts plan here.


posted by Hanh Kim Quach | Permalink | 12:57 PM


Healthy blogging...

Sunday, June 01, 2008
Those interested in health policy should be subscribed to the news summary that the Kaiser Family Foundation puts out on a daily basis. Now, those summaries will often include a health policy blog roundup, which will be another way to keep up-to-date. Here's several gold nuggets they found from panning the blogosphere about McCain's health plan:

Joe Paduda of Managed Care Matters examines presumptive Republican presidential nominee Sen. John McCain's (Ariz.) health care plan and whether it could increase the number of uninsured residents by destabilizing the employer-based health care system. Robert Laszewski of Health Care Policy and Marketplace Review builds off of Paduda's post to argue that McCain's market-based plan reforms might work well for some voters, as long as advisers present certain changes carefully. Bob Vineyard of Insure Blog reacts to a Slate article and discusses McCain's proposal to allow individuals to purchase insurance across state lines. Peter Harbage from the Wonk Room Blog discusses a new Center for American Progress Action Fund paper about McCain's health care plan and administrative costs.

Really good stuff there.

Don't forget the biweekly Health Wonk Review, which this week is hosted by Hank Stern at InsureBlog. We are listed in there with over a dozen interesting posts from around the web.

Finally, for those who prefer to read offline, our state-based colleagues at the Connecticut Health Policy Project have a blog of interest, CT Health Notes Blog, and have a recommended booklist for your summer reading.

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posted by Anthony Wright | Permalink | 1:10 AM


Overcoming California's unique health reform hurdles...

Monday, January 28, 2008
Part of last week I was with many of my fellow health and consumer advocates in Washington, DC. I learned about all the good and promising efforts they were embarking on in states like Minnesota, Oregon, Ohio, Colorado, Illinois, Maryland, Pennsylvania, Washington, Maine, Vermont, and yes, my previous home states in New York and New Jersey.

They were using the progress that we made in California in their own efforts. In one blue state, advocates are pushing the most progressive legislator in their StateHouse to improve his nascent proposal on the employer contribution, to be more like what was agreed to by Assembly Speaker Nunez and Governor Schwarzenegger.

Our efforts, in short, have already been helpful to my colleagues in other states. I know other states are already borrowing some of the policy elements that were developed in this exhaustive process.

But it's cold comfort for Californians, now that the bill has stalled. What is the implication for my colleagues in other states?

With apologies to my New York background, if we could have made it here, we could made it anywhere. It would have been a boon to efforts around the country and in DC.

But there's reasons why the opposite is not true.

California has all the obstacles that seem to frustrate federal reform, but without the flexibility or financing ability.

* National health reform is hard because health care has an enormous number of stakeholders that are impacted by any change, and it's hard to get a consensus, especially in a country so large and diverse, both in terms of the on-the-ground infrastructure, and in terms of ideology. On health care, Washington, DC has been polarized on any solution (see the SCHIP debate), which has resulted in either neglect or gridlock.

* It is because of this gridlock that the states have taken the lead with their own efforts. And while states have clear jurisdiction and responsibilities in many health areas, state health reform is hard because there's contraints in policy and process: Medicaid rules, ERISA, and the biggest of all, the ability to finance the system overall. States have balanced budget requirements and it's harder to raise revenues. (Among other things, we don't have a Bush tax cut to repeal, as is the suggestion of many Democratic presidential candidates.)

A nation-sized state, California has the size and diversity that makes consensus hard (think Berkeley and Bakersfield, Orange County and Oakland), and has one of the worst problems, with Californians more likely to be uninsured than in all but five states. As we have said before, Massachusetts, with 10% uninsured, had to close a gap; California, with nearly 20% uninsured, has to jump a chasm.

So California has all the obstacles at the federal level, with all the obstacles at the state level, plus some of California's very own--in particular the 2/3 vote rule to pass any revenues in a legislators (a threshold only Arkansas and Rhode Island share) that empowers a solid Republican blockade against taxes; and the ballot-box culture of initiatives and referendum.

Yet in spite of all this--look how far we have come.

In the past five years, the legislature has passed four measures to dramatically expand health coverage--SB2; AB772; SB840; AB8. Until recently, it was the Governor that was the obstacle. The Assembly and the Governor agreed on a fifth proposal, AB x1 1, and now it's the Senate.

Despite all the obstacles, it's clear that political will can make it happen, from Senate President John Burton in 2003 to Assembly Speaker Fabian Nunez and Governor Arnold Schwarzenegger in this special session.

We just don't yet have the needed political will. But that is something we can build, and change, and make happen.

I cringed when some Democratic Senators in committee made comments about the Legislature--talking about themselves!--being unable to functionally monitor and make adjustments to a health reform if they are needed. There are clearly constraints with health reform, but that sounded like abdicating leadership. Finding an excuse, rather than solving a problem.

If I learned anything in the past five years, it is that reform in California is possible, but that it takes political will and leadership from multiple sources, a major effort to engage and mobilize Californians to demand and expect results, and that it also takes multiple efforts and time to make it happen.

This wasn't the first year of health reform, and it won't be the last. We'll see to it.

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posted by Anthony Wright | Permalink | 7:20 PM


More on Massachusetts, and comparing to California...

Tuesday, January 15, 2008
Tuesday, January 15, 2007

* Fundamentally Different in Financing, Cost Containment, and Other Concepts
* Broader Benefit in Providing Premium Relief, Insurance Market Reform
* California's Proposals Learns Some of the Lessons from Massachusetts
* Senate Health Committee to Hear AB x1 1(Nunez) Next Wed, Jan 23rd, 9am

New on the Health Access WeBlog: LAO on the Budget; California in Health Wonk Review; A Single-Payer Supporter for AB x1 1; More on the SF Court Case; U.S. Health Rankings;

The Senate Health Committee, chaired by Senator Sheila Kuehl, has postponed the hearing considering AB x1 1 (Nunez), the current health reform proposal negotiated with Governor Schwarzenegger, as they await the analysis by the Legislative Analyst's Office. The hearing will now be next Wednesday, January 23rd, starting at 9:00am and is expected to last all day. The deadline for letters of support or opposition on the measure are due this Wednesday.

NEW MODEL: As the Senate Health Committee awaits a financial analysis, the California Health Care Foundation has released another analysis, showing the results of modeling of AB x1 1 and the related ballot measure. The report, by MIT Professor Jonathan Gruber, shows how 3.6 million Californians would have coverage under the proposal, mostly through expanded public programs, a new subsidized purchasing pool, and greater availability of on-the-job coverage. The report is at the Cal Health Reform website, at:

NEW ANALYSIS: Health Access is also releasing a new analysis today, comparing AB x1 1 (Nunez) with the recent reform in Massachusetts . This new comparative analysis shows that the pending California Health Security and Cost Reduction Act, AB x1 1 (Nunez), takes major steps in health reform far beyond the much-discussed Massachusetts reform of 2006.

A full copy of the 8-page analysis is available at the Health Access website, at: http://www.health-access.org/advocating/docs/2008CA-MAReformComparison%2001%2014%2008.pdf

The analysis, entitled "Health Reform in California and Massachusetts : Different from Start to Finish," concludes that AB x1 1 would provide a broader benefit to California consumers than what was passed in Massachusetts . In addition, the California proposal has a much more stable financing structure of significant new dollars to improve the state's health care system, and goes far beyond Massachusetts in trying to control health care costs.

The report lists "top ten" major differences between the California 's AB x1 1, and the health reform law, Chapter 58, passed in 2006. In contrast with Massachusetts, the California proposal includes:
1) New, Broader Financing, including a Tobacco Tax
2) A More Meaningful Employer Contribution
3) General Fund Protection
4) Significant Cost Containment
5) Subsidies up to and above 400% of the federal poverty level
6) Key Differences in the Individual Mandate, Affordability and Enforcement
7) A Transition to Guaranteed Issue
8) Medical Loss Ratios and Increased Insurer Oversight
9) Not Just a Connector, but a Negotiator
10) New and Improved Public Health Care Options

The report shows that while there are similarities in the framework, California's pending proposal goes far beyond Massachusetts in numerous areas. At the same time, even with their more limited reform, Massachusetts has taken the major step of covering over half of uninsured--over 300,000 people through public program expansions--in a short amount of time, and is on path to close the gap further. The biggest critique is that this success in signing up patients quickly has led to higher-than-expected general fund costs.

The report explains how the Massachusetts plan never raised significant new revenue--it mostly redistributed existing state and federal funds, and relied on new funding from the general fund. In stark contrast, the California proposal would raise $15 billion in new funding, to be in a lock-box protected from the general fund, and vice versa. The new funds raised are from a much more meaningful employer contribution, individual contribution, a hospital fee, significant new federal matching funds, reinvested savings from county and state governments, and a tobacco tax.

In fact, research into the history of the Massachusetts law shows the California's proposal is much more like the ballot measure originally proposed by the consumer and community advocates, which included significant employer contributions, middle-income subsidies up to 400% FPL, and a tobacco tax--none of which made it in the final Massachusetts package, but is included in the pending California plan. The study goes into the details of the different iterations of these measures.

The conclusion of the report is that Massachusetts and California start from different places, and the plans are different enough, that they will end up having different results. Critiques of the Massachusetts plan simply do not apply to California 's reform.

Again, a full copy of the 8-page analysis is available at the Health Access website, at: http://www.health-access.org/advocating/docs/2008CA-MAReformComparison%2001%2014%2008.pdf

To view other resources from the Year of Health Reform, visit our website,at:

CALL TO ACTION: With the new hearing time, letters are due into the Senate Health Committee TOMORROW, Wednesday, January 16th, in order to be included in the committee analysis.

Health Access California has sent a letter expressing support, while also seeking amendments to get clarifications on affordability and benefits. The letter is available on our website. Letters of support should be sent to the Senate Health Commitee at:

The. Hon Sheila Kuehl
Chair, Senate Health Committee
State Capitol, Room 2191
Sacramento , CA 95814
FAX: 916-324-0384

Advocates should also write letters to the individual members of the Senate Health Committee:

Senator Sheila Kuehl (Chair); Senator Samuel Aanestad (Vice Chair); Senator Elaine Alquist; Senator Gilbert Cedillo; Senator Dave Cox; Senator Abel Maldonado; Senator Gloria Negrete McLeod; Senator Mark Ridley-Thomas; Senator Darrell Steinberg; Senator Mark Wyland; Senator Leland Yee

Health Access will continue to provide updates on ABx1 1, the initiative and other health reform efforts, including late-breaking developments that will be posted on our blog, at:http://www,health-access.org/blogger.html

To view other resources from the Year of Health Reform, visit our website, at:http://www.health-access.org/advocating/2007_healthdebate.html.

This includes a new analysis, "Who Gets What Help?" so that California consumers can find out how they would be helped under the proposal in getting health coverage.

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posted by Anthony Wright | Permalink | 10:37 AM


Mid-terms for Massachusetts...

Saturday, December 22, 2007
Community Catalyst, a national consumer advocacy organization we work with, published an end-of year analysis of the much-discussed Massachusetts reform, which provides a direct look and the successes and the shortfalls of that effort.

Entitled "Revisiting Massachusetts Health Reform: 18 Months Later," the report comes out just as the state has indicated that 300,000 people got covered--half of the state's uninsured. At the same time, it acknowledges some of the issues, including their lack of meaningful employer contribution and other questions about long-term financing.

While Massachusetts largely redistributed existing funding, California's proposed AB x1 1 raises significant new resources, so perhaps we've learned some lessons already. Health Access California will be putting out an analysis comparing the two state and the two plans in short order.

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posted by Anthony Wright | Permalink | 6:22 PM


We're not alone...

Sunday, November 25, 2007
The Kaiser Family Foundation has a new interactive map showing what other states are doing on health reform. It's a far cry from when California started this conversation in 2003, where only Maine was having a similar conversation...

Some quibbles: the description of California is short, and neglects key pieces of history and policy. And the map classifies the reforms in Massachusetts, Maine, and Vermont as "universal," which I understand has come to be shorthand for any sort of comprehensive reform package, but I don't think advocates in those states would say their plans are fully universal.

Still, it's useful to get a sense of what is being discussed around the nation...

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posted by Anthony Wright | Permalink | 8:43 PM


Getting educated from the Commonwealth...

Sunday, October 28, 2007
So I have a love/hate relationship with Massachusetts.

I am a Bronxite who roots for the Yankees, and I'm beside myself that the Red Sox are up 3-0 in the World Series. (Go Rockies!) But I have fond memories goingt to college at Amherst, and loved the formal close of our Commencement, with the banging of a large staff and the pronouncement: "God save the Commonwealth of Massachusetts."

On health policy, I was happy that Massachusetts helped focus attention on state reforms for expanding coverage, although I remind folks that California was one percentage point away a few years earlier, in 2003, with SB2 and Prop 72.

On the actual reform plan, it's not our place to support or oppose the MA plan, but we have produced both discussion papers and fact sheets that discuss the various provisions, and to make clear the major differences between our two states.

Even so, there is lots to learn from the discussion going on in Massachusetts. Our colleagues from Health Care for All Massachusetts (not affiliated with our board member Health Care for All California) have been liveblogging the deliberations of their "Connector" board, which makes for interesting, although wonky, reading. As expected, there's things that are working, and things that aren't.

It's odd that the Governor's health proposal seems oblivious to these discussions, especially with regard to the individual mandate (whatever you think of the concept). No condition or exemption based on affordability and availability? No simplification/standardization of the individual market that we are requiring people to go into? Exempting employer-based coverage from what constitutes "minimum coverage" for the mandate?

The Governor's proposal would benefit from a closer look at the consumer protections in the Massachusetts market (Health Access prepared a chart), and learning from their deliberations of what is working and what isn't...

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posted by Anthony Wright | Permalink | 9:40 AM


SCHIP Impacts in California...

Tuesday, October 02, 2007
Two good stories over the weekend spotlight the impact of the President's SCHIP veto to California. Bill Ainsworth in the San Diego Union-Tribune and Barbara Anderson in the Fresno Bee report that potentially hundreds of thousands of children wil lose coverage, as well as the wrench it throws into our health care reform debate.

Beyond making clear the scale of the disruption, I tried to make the point in my quotes in these articles that there should be political ramifications, especially for the 18 California Congressional Representatives from California that voted against SCHIP.

Today, according to the San Jose Mercury News and the Washington Post, California is joining several other states, including New York and New Jersey, in suing the Bush Administration about their unilateral efforts to restrict SCHIP.

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posted by Anthony Wright | Permalink | 10:26 AM


Who fought for their state?

Tuesday, September 25, 2007
It's disappointing SCHIP didn't get a veto proof majority. It's even more disappointing how little California was able to get there, compared to other similar states.

In the SCHIP battle, a few states have been targeted, namely New York, New Jersey, and California, as states that expanded their state child health insurance programs above the norm of twice the poverty level. All three started their programs under Republican Governors (Pataki, Whitman, and Wilson, respectively). And all three have lots of children on the program now, have a high cost-of-living and are thus justified in a higher eligibility level, and recognize that SCHIP reauthorization is a big deal for the state to draw down federal funds--not to mention the benefit of providing health coverage to the children of the state.

So how did we do compared to the other states that are particularly targeted? In comparison, California did poorly in getting our House Representatives to vote for the interests of their state.

Of our 19 California House Republicans, only one--Mary Bono--voted for the measure. (Another did not vote.)

In comparison, New Jersey had 3 out of 6 Republicans in a 13-member delegation vote for SCHIP. New York both had 4 out of 6 House Republicans in a 29-member delegation vote the interest of their state over their President. (To complete the tri-state area, Connecticut also meets the criteria above, and has only one Republican Congressman out of a 5-member delegation, and yes, he voted for SCHIP.)

For whatever reason, our counterparts in the Mid-Atlantic did a much better job in getting their Representatives to represent them, in bringing in federal funds and extending coverage to children. As a result of California's inability to produce the votes, we may have to have hundreds of thousands of children disenrolled from California's Healthy Families program shortly.

One would have hoped that the broad support of Republican Governors--including Governor Schwarzenegger--would have made more of an impact on the Republican Congressional Representatives. New York and New Jersey actually have Democratic Governors now, but they still were able to have some sway with their Representatives. So what's wrong with our delegation?

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posted by Anthony Wright | Permalink | 11:16 PM


What it looks like on the other side

Friday, August 24, 2007
As California moves toward health care reform ...oh -- in the next 3 weeks -- we had a visitor from a state that is in the middle of implementing it's health care reform from last year.

Jon Kingsdale, executive director of the Commonwealth Connector, which is the board in Massachusetts that is charged with implementing its health reform, gave us a glimpse of what life would be like once legislation was passed. They're in the first of a three-year process to implement the new law.
Kingsdale was in the Capitol today courtesy of the California HealthCare Foundation.

While the most highly publicized part of the Massachusetts reform legislation was the fact that it would require every citizen to purchase health insurance, the pieces of the plan that are furthest along -- at this point -- are the expansions in public programs. More than 70 percent of those that qualify for Medicaid are now enrolled; 75 percent of those qualified for subsidized health coverage have purchased coverage.

That means nearly 3/4 of Massachusetts residents who earn less than $41,000 (a couple) are in some kind of publicly funded program. If we transplant that rate of enrollment success to California, we'd be covering 2.7 million people!

Of course, we can't really compare Massachusetts to California -- on MANY levels.

Population- and coverage-wise:

  • First, the entire state has 6.2 million people. That's FEWER people than California has in uninsured.
  • Secondly, only 6 percent of its population was uninsured prior to reform, compared with California's 20 percent.

My colleague Beth has a great one-page fact sheet on how much more robust coverage in Massachusetts was before they began their reform, which includes the fact that more employers were providing coverage before reform (69.4 percent in MA compared with 57.7 percent in CA), and Medicaid spending was higher there ($5,400 per enrollee in MA versus $2,250 in CA)

Market-wise, we're in completely different places, as my colleague Anthony has written about before, MA providing more consumer protections than in CA.

But, in spite of the differences in regulation, population, politics, and coverage, one thing Kingsdale said resonated:

"Nowhere in the country does the non-group market work.''

Translated: the market where poeple must go out and search for coverage on their own without an employer or public group is a wreck, which says to me that any attempts to rely on the individual market to diminish the number of uninsured, or shrink group markets by thrusting people into the individual market is a bad idea.


posted by Hanh Kim Quach | Permalink | 11:39 AM


Jersey Devils...

Friday, July 20, 2007
It's astounding that the debate on the State Child Health Insurance Program (SCHIP) has gotten so polarized, with President Bush campaigning against it. This is a program that has been bipartisan since its beginnings, passing a Republican Congress, including one led by former Speaker of the House Newt Gingrich.

The talking points by President Bush and some Republicans legislative suggest that the program has gone well beyond its original intent, covering children above twice the federal poverty level, and parents as well. Even some supporters of expanded SCHIP tell their conservative colleagues that SCHIP reauthorization is a way to reign in states.

The poster child for this bad behavior is New Jersey, and I now I must confess my role. I ran the state health consumer advocacy coalition when working at New Jersey Citizen Action, when we were able to win expansions of coverage for:
* children up to 350% of the federal poverty level (around $60K for a family of 3), and
* their parents as well, up to 200% of the federal poverty level ($34K for a family of 3).

This goes well beyond what most other states have done, including "left-coast" California, which only covers children up to 250% of the poverty level ($43K for a family of 3), and is currently proposing to go up to 300% ($52K for a family of 3) as part of broader health reform. [California did approve but never implemented a parent expansion.]

But it wasn't just me and the various children's, consumer, and community groups in support of this conspiracy of New Jersey devils toward "government-run health care for every American," according the President Bush.

The New Jersey Legislature that approved these changes was a Republican Assembly and a Republican Senate. The Governor was Christie Todd Whitman, a blue-blood Republican that President Bush thought highly enough of that he included her in his Cabinet the next year.

How times have changed.

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posted by Anthony Wright | Permalink | 12:19 PM


Just above Tennesee and Alabama.

Monday, June 18, 2007
The Commonwealth Fund put out state rankings, based on a Scorecard of Health System Performance. Interesting data.

California's profile is here. And it's not good: 39th overall. 44th in "Access." 50th(!) in "Quality." The national report indicates there's a correlation: "insurance matters." Either way you look at it, there's a lot to work on here.

We do well on the "Healthy Lives" indicator (3rd), although that may be related to the relatively younger mix of California's population.

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posted by Anthony Wright | Permalink | 4:22 PM


More fact-checking, from Fresno to Albany...

Thursday, May 24, 2007
Another study that explodes BlueCross' stunning assertion about the "affordability" of the California individual insurance market.

Bottom line: If you are 20 and never had a health issue ever, you can probably get a good deal in California. But if you are older and/or and in less-than-perfect health, California becomes less "affordable," quickly. In New York, with guaranteed issue, access to coverage is ensured, and the standard rate for a comprehensive package may be more expensive for some, it is less expensive for others.

The study: A national study in 2001 by the Kaiser Family Foundation, authored by Karen Pollitz and Richard Sorian at Georgetown University, and Kathy Thomas, had seven hypothetical applicants, from a 24-year old waitress with hay fever, to a 36-year old with knee surgery 10 years ago, to a 48-year old breast cancer survivor, apply for insurance. They applied to 19 insurers and HMOs in eight markets, including Fresno, California.

The result: Only 10% of application were accepted as "clean" offers--35% were either rejected, and over half (53%) were offered with a premium increase or a benefit limit.

The California conclusion: Carriers in Fresno (and Indiana) had more frequent rejections and premium surcharges than insurers in other markets. On average, applicants were offered coverage only about half of the time in Fresno, compared to about two-thirds of the time in other communities. Applicants in Fresno had surcharges apply 58% of the time, compared to 25%-39% in the other markets.

So any "rate" listed for California ignores how many people are rejected, and how many get a different and higher rate, due to their age and health status.

Comparison with New York: Blue Cross also slams guaranteed issue states, including New York, for having the highest rates in the nation. As a born and bred New Yorker, I hate to break it to them--everything, including insurance, costs more in New York.

But from this study, the hypothetical consumers applied for health insurance in Albany, New York--all got coverage. They all would have been sold a standard policy at a standard rate without any exclusion riders or other coverage penalties for their health conditions. The average premium for our single applicants in Albany was $4,104 per year--only slightly higher than the average premium ($3,996 a year) quoted to many applicants in less regulated markets.

In short, costs in New York, with "guaranteed issue" and "community rating" were similar to those in unregulated states, on average (recognizing that in other states, some paid more and some paid less). But everybody had access to comprehensive coverage, which is not the case in California, despite what BlueCross says.

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posted by Anthony Wright | Permalink | 3:44 PM


WWJD? in PA? in CA?

Sometimes, you don't need to comment. The lead of this Pennsylvania Patriot News story is "What would Jesus do about Pennsylvania's health care crisis?"

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posted by Anthony Wright | Permalink | 1:42 PM


"Unintended consequences" of BlueCross' ad campaign

In opposing reforms to prevent them from denying Californians coverage, Blue Cross is bringing up the energy crisis, but the analogy might backfire.

Newspapers and even this blog have already chronicled BlueCross' bad behavior in the marketplace, and their overall opposition to any health care reform.

Now they have launched a $2 million-plus ad campaign, under the name "Coalition for Responsible Healthcare Reform." (The LA Times' Political Muscle covers it here.) Blue Cross should be ashamed, spending millions to retain their ability to deny coverage to Californians.

The ads say "Remember how the rash enery deregulation of the energy market in California spawned power outages and soaring rates? Let's not go there again."

But if the energy crisis is the analogy, then Blue Cross is Enron, taking advantage of an unregulated California market and leading to a blackout of coverage for millions. But even the now-disgraced Enron never had the gall to run ads arguing that they should be allowed to continue to manipulate the market.

Because there are so few rules on insurers now, Californians are concerned now they are one job change or life event away from facing a blackout of coverage. We have over 6 million Californians in a coverage blackout. Frankly, we have tolerated deregulation for too long: new and fair rules would increase the security that Californians have now with their coverage, so they are not denied because of their health status.

BlueCross' ad campaign may backfire with the public. They won't believe BlueCross, and they will make it clear to Californians what we can win with health reform.

DOING A FACT CHECK: I think Californians know better than to believe Blue Cross and their misleading statements, especially the absurd notion that buying health coverage as an individual is affordable now. Their ad won't persuade most Californians that individual insurance is affordable now, from a 50-year old woman in the Bay Area, to anybody that takes a handful of prescriptions a year.

Blue Cross' price comparisons matches apples and oranges. It's different products, different people, and different states:
* The list price in many states does not include the significant mark up for age or those who have even minor health issues.
* The states with "guaranteed issue" are Northeast states which started with higher costs of living and higher insurance costs generally.
* Finally, you can't compare a product that actually covers you when you are sick, to one that will not.

We'll have more later in the day.

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posted by Anthony Wright | Permalink | 11:01 AM


The health debate goes multimedia...

Sunday, May 20, 2007
After a big week, it's time to take a quick check of other blogs and media:

TEXT: There's another edition of Health Wonk Review at Health Care Policy and Marketplace Review blog, which links to several articles of interest, including a conservative critique of the Massachusetts reform, an assessment that highlights the good and the bas about "retail" health clinics, and a detailing of the most recent bad acts by insurance companies.

Of most interest to me was the two links commenting on the new study about the uninsured getting charged multiple times what insurers get charged for the same service. On is at Health Affairs. InsureBlog has a critique that totally misses the point: I would imagine that if hospitals didn't charge such outrageous prices, maybe a few more of the uninsured might actually be able to pay the bill. And regardless, the charged amount--the inflated rate--is the bill that goes to collections and court. The price matters to the person getting the bill.

AUDIO: Back to California politics, KQED's Capitol Notes has now started a weekly podcast of analysis of Sacramento happenings. This week's features the health care, along with the budget and whales(!)

The health care section is amusing. It starts with a negative tone, led by Anthony York playing Eeyore, suggesting all the reasons health reform won't happen this year. But then after ten minutes of conversation, they all seem to come around to the notion that something might happen. (Will business accept a 7.5% minimum employer contribution? Don't most do a lot more now? Aren't some businesses signalling they would support such a standard?... Won't somebody simply put anything that passes on the ballot to kill it? But didn't it come very close time? And wouldn't Schwarzenegger be on the other side of the issue this time?...

VIDEO: Finally, Michael Moore's new film Sicko premiered at Cannes this weekend. It's a comparison of the American health care system with that of other countries. The reports suggests it focus on not just the uninsured but the insured who have issues with our private insurance companies.

Health Access was contacted for stories for the feature, although I hear we were not the only ones: one rumour was that they had hundreds of stories to choose from by the time they were done.

The movie comes out June 29th. It should be interesting to see how it impacts the debate in California and around the nation.

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posted by Anthony Wright | Permalink | 10:50 PM


Now, is there a return policy on that kidney too?

Friday, May 18, 2007
I always thought it was really screwy that medical professionals could bill patients to correct medical mistakes that the professionals -- not the patients -- made.

Really, we all make mistakes. So the issue really isn't that doctors are making mistakes; it's what they do to make up for them. For most of us, making a mistake is mortifying and often means fixing it -- even if we have to eat the cost.

Unfortunately, that's not always the case in the medical profession. If a mistake is made and a patient ends up back in the hospital/doctor's office, then it means a second or third chance to charge for what should have been done right the first time.

So it really seems like a no-brainer that a Pennsylvania hospital system is providing a warranty for medical care, according to this story in the NY Times.

Already, the Geisinger Health System in Pennsylvania has seen results. Last year, patients who received heart bypass surgeries could return back to the hospital if they had complications -- at no cost to the insurance company.

Well, duh. That seems reasonable. I'd be mad if I had to pay twice.

Since they implemented that policy, the system has found that patients don't return as often, and spend fewer days in the hospital.

Seems like this kind of policy could be a good deal for everyone. No one likes being sick and getting sicker, after you thought you were taken care of, is the worst. And...it's cheaper.

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posted by Hanh Kim Quach | Permalink | 1:27 PM


Arnold's day...

Tuesday, May 01, 2007
We hear that now that the prison issue has come to some resolution, the Governor is re-focusing on health care reform.

John Myers at KQED Capitol Notes suggests his day today has a significant health care theme:

Fly On The Wall: Most political reporters would love to be at two unusual events today on Governor Schwarzenegger's schedule... both of which are private meetings.

This afternoon, the guv is speaking to a meeting of the California Restaurant Association and, we're told, taking questions from those in attendance. The topic: Schwarzenegger's health care reform ideas. That's a proposal about which the restaurant industry has been quite vocal about its unhappiness, especially on the governor's call for new health care mandates on employers.

Let's remember that it was the fast-food and chain restaurants (McDonald's, Yum Brands, Outback Steakhouse, etc.) that were the bulk of the opposition to Proposition 72, raising around 70% of the funds against that proposal.

But also check out the other item on the Gov's agenda:

Later this afternoon, the governor is scheduled to meet here in Sacramento with GOP presidential candidate Mitt Romney. While the two have spoken on the phone before, the governor's aides say this is their first face-to-face chat. Romney has been working hard in recent weeks to plant his flag on the conservative side of the GOP universe for the coming primary... a place that Schwarzenegger seems to have taken off his political map. By the way, Schwarzenegger is also scheduled to attend Thursday afternoon's GOP presidential debate at the Ronald Reagan Library in Simi Valley.

Gov. Mitt Romney was supposed to be at Gov. Schwarzenegger's "Health Care Summit" last year to present the plan he signed (and partially vetoed). He couldn't make it, and he sent his Secretary of Health (who I sat next to). You would imagine health reform would be a big discussion point for their first meeting. But since then, Gov. Romney has been suspiciously quiet about health reform in his home state during his presidential campaign.

He doesn't want to own the individual mandate, nor the costs of the private market plans, nor other elements he insisted on. Yet he also doesn't want to highlight what many would consider the good aspects of the Massachusetts plan, including more than a 100,000 people getting coverage--through the expansion of public programs.

Maybe they will talk about the weather.

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posted by Anthony Wright | Permalink | 5:32 PM


Building blocks ...

Monday, April 30, 2007
Even though President George Bush only wants to provide health coverage to the poorest families, many states are planning to extend coverage to an increasingly middle-income population, according to an Associated Press story today.

Under current law, only children in families up to 200% of poverty ($41,300 for a family of four) could qualify for the program.

But 18 states, including California, allow children to qualify if the family income is higher than 200%. (In California, children in families at 250% of the poverty level could qualify, though many proposals in the Legislature -- including Gov. Arnold Schwarzenegger's -- would increase that to 300% of poverty - $51,510 for a family of four).

New York state just expanded its program to include children in families earning up to $82,600 a year -- or four times the poverty level.

This irritates the Bush administration, which opined that if everyone followed NY's lead, then 71% of children in the country would be covered through public programs.

Now, that doesn't seem like such a bad thing.

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posted by Hanh Kim Quach | Permalink | 10:48 AM


Grading on a curve

Saturday, April 21, 2007
Public Citizen put out a report last week ranking each state's Medicaid programs, based on the question, if you were poor and/or sick, how well could you get the care that you need?

Especially after fighting all the proposals to cut Medi-Cal during the last budget crisis, there should be some pride in California's ranking of 14, although it's sobering how restrictive Medicaid can be in other states. California did better than others: California didn't top the list in any category, but is better is eligibility and benefits than many states, and near the bottom of the pack in paying providers, which has an impact on these 6.8 million children, seniors and people with disabilities being able to access a provider. It does show that California can do more, and the report recognizes the health reform conversation we are having now.

The report does provide a useful reminder about how important and foundational the Medicaid program is for all of us. Page 61 focuses specifically on California.

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posted by Anthony Wright | Permalink | 11:14 AM


The dreamers, the lawyers, and me...

Wednesday, April 18, 2007
I am disappointed that the LA Times/Political Muscle's Bob Salladay didn't challenge the San Diego Union-Tribune's Chris Reed when repeating his assertions that health reform at the state level is not legal.

I'm not a lawyer, but given all the activity at the state level across the country, it doesn't seem many agree with him. His entire argument is based on a split ruling by the most conservative appeal circuit in the nation, about a specific law in Maryland that is structured differently than the proposals in California, which is in a different circuit anyway.

It's true that Maryland decided earlier this week not to appeal the court decision against their infamous "Wal-Mart law" to require the large retailer to spend at least 8% on health benefits. Reed compares the court decision--and I am not kidding or embellishing--to the Soviet tanks rolling into Prague as a final act against state health reform efforts.

We could get into the details of the federal ERISA law, but let's quote the actual decisions:

* The lower trial court: "Of course, I am expressing no opinion on whether legislative approaches taken by other States to the problems of health care delivery and its attendant costs would be preempted by ERISA. For example, the Commonwealth of Massachusetts has recently enacted legislation that addresses health care issues comprehensively and in a manner that arguably has only incidental effects upon ERISA plans. In light of what is generally perceived as a national health care crisis, it would seem that to the extent ERISA allows, it is strongly in the public interest to permit states to perform their traditional role of serving as laboratories for experiment in controlling the costs and increasing the quality of health care for all citizens." (From footnote 15)

* Characterizing and quoting the appeals court, the Center for Policy Alternatives writes: "The majority (2-1) opinion was written by a very conservative Reagan and Bush Sr.-appointed judge and was based on the assertion that "the Fair Share Act leaves employers no reasonable choices except to change how they structure their employee benefit plans…", an assertion that is simply false (as the dissenting judge pointed out).

* From the the dissenting appeals judge's statement: "Maryland is being buffeted by escalating Medicaid costs. The [Maryland] Act is a permissible response to the problem. Because a covered employer has the option to comply with the Act by paying an assessment — a means that is not connected to an ERISA plan — I would hold that the Act is not preempted."

It's about choices: The basis of the decision by the appeal court was that while there was technically an "option" for employers, it wasn’t "meaningful." Their ruling was based on the notion that no employer would choose to pay the 8% assessment to the state, for which they or their workers get no benefit, rather than directly provide coverage to their workers.

In San Francisco, and to various extents in Massachusetts and Vermont, and what is being debated in various states including California by our Governor and legislative leaders, the employers who pay the fee get the benefit of a workforce with access to health care, a workforce that is healthy, more productive, and has less turnover and training costs. For example, the "pay or play" models give employers "reasonable" and "meaningful" choices to benefit their workers, and thus themselves. Employers have options to comply with these local proposals without impacting their national ERISA health plans.

On Reed's challenge: Reed make a big deal that he can't find a ERISA lawyer to endorse Schwarzenegger's health plan. But lawyers are notorious about not giving a straight answer: most wouldn't endorse an Arbor Day resolution without five caveats.

But to say that you can't do state health reforms? I can find several through Google. Reed may be admitting he didn't read the court decision: I quoted above the dissenting judge who is undoubtedly a lawyer, who seemed OK with Maryland's law, even with its structure. Reed himself cites Pat Butler and other authors of various papers. And he mentioned that several states (Illinois, Pennsylvania, etc) have come out with their own proposals since the court decisions, and they all have their own legislators and lawyers in support.

California dreaming: Finally, Reed compares health reformers to the Dreamers during the Prague Spring, a time of creativity, liberalization, and openness before the Iron Curtain fell over Czechoslovakia.

But in the end, didn't the Iron Curtain fall? Didn't a playwright become president? Didn't the Dreamers ultimately win?

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posted by Anthony Wright | Permalink | 6:49 PM


Wonks, Flacks, and Hacks

Tuesday, April 17, 2007
One last comment on the TPMCafe Book Club on the new Jonathan Cohn book Sick. The discussion was useful in moving beyond the debate among progressives about what specific proposal to support, and focusing on the hard work at hand. In the last four years in California, we've shown that we can successfully advocate for different proposals at the same time, from setting standards for on-the-job benefits to expanding children's coverage to creating a universal single-payer systemmm, and each effort can build momentum for one another. There's more focus on health care this year because of all these efforts complementing each other.

One correction: Robin Podolsky wants it clarified that she wrote that she copped to being a "flak," not a "hack," as I mistakenly wrote. She was originally objecting to the term "wonk." I'll claim all three descriptions for myself...

That reminds me that I never linked to the newest version of Health Wonk Review, at the Health Affairs blog, which is chock full 'o interesting posts and analyses, about the national health policy debate. There's a reading list on lessons learned from the Clinton-era efforts; comments on the Democratic presidential candidate's plans, Massachusetts, single-payer, and other ideas, issues raised about transparency, and even a April Fool's post...

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posted by Anthony Wright | Permalink | 4:42 PM


The Connector vs. The Terminator

To inform our debate about "individual responsibility" in California, let's be clear that the only state in the nation to even try an individual mandate has last week allowed for broad "affordability" exemptions, for 20% of the uninsured. These folks are likely not offered public subsidies or affordable employer-based coverage, yet were facing the penalty of enforcement.

Under the Massachusetts plan, staying uninsured was the least worst option for these uninsured folks: the other option is to be forced to buy a coverage product that they don't have the money for, and given the deductibles and cost-sharing, may not be of particular use or value to them. Under the exemption, it's not great that they stay uninsured, but at least it meets the "first, do no harm" policy test.

I post this schedule not to endorse these standards, but to show that even proponents of the individual mandate need to recognize its problems. The Governor's proposal does not have any exemptions or considerations in this regard.

From "The Connector" in Massachusetts:

An example of what monthly premiums are deemed affordable, based on income under the recommended schedule, is set forth below. As an example, a single individual earning under $15,315 who is not eligible for Commonwealth Care because he or she is eligible for employer-sponsored insurance would not be penalized for passing up the employer-sponsored insurance offer unless it were free. At the other end of the income scale, a single individual earning between $40,001 and $50,000 would not be penalized for passing up the offer if the monthly premium were more than $300.

Singles ---------------------- Couples -------------------- Families w/Children
$0 - $15,315 ($0) ----------- $0 - $20,535 ($0) ----------$0 - $25,755 ($0)
$15,316 - $20,420 ($35) ---- $20,536 - $27,380 ($70) --- $25,756 – $34,340 ($70)
$20,421 – $25,525 ($70) ---- $27,381 - $34,225 ($140) -- $34,341 - $42,925 ($140)
$25,526 – $30,630 ($105) -- $34,225 - $41,070 ($210) -- $42,926 - $51,510 ($210)
$30,631 - $35k ($150) ------ $41,071 - $50k ($270) ----- $51,511 - $70k ($320)
$35,001 - $40k ($200) ----- $50,001 - $60k ($360) ----- $70,001 - $90k ($500)
$40,001 - $50k ($300) ----- $60,001 - $80k ($500) ----- $90,001 - $110k ($720)

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posted by Anthony Wright | Permalink | 3:46 PM


Health Care for children

Sunday, April 15, 2007
There is this misconception that health care is readily available to anyone -- that any person who is sick can see a doctor at any time.

Not so.

We advocates know that without health coverage, the neediest among us end up paying the highest prices for health care, or going without.

Congress is now trying to change this situation for legal immigrant children and pregnant woman. Currently, low-income immigrant children, who are here legally, cannot enroll in Medi-Cal or Healthy Families until they have been here for five years.

The Legal Immigrant Children’s Health Improvement Act (ICHIA) (S. 764, H.R. 1308) would allow states to enroll these children in those programs.

California already covers legal immigrant children and pregnant mothers. However, we don't get paid for it. If this law passed, it would go a long way toward helping pay for these services and create a more solid foundation for the state’s efforts this year to provide universal health care to all Californians.

A letter to Congress from governors is currently being circulated, but Gov. Arnold Schwarzenegger has not yet signed on. If our governor signs on, many Republican governors have also signaled they’d join in the fight.

We need you to contact the Governor's office TODAY and voice your
group's support for this letter.

Governor Arnold Schwarzenegger
Phone: 916-445-2841
Fax: 916-445-4633

California Partnership has a script (www.california-partnership.org) for calling.

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posted by Hanh Kim Quach | Permalink | 3:10 PM


Fine for insurers, fines for individuals

Wednesday, April 11, 2007
OToday, there's a story in the Los Angeles Times by Jordan Rau that talks about what the Governor's office is thinking with regard to enforcing their "individual mandate," including trying to find people though data matching and using fines and other collections techniques.

Let's be clear: there's lots of problems with the "individual mandate," starting with the premise that there's lots of folks who don't want health coverage, before you ever get to the sticky issues of enforcement. (It's also the subject of renewed crosstalk at Daniel Weintraub's Sacramento Bee health care blog.)

The enforcement issues go from deeply troubling to downright scary when the Governor's plan never acknowledges that there's some people who won't be able to afford coverage. As much as the Governor and his health team have said they are willing to consider ideas and that everything is up for negotiation, there has been no evolution of his health plan yet, despite the feedback received and the lessons learned. And that makes the enforcement discussion that much more disturbing.

For example, we are learning a lot from Massachusetts, at the one-year mark of passage of its reform law, and we should be mindful of lessons of what to do and what not to do. They will vote tomorrow on a range of decisions about "affordability," which should inform our own work here in California.

While taking no position on the stances they have taken, our advocacy colleagues at Health Care for All Massachusetts have some early information at their blog.

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posted by Anthony Wright | Permalink | 10:18 PM


400 is the new 300

Tuesday, March 13, 2007
When health care policy types talk about "300," they aren't talking about the new hit Spartan war movie with gruesome and ultraviolent battle scenes and homoerotic tones.

We wonks usually are referring to 300% of the federal poverty level, which is $30,630/year for an individual, and $51,510/year for a family of three. Even though this is literally three times the poverty level, this isn't a lot of money, especially in a high cost-of-living state like California. Housing and other expenses in the San Diego, Los Angeles, the Bay Area, and elsewhere don't leave a lot for other necessities, including health care.

Some of the health care proposals out there recognize this, to a point. For example, Governor Schwarzenegger, Speaker Nunez, and Senate President Pro Tem Perata all propose to expand public programs to children in families up to 300% of the poverty level. Several counties already go up beyond the 250% of poverty ($25, 525 for an individual, $42,925 for a family of three) -- the upper limit of Healthy Families eligibility now.

The Governor doesn't go so far for adults, proposing subsidized coverage for adults up to 250%, even though he would still impose an "individual mandate" on those above that amount, who get no financial assistance to help meet that requirement. Even the plan in Massachusetts provides subsidized coverage for families up to 300%.

But now there is a greater recognition that help is needed for the middle-income families, up to 400%. Illinois Governor Rod Blagojevich has proposed his own health reform plan, which provides subsidies for families up to 400%. Presidential candidate Hillary Clinton and key Congressional leader John Dingell have proposed reauthorizing the children's coverage program (SCHIP, Healthy Families here in CA) to cover all children up to 400%. New York Governor Eliot Spitzer has proposed the same for children's coverage in his state.

Health care is getting costly enough that help is needed for both low- and moderate-income families. Some will argue that such ambitious proposals are harder to pass and to fund. But the recognition that health care is a middle-class issue might be the very reason health care reform is getting such attention from political leaders in the first place.


posted by Anthony Wright | Permalink | 10:38 PM


A tale of two states...

Monday, March 12, 2007
Clea Benson in the Sacramento Bee touches on some of the debate that the Massachusetts health reform has sparked in that state, and the implications for California.

So how is the Massachusetts reform going? My take: It is the best of times; it is the worst of times.

It's not a surprise that of the mix of policy changes, some are working, others are not: A useful guide to see what we want to pick and choose here.

The best of times: The expansion of public programs there has enabled over 100,000 uninsured folks to get coverage, moving Massachusetts to have the lowest rate of uninsurance of any state in the country, alongside Hawaii and Minnesota. Appropriately, the help is greatest where the need is greatest, with low-income individuals and families. These sort of expansions of proven public programs are what work in our health system, and that's why we support similar proposals here in California, to expand Medi-Cal and Healthy Families.

Let's also remember context: MA was already 6th lowest uninsured before their reform. CA is on the other end of the spectrum, with the 5th highest uninsured. So we have a longer ways to go.

The worst of times: The idea that consumer advocates have been most alarmed about, the "individual mandate," is raising alarms there, too, as they approach the July 1 date for its implementation. The problem is that for many, the coverage that is available is simply too expensive for those with middle-class incomes. Policymakers are trying deciding between an unaffordable premium, or an unaffordable benefit, one that either has too high cost-sharing or that doesn't cover key services, like prescription drugs. And for that latter choice, what's the point of having coverage if it doesn't cover what you need, or is too expensive to use?

This debate is being well-documented by the MA consumer group, Health Care for All. Massachusetts does has an escape valve, stating that the individual mandate does not apply if coverage is "unaffordable," so it is likely that some category of individuals above $30K/year or families of four over $60K/year--who won't get subsidized coverage--will simply be exempt from the plan. (FYI, Governor Schwarzenegger's individual mandate proposal does not include any exemption whatsoever.)

For these Massachusetts individuals that don't have the benefit of employer based coverage (and the MA plan does virtually nothing to help them get it, and Governor Schwarzenegger's plan won't help most), the *best* case scenario is that they stay uninsured--and face the health and financial consequences of being uninsured. The *worst* case scenario is that they are forced to spend an unaffordably large percentage of their income to get stripped-down and/or high out-of-pocket cost coverage that will not be useful to them.

And that would be Dickensian, indeed.


posted by Anthony Wright | Permalink | 1:56 AM


MD law may need an MD, but CA could have an Rx

Wednesday, January 17, 2007
A federal appeals court Wednesday upheld a lower court's decision that struck down Maryland's so-called Wal-Mart Act.

In 2005, Maryland passed legislation requiring businesses with more than 10,000 employees to spend at least 8 percent of their payroll on health coverage. Only four businesses met the law's description, Johns Hopkins University (which was exempt because it is a non-profit), Giant Food (a union grocery chain which spends more than 8 percent), Northrop Grumman, a defense contracter (which also spends more than the law required because of its high-salaried workers), and Wal-Mart -- ultimately the only target.

After the law passed, retailers sued, claiming -- among other things -- that Maryland could not legally force businesses to spend a certain amount on its "health insurance costs'' because it violated the 1974 federal law that says states can't interfere with businesses' benefit plans. The courts so far have agreed with Wal-Mart.

What implications does this ruling have for an employer requirement in California, in the different variations proposed by Governor Schwarzenegger, Speaker Nunez, or Senate President Perata? Not much.

The courts -- and ERISA -- do not say that state and local governments can't dictate spending on "health care services'' -- just benefits. So -- there is a way for states to make policy in this area without running into the constraints of the federal law.

San Francisco's Health Access Program (no relation), which has created an employer mandate, is believed to have a much stronger legal case to actually get around the federal restrictions.

San Francisco's Health Access Plan requires employers to spend a minimum amount on 'health care services.' Businesses could satisfy this requirement several ways--by providing insurance, contributing to a city pot to cover the uninsured, or reimbursing employees for medical expenses, among other things. The latter two examples would not violate federal law because it has nothing to do with a specific benefit plan.

A second point -- which is mainly just a beef but I'll make it anyway -- is that Maryland's 8 percent threshold would have hardly caused Wal-Mart to make any changes to its workers' health benefits. Wal-Mart testified in court that its coverage spending was between 7-8 percent, already (7.7 percent if their website is to be believed).

For Wal-Mart, that means having to increase its spending on 16,000 Maryland employees, who make an average of $14,400 a year. That means -- at most -- another $2.3 million a year. That doesn't even amount to one-one thousandths of Wal-Marts net profits in 2006.

The passage of the Maryland law was a important signal, after SB2/Prop 72 in California, that other states were looking at the issue of employers scaling back or dropping coverage, and the impacts not just on the uninsured, but on the public programs and thus taxpayers as well.

The concept that everybody--including employers--should pay their "fair share" is an important one. But given how different Maryland's law is from similarly-themed approaches, including those in New York City, Massachusetts, San Francisco, etc, the court ruling will have little actual impact on what has passed in other places, or what is being proposed.

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posted by Hanh Kim Quach | Permalink | 10:12 PM


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Anthony Wright is the executive director,
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