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Uninsured ranks swell as Congress works...

Thursday, October 08, 2009
Our need for health care coverage that doesn’t vanish when the jobs vanish becomes ever clearer each month, as the number of newly unemployed piles up. Given the mounting jobless toll – and subsequent swelling of the uninsured population -- it’s a wonder that debate lives on over whether reform is needed.

Surely, by now we all know someone who has been stripped of their livelihood in this recession. Surely, by now most of us feel that, there but for the grace of God, go I.

Yet Congress members are willing to entertain scaling back health care reform’s figurative big tent of coverage, accepting that millions more than first envisioned may be left out in the cold, uninsured.

At least one prominent commentator with a substantial soap box believes this is absurd, and devoted an entire hour-long program this week to telling TV audiences that everyone, everyone deserves health care. For MSNBC’s Keith Olbermann, the argument is black-and-white. The host of Countdown suspended his news format Wednesday for a soliloquy on his viewpoint that all Americans should have access to quality, affordable care.

Moved by helping care for his ailing elderly father, Olbermann deemed it flat-out unfair that those with means -- like himself – had access to quality care, while others without means were shut out of access. The episode is worth watching, if only to witness the passion of his argument.

Meanwhile, matters are worsening in real time, as joblessness continues to broaden the problem Congress is trying to solve. The elephant in the room is getting bigger by the day, so to speak.

A new report by Families USA calculates the impact of the economy’s double whammy on the workforce. Titled “One-Two Punch: Unemployed and Uninsured,” the report seeks to update U.S. Census Bureau figures from 2008 that were recently released and widely reported:

“Given the close link between unemployment and uninsurance, and given the marked increase in the unemployment rate between 2008 and 2009, we estimate that the number of uninsured working-age adults (19-64) today is substantially higher than the Census Bureau’s 2008 estimate.”

In California, the number of uninsured working-age adults in 2008 was 5.4 million, or 24.3 percent of the population. Families USA expects that number to rise to 6.1 million, or 26.7 percent, when 2009’s job-shedding is taken into account.

The new report says California’s unemployment rate has already grown 4 percent, from 7.2 percent in 2008 to 11.3 percent through August 2009 (the 2009 figure is calculated by averaging the jobless rate from January through August.)

By the end of 2009, California will have “suffered the largest numerical loss in health coverage among working-age adults” of all the states, Families USA says. The organization projects that loss at 661,600 adults. Texas is second-worst with a loss estimated at 396,900, and Florida has the third-worst loss, with 297,600 losing coverage.

That elephant in the room? Families USA projects that by the end of the year, the uninsured ranks nationwide will plump up from 46.3 million to 50 million. Pity Congress: It’s not easy to negotiate a solution to a problem that continues to expand as compromises are being crafted.

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posted by Cynthia Craft | Permalink | 8:08 PM


Coverage at the county level...

Tuesday, August 18, 2009
Plenty has changed since 2006, the latest year that the uninsured of California was counted by the U.S. Census. But even then, many months before the current recession hit, the percentage of people living without health insurance in our state was startling.

This week, the Sacramento Bee laid out the statistics, finding quite a disparity between those with health insurance and those without. Just in the five-county region The Bee covers, Yolo County posted an uninsured rate of 22 percent of people under 65, while the more prosperous Placer County -- with more employment-based coverage -- posted a 13.7 percent rate.

That's quite a disparity, and the article by Phillip Reese and Anna Tong is worth reading. But the Bee doesn't limit information to its circulation area, it also posts online a comprehensive rundown of each of California's 58 counties' uninsured rate, along with an interactive map of the state and rollover charts.

Here's a sampling of what the authors wrote:

"The uninsured present an immense fiscal and public health challenge: 18,000 Americans die each year because they aren't covered, according to the Institute of Medicine, a nonprofit research organization. This is because having insurance is closely tied to health outcomes: The uninsured won't see a doctor regularly, and if they seek care it is likely to be inadequate or too late.

Moreover, the uninsured are a cost for society: One economist recently estimated the tab at $56 billion per year, 75 percent of which is paid by governments. In cash-strapped California, that cost is critical: 6.6 million residents went uninsured in 2007, more than in any other state, according to the California Healthcare Foundation."

You can bet that, with massive layoffs and small businesses closing since that Census count, the number of those among us -- members of our communities -- who are going without health insurance is a great deal larger. Factor in the Governor and Legislature's cuts in health and insurance programs for lower-income Californians, their children and the elderly, and you get an unimaginable sum of fellow Californians without access to affordable, quality health care -- notably, preventative health care, with better outcomes.

This is what the conversation about health care reform boils down to, not pumped-up talking points and hyper-emotive protests based on misinformation. This is not a partisan issue. It is a people issue. And the bottom line is that the majority of Americans have already voted -- for substantive change for a better future for our country.

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posted by Cynthia Craft | Permalink | 8:31 PM


It just gets worse... We're #4!

Monday, August 03, 2009
The Census Bureau came out with new data today, and it's not pretty. California jumps from the 7th highest in the nation in uninsured rate--to 4th. Here's Sacramento Bee's Capitol Alert:
The new data, based on a 2006 survey, indicate that California has the nation's fourth lowest level of medical insurance, with 21.3 percent of its residents under 65 years old lacking coverage - and recent reductions in Healthy Families and other state-sponsored medical care programs will, authorities say, push that number higher...

Only Florida, Louisiana and Texas have lower levels of health insurance, with Texas last at 27.6 percent uninsured. The Census Bureau data, which confirm earlier estimates by state officials and health care advocates, found that 6.8 million Californians lacked health insurance in 2006 out of 32 million Californians under 65. (Those over 65 are not counted because it's presumed they have Medicare coverage.)

At the other end of the scale, just 9.4 percent of under-65 residents of Minnesota, 9.6 percent of those in Massachusetts, 9.8 percent of Hawaiians and 9.9 percent of Wisconsinites lack insurance.

Our uninsured rate will only get worse: these numbers don't take into account the projected 500,000+ people who have lost coverage related to the recession in its first 18 months, nor the impact of the more recent budget cuts, including the closure of Healthy Families enrollment, denying coverage to up tp 900,000 children.

We need federal health reform, and fast.

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posted by Anthony Wright | Permalink | 8:32 PM


Without reform, it's bad and getting worse...

Wednesday, May 20, 2009
On the eve of new unemployment figures to be released by California's Employment Development Department, a new Health Access study documents an increasing rate of uninsurance to accompany the growth in unemployment, with at least a half-million Californians losing health coverage in the last 18 months of recession.

A second, national study shows how current trends, especially the erosion of employer-based coverage, could leave millions more uninsured over the next 10 years. Under the best economic scenario, this could result in 53 million Americans becoming uninsured; under the worst scenario, 66 million could lose coverage.

Both studies document the very high cost of maintaining the status quo. The need for health investment and health reform is urgent, as California legislators begin to consider significant health care cuts, but also as key Congressional committees start to consider comprehensive health reform--reforms which could change these trends.

The new Health Access report, "Resuscitating an Ailing Economy: Investing in Health Care," finds:

* As a result of the economic recession, over 1 million Californians have become unemployed in the past 18 months.
* As families lose jobs that provide coverage, over 500,000 Californians have become newly uninsured.
* These numbers may increase when the Economic Development Department releases new information about the state's unemployment figure (now at 11.2%) on Friday, May 22nd.
* The report suggests that investment in health coverage programs and health reform can prevent Californians from becoming uninsured, can help create jobs and spur economic growth -- as well as prevent negative health, economic and community impacts of increased uninsurance.

The report is available at:

The new Robert Wood Johnson Foundation (RWJF) report, "Health Reform: The Cost of Failure," had researchers from the Urban Institute prepared the analysis using its Health Insurance Policy Simulation Model, estimating how coverage and cost trends would change between now and 2019. The study examined three alternative scenarios, including a "best case" and a "worst case" based on employment, income growth, and increase in health care costs. The report finds:

* Individuals and families would see health care costs dramatically increase. Total individual and family spending on premiums and out-of-pocket costs could increase 68 percent by 2019 in the worst-case scenario. Even under the best case scenario, health care costs would likely increase at least 46 percent.
* Businesses could see their health care costs double within 10 years. The model shows that employer spending on premiums would more than double – from $429.8 billion in 2009 to $885.1 billion in 2019. Even under best-case economic conditions, employer spending on health insurance premiums would increase 72 percent. The result would likely be far fewer Americans being offered or accepting employer-sponsored health insurance (ESI). Estimates suggest a drop from 56.1 percent of Americans being covered by ESI in 2009, to as few as 49.2 percent by 2019.
* Spending on government insurance programs could double. In the worst case scenario, spending on Medicaid and the Children’s Health Insurance Program could increase from $251.2 billion this year to $519.7 billion in 2019, as more people are priced out of private insurance and become eligible for government programs. Enrollment in these programs could increase to 20.3 percent in 2019 in the worst case, or one in every five Americans. That’s an increase of 13.3 million people from current figures.
* Millions more people would be uninsured. The model projects that without reform, 65.7 million people could be uninsured by 2019, compared to 62.2 million in the intermediate case and 53.1 million under the best case. The report makes clear that the biggest effects of not having health reform would be felt by families with moderate incomes, who have less access to public coverage. Under the model, the number of middle-income earners without insurance would increase sharply from 12.5 million in 2009 to as many as 18.2 million in 2019.

The full report is available online at http://www.rwjf.org/ and http://www.urban.org/.

"We need national health reform not just to prevent our broken health system from getting worse, but to allow for a sustainable economic recovery that is not burdened by increasing health care costs and rising numbers of uninsured." said Wright. "We need health reform that brings down the cost of health care, and provide coverage that Californians can count on when they need it."

For more information about the reports, the implications for proposed health care cuts in California, or for the debate in Washington, DC, on health care reform, contact Health Access, or visit our newly updated website and blog, updated daily, at http://www.health-access.org/.

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posted by Anthony Wright | Permalink | 8:08 PM


Getting to universal...

Monday, May 18, 2009
Ezra Klein, now at his new web address at The Washington Post, tags off the report by The New Republic's Jonathan Cohn that health reform might not cost as much as believed. The Congressional Budget Office is projecting that some portion of the uninsured will stay uninsured, even with the "individual mandate."

But this should not be a surprise. We have an "individual mandate" for drivers to have auto insurance, and yet have a noncompliance rate of around 15%--although it ranges depending on the state. For the most part, the issue isn't enforcement: my assumption--confirmed by survey research--is that the vast majority of people want health coverage-desperately; the question is will the reform remove the barriers and provide the assistance needed? Will the reform make coverage more available and affordable? Will it be easy to enroll--or even automatic?

So what the reform includes matters a lot in terms of how "universal" it is. Provided that affordability is assured, I don't think the mandate is as important as an automatic-enrollment mechanism, as with Medicare or on-the-job benefits.

These kinds of structural issues matter, I think, even more than Ezra's initial take that some of the remaining uninsured will be undocumented immigrants. According to UCLA research, undocumented are a small fraction--about one-fifth--of the uninsured. Around 75% of them are workers or family members of workers, more of whom may--and should--get coverage from their employer under a reformed health system. At the very least, we can all agree that if you work and pay your dues, you should get coverage. And Ezra points out why that's important, regardless of where you are in the immigration debate. But health reform is a much broader issue that affects everyone, insured and uninsured.

Our job as consumer advocates and organizers is to push for the policies to make coverage more available and affordable for all, and for the financing to make that a reality.

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posted by Anthony Wright | Permalink | 4:39 PM


Putting the stimulus to work

Wednesday, May 13, 2009
Making health care coverage more affordable for Californians who are laid off from their jobs is certainly a priority. And so, Gov. Arnold Schwarzenegger has signed legislation that does just that for former employees of small businesses.

The bill, AB 23, uses federal stimulus funds to subsidize 65 percent of the cost of Cal-COBRA coverage for the newly unemployed of businesses from 2 to 19 workers.

COBRA coverage, which continues a laid-off worker's existing health care coverage for a period of up to nine months, is notoriously expensive and priced out-of-reach for many who have lost their jobs in this down economy. While the individual would still have to pay 35 percent of the premium, the subsidy can help a lot of Californians "between jobs" make ends meet while staying covered.

While the federal COBRA law only goes to employers of 20 or more, Cal-COBRA extends the option to workers of smaller employers. The bill, co-authored by Assemblymembers Dave Jones (D) and Nathan Fletcher (R), extends the new subsidy as well--but it requires proof of involuntary termination, and allows anyone who was laid off since September 1, 2008 to resume coverage.

The legislation, on a fast-track to take advantage of federal premium assistance, was sponsored by California Insurance Commissioner Steve Poizner. Health Access California was in support with many other organizations.

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posted by Cynthia Craft | Permalink | 2:15 PM


When things get worse...

Sunday, April 05, 2009
Two California-specific reports came out this week on the uninsured, as noted by the Sacramento Bee and other papers, and they are sobering.

Families USA came out with a California-specific report, Americans at Risk, that showed a new light to the regular uninsured numbers. It's commonly understood that the number of uninsured is in the 5-7 million range in California, 44-46 million nationally. But those numbers seem to imply that the uninsured are a self-contained, even if large, population--rather than the reality than being uninsured is a condition that anybody can fall into.

In fact, Californians are more likely to become uninsured than residents of all but a few other states. The studies looks at the uninsured over two years, and finds that over 12 million Californians, or 37% of Californians under 65, have been uninsured at some point in 2007-08. More about the research is reported by the Los Angeles Times, as well as public radio.

The UC Berkeley Labor Center also released a new health care study this past week: “No Recovery in Sight: Health Coverage for Working-Age Adults in the United States and California.” As reported in the Sacramento Business Journal article, the UC-Berkeley researchers calculated how many people in California have lost their health insurance during the current recession--500,000.

Even more distressing is that the researchers projected what would happen to health coverage rates as the economy recovers, and they found that even when the economy recovers from the recession, the number of people who are uninsured will continue to grow.

Certainly a compelling context for the Forum on Health Reform Monday, in Los Angeles, which is ground zero for the uninsured crisis nationally.

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posted by Anthony Wright | Permalink | 12:36 AM


Health Wonk Review, Yogi Berra edition...

Thursday, April 02, 2009
This week, we have the privilege of hosting Health Wonk Review, a regular compendium of the best blog posts on health policy. While the beginning of April signals the end of spring training and the call of "Play Ball," this year this is true of health reform as well.

Next week, the Obama Administration's road show on health reform ends here in California, and the health reform debate back in Washington, DC, moves from a broad framework to working through the thorny policy and financing issues, starting with the crucial question of whether they include money in the budget for health reform. The goal is action in the summer, for passage in September-October, right during the playoffs.

For those of us in California, it's like baseball great Yogi Berra said, "it's like deja vu all over again." As the statewide health care consumer advocacy coalition, we've been involved in many efforts for comprehensive health reform at the state level, most recently in a high-profile effort that stalled last year (which was the subject of three recent web articles of interest in Health Affairs). Many that we work with in California and nationally have longer histories in health reform; our scars are merely fresher.

In the spirit of the baseball season, it seems that health wonks can learn a lot from Yankee great Yogi Berra, who will soon attend the opening of a new Yankee Stadium in my hometown of the Bronx. He was savvy enough to understand the blogosphere before it was even invented, when he said: "It was hard to have a conversation with anyone. There were too many people talking." So onto the posts, some of which were suggested and nominated, and others that we found and liked:

Let's start with health care costs, where much of the conversation on health reform is focused. As Yogi said, "a nickel ain't worth a dime anymore."

Matthew Holt of The Health Care Blog asks "So what's the real usual, customary and reasonable price of care?" As Yogi says, "I wish I had an answer to that because I'm tired of answering that question." Holt's answer: "They’re what providers have made up over the years." So his take on the Ingenix scandal is that the whole pricing structure of health care system is screwed up.

I can't disagree, given that I've seen too many uninsured or underinsured patients who are sent to collections and court for hospital and doctor bills that are multiple times what insurers pay, that have no relationship to the actual cost of providing care.

These bills not only have financial impacts, but deter people from getting the care they need. Ill and Uninsured in Illinois tells a personal story in the post Lutheran General: Pay first, and we'll put a Band-Aid on it. "This personal story illustrates why access to emergency-room treatment does not constitute access to health care in any meaningful sense."

Another big issue is government's role in the insurance market, as a regulator, a negotiator, and a competitor.

There's one view by Jared Rhoads at The Lucidicus Project, who even opposes government as an information provider, because as he describes it, "the government should not be funding comparative effectiveness research because it should not be involved in healthcare at all."

Another skeptic about new rules for the marketplace is Bob Vineyard at InsureBlog, who asks in Good News, Bad News if the insurance industry's "offer" to give up medical underwriting really a good thing, wondering if it could means higher rates.

Frankly, I would much rather if insurers competed on cost and quality rather than on their ability to avoid risk--a.k.a sick people. My colleague Jason Rosenbaum at the Health Care for America Now campaign is also skeptical of "the insurance industry's disengenuous concession," but from a totally different position. This is something the industry should have started with, and they are still screaming against a public health coverage option for consumers. As Yogi said, perhaps about the distance the insurers have come, "it's not too far, it just seems like it is."

Maggie Mahar at HealthBeat also thinks there's a lot more distance for the insurers to go, with regard to new rules for the road, and a public option to keep them honest.

Jaan Sidorov of the Disease Management Care Blog posts about the debate about a public health coverage option, and fears that a public option would use its significant market power to dictate rates, undermining the private insurer competition.

The wunderkind Ezra Klein at The American Prospect, in a "primer" on the public health coverage option, hopes that any potential compromise does not take away the main benefit--the public health insurance option's ability to negotiate for the best possible rate.

Jeffrey Seguritan at nuts for healthcare has a detailed post on the back-and-forth in the blogosphere around health reform and the public health coverage option. He ultimately argues that the lessons from the Massachusetts univeral coverage experiment is that expanding access cannot be sustainable with a cost containment strategy, and while a public health plan would be potentially a dangerous competitor, its main appeal would be its market power to implement broad changes in provider payment paradigms.

I wonder what all the fuss is about. After all, more than a third of the population is in a public health coverage program already, including Medicare and Medicaid. Here in California, we have lots of public health plans, run by counties. The concept was part of the reform agreed to be our Republican Governor Arnold Schwarzenegger, and part of the Healthy San Francisco reform as well. This isn't some new concept, and people tend to like their coverage. As Yogi said, "nobody goes there anymore, it's too crowded."

But let's all take a step back. At The New Republic's The Treatment, (where I post regularly as well) the host and ace reporter Jonathan Cohn wonders whether all the fuss about public insurance plans, individual mandates, and such is premature. "None of these things will mean bubkes if we don't come up with the money to pay for reform," he writes--and offers some options for solving that problem. Some of those are controversial--for example, removing some of the tax deductions for employer-based coverage--but forgive him, he's a Red Sox fan. He's seen the improbable happen twice in this decade.

Other posts of note cover the range of health policy, and feature some original reporting. As Yogi said, "You can observe a lot by watching.":

* Joe Paduda reports over on his blog Managed Care Matters, on the interesting turnaround, after years of providers not liking being rated by insurers, that now providers are rating health plans,

* Jason Shafrin provides a comparison of pharmacists and primary care providers as immunizers, posted at Healthcare Economist. In a paper evaluating whether pharmacists can be effective vaccinators, he finds that pharmacists proved more consistent in following safety protocols, had lower unit costs, and were more efficient than vaccinators in traditional settings.

* Yogi once explained, "you've got to be careful if you don't know where you're going cause you might not get there." Some of those lessons for improving health outcomes at a hospital--leadership matters, the need to set clear goals--are described in the post "GOOD NEWS: How the Baylor Health Care System Disseminates Quality Improvement (Part III)" posted by Joanne Kenen and Tom Emswiler at New America Blogs.

* David Williams of the Health Business Blog wonders if how newspapers report about deaths--from detailing whether seatbelts were worn in car crashes, to describing other circumstances of potentially preventable deaths--could be a form of public education, in the post "Death reporting: Time to wade into medical matters in cases like Jade Goody’s?" The dead (and their survivors) might object, as everybody looks better in life: as Yogi said, "Steve McQueen looks good in this movie. He must have made it before he died."

* Julie Ferguson at Workers’ Comp Insider posts on the high price of fresh tomatoes: more on agricultural slavery in Florida. She posts about modern day slavery and human trafficking, especially within the immigrant workforce in the agricultural industry, particularly in Florida. It's an issue in California as well, where the agricultural workers do not have healthy conditions, and largely don't get health coverage or care.

UPDATED: Here's some worthy lost-in-the-E-mail-deluge nominations:

* Also from a public health perspective, Boston Health Notes' Tinker Ready reports that health disparities are not just black and white. We in the hyper-diverse California agree.

* Speaking of universities, Roy Poses at Health Care Renewal writes about "the political incorrectness of discussing conflicts of interest in medical adademia." He reports on how Tufts administrators withdrew from a panel discussion to avoid appearing with an aide to Senator Grassley--perhaps because of their discomfort with the Senator's views on conflicts of interest in academia.

So there's a lot of work to do. There always will be, since as Yogi said, "if the world were perfect it wouldn't be." But the status quo is decidedly not perfect, and it's deteriorating, and so the task of health reform is even more urgent.

Attempting health reform might qualify as a national pastime, given that our country has been trying in multiple effort since the Cubs last won the World Series when Teddy Roosevelt was president. In previous efforts, "we made too many wrong mistakes." Can we learn from them?

What plan should we advocate? As Yogi said, "when you come to a fork in the road, take it." As consumer advocates, Health Access California has advocated for a range of solutions, from single-payer to pay-or-play. But as with any directions, we want to make sure we are going roughly in the right direction. It will always be a balancing act, pushing the dire urgency of reform while also advocating the right reforms--and even figuring out what those are.
Health Wonk Review continues two weeks from now at Pizzazz. Until them, let's end with Yogi Berra's best advice, on the value of persistance: "It's not over till it's over."

Play ball!

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posted by Anthony Wright | Permalink | 2:10 AM


House rules...

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

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

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

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

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posted by Anthony Wright | Permalink | 7:43 PM


Insurance for Insurance

Wednesday, December 03, 2008
So UnitedHealth is going to start offering coverage that will ensure you can get coverage. Doesn't it sound like a bizarre movie plot?

So basically, if you pass a health test, and anticipate that you might have a pre-existing condition issue later that may prevent you from getting coverage, and may need itinerant coverage on the individual market, you get coverage to ensure you can get coverage.

There has got to be a simpler way: it's called Guaranteed Issue.

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posted by Hanh Kim Quach | Permalink | 11:26 AM


Flying without a parachute

Wednesday, October 29, 2008
The San Jose City Council will soon consider a "living wage'' that would increase wages for airport workers. For those with health benefits, the wage would be $12.83 an hour. For those without benefits, the wage would be $14.03 an hour.

The difference, then, between having benefits and going without is $1.20 an hour. Over the course of a year, that's an extra $2,400 in your pocket, assuming employees work 2,000 hours. That's $200 extra dollars a month. But that also means that a worker would have to go out and find insurance on their own.

Airport workers, the ones that push wheelchairs and check baggage, are not young. In a Google search, I find that in Dallas, the average age of an airport worker is 45, so I'm going to use that for my illustration.

It is possible to find an individual health insurance plan for a 45-year-old woman in San Jose for less than $200 a month. However, it also means
  • paying deductibles ranging from $500 to $5,000;
  • paying high co-pays for limited doctor's visits (and for a 45-year-old with a physically taxing job, that may not be a wise choice. Not to mention the regular health needs of a 45-year-old woman.);
  • having *only* generic prescription drug coverage;
  • paying the full cost of labs and X-rays until the deductible is met;
These are bills that make your stomach ache. They're not fun to pay, but you need to pay them because you need to stay healthy. And for a person earning about $28,060 a year, these costs represent, proportionally, an even bigger financial sacrifice. The premium alone is 9.5 percent of wages.

Of course, the big question, is whether a person $28,060 can really afford -- with housing, food and gas expenses -- to spend another $200 a month on a skimpy health care plan.

The answer, most likely, is no.

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posted by Hanh Kim Quach | Permalink | 8:55 AM



Monday, October 27, 2008
The Sacramento Bee this weekend told the very real story of counties stepping in to provide medical care when people find themselves without health insurance.

What struck me is the very palpable sense of vulnerability -- that at any moment, you or someone you know could become uninsured and wait in this line. That at any moment, you or someone you know could be layed off and lose your benefits. Could lose all access to credit and a way to pay for medication and other necessary care.

"I think people have a misconception about who the medically indigent are," Pitman said. (Dr. Dorothy Pitman is the medical director of the Sacramento County clinic branches).

On some days, cars circle the clinic's parking lot.

Some patients arrive in beat-up Toyotas or late-model cars, others in SUVs and, occasionally, even a Lexus or an aging Mercedes.

"Folks lost the house, but kept their fancy cars," said Fred Heacock, the clinic manager.

His point: Bad things can happen to anyone at anytime.

The sense vulnerability -- of exposure -- is also echoed in this LA Times story -- about Wall Streeters having to tighten their belts. Most of the story is about how even the investment bankers on Wall Street earning $400,000 will have to scrimp some. But what jumped out at me, was this vignette:

A few weeks ago, a wife, six months pregnant and about to enter the operating room to have a masectomy for cancer, does not talk to her husband about her imminent surgery. Her husband worked at Lehman brothers. The discussion was about whether she would still have health coverage for *that day* if Lehman Bros. declared bankruptcy.

As an advocate, I see academic research coming across my desk that says higher income earners do worry about the *big event* that will eviscerate their savings. But it has never been spelled out as starkly as this...

And no one polled on the street would likely guess that a family with a $400,000-a-year income would also have to worry about how they will pay for medical care.

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posted by Hanh Kim Quach | Permalink | 9:18 AM


Erosion could lead to eruption

Thursday, October 16, 2008
It wasn't a huge surprise that the Economic Policy Institute reported this week that employer-based coverage is continuing to erode. Since 2000, 3 million fewer workers are insured through work -- the place where 61 percent of Americans get their coverage.

For those Americans who are still lucky enough to get their coverage through work (19 million in California), is it any surprise that you're paying more? A new report released today by Families USA shows health premiums for workers rose five times (5) more quickly than earnings. Here's the Sacramento Bee's story on the report.

These reports, together, tell us that our foundation of employer-based insurance coverage is in trouble. Already, fewer Californians get their coverage through work as contrasted with the rest of the country (52.3% versus 61%). Fast-escalating premiums make it harder for both employer and employee to afford coverage, especially if the insurance products get worse and worse every year.

And if people are finding coverage through work unaffordable, wait until they hit the individual insurance market, where they would be responsible for 100% of the premium costs and not buying as part of a group that can leverage lower rates. Further erosion in job-based coverage just means more uninsured.

Meanwhile, in other health news. The LATimes reports on the United States' abysmal infant mortality rates. I can't seem to find the CDC report that the Times is referencing, but looking at the OECD numbers reflects our same sorry state. We spend the most of any industrialized country on health care (15.3% of our gross domestic product, and $6,700 per person), yet our infant mortality rates are high -- 6.9 deaths per 1,000 infants -- compared to Sweden, which has the lowest infant mortaliy and spends less than half what we do per capita.

All this leads to cheery comments written by the director of the Congressional Budget Office today -- Peter Orszag, a health reform champion.

Many observers have noted that addressing the problems in financial markets and the risks to the economy may displace health care reform on the policy agenda — and that may well be the case for some period of time. ...

Although it may not seem immediately relevant given our current difficulties, it will be crucial to address the nation’s looming fiscal gap — which is driven primarily by rising health care costs — as the economy eventually recovers from this current downturn.

Translation: Failure to keep health care costs in check will make things even worse.

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posted by Hanh Kim Quach | Permalink | 1:26 PM


Why the ERISA Ruling in San Francisco is a Big Deal

Thursday, October 02, 2008
The ruling on the San Francisco health care ordinance is important for several reasons: first, it clearly dismisses the arguments of the fast food industry and the Chamber of Commerce that the employer requirement violates ERISA.

Second, the ruling takes head on the decision by the Second Circuit Court on Maryland (known as RILA after the Retail Industry Leaders Association that filed that case). The Ninth Circuit says that the other court demonstrated that Wal-Mart was the only employer required to change their behavior as a result of that law and that the Maryland law did not give Wal-Mart (or any employer) a genuine alternative for providing health benefits for workers. In contrast, the San Francisco health plan is a real alternative for employers (and their employees). An employer that is not meeting the requirements of the SF ordinance can choose to provide health benefits to more employees—or they can keep doing what they were doing and pay into the City plan which their uninsured employees can access. What is critical here is that the City plan, the Healthy San Francisco Plan, provides a real choice by offering health care for low and moderate income San Franciscans, including basic services such as physician and hospital care with only modest out of pocket costs.

Third, the San Francisco ordinance is a per-worker per-hour obligation (now $1.17 per hour or $1.76 per hour, depending on employer size and non-profit or for-profit tax status). This means that the San Francisco ordinance creates the equivalent of a minimum wage for health benefits: employers must spend a specified minimum on health benefits for each worker. (There are of course some exemptions and caveats, as there are for the minimum wage.) It is no surprise that the same elements in the business community that routinely oppose minimum wage increases and living wage ordinances have led the fights, both political and legal, against an obligation for employers to contribute to health benefits.

Yet economic research has demonstrated that moderate increases in the minimum wage actually stimulate the economy because low wage workers spend what they make: indeed the original micro-economic case study by Card and Krueger found that employment in fast food restaurants increased, apparently because low wage workers and their families were able to spend more at fast food restaurants! The same thing applies to health benefits: providing low and moderate income working families affordable health benefits with reasonable out of pocket costs gives those families more disposable income to spend on other things—though as health people, we recommend more fruits and vegetables rather than fast food!

Over the last several years, the UC Berkeley Labor Center has done several research pieces that estimate the impact on businesses and the economy of various reform proposals: these have consistently found that a thoughtfully designed employer obligation is not a job killer. Instead, in analyzing AB8 (Nunez/Perata) and the Governor’s proposal, in July, 2007, Jacobs et al found a net positive economic impact. More on this to follow.

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posted by Beth Capell | Permalink | 11:50 AM



Thursday, September 18, 2008
Lots of interesting reading around the blogosphere.

  • First, Matthew Holt at The Health Care Blog reports on the insurance industry's Astroturf movement – and how it's not going as well as expected.
  • Peter Orszag, head of the Congressional Budget Office, blogs and lectures about behavioral health care patterns.
  • Ezra Klein blogs about new Lewin Analysis of Wyden's Healthy American's Act.

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posted by Hanh Kim Quach | Permalink | 4:27 PM


Values Judgements

Wednesday, September 17, 2008
So I know that we're just loaning American International Group, Inc. $85 Billion (that's with a B) for two years while they sort out the mess they're in. And I know it comes from the federal governments reserve fund, not the main fund that pays for all of our programs. I get that.

And to be sure, officials are not sanguine about their decision to rescue the insurance giant. They came to it reluctantly after careful deliberation. That said, I still can't help but notice that the $85 billion that the feds are putting up to keep the gigantic insurer AIG from roiling the markets is about the same amount (actually, it's a little more) than what health and children's advocates have been asking for the past couple of years to help fund children's health insurance (SCHIP) -- and provide universal children's coverage -- that's the remaining 10 million uninsured children -- for five (5) years.

It's interesting to look at the panicked language associated with the decision to rescue the insurer. From the New York Times:

If A.I.G. had collapsed — and been unable to pay all of its insurance
claims — institutional investors around the world would have been instantly
forced to reappraise the value of those securities, and that in turn would have
reduced their own capital and the value of their own debt. Small investors,
including anyone who owned money market funds with A.I.G. securities, could have been hurt, too. And some insurance policy holders were worried, even though they have some protections.

“It would have been a chain reaction,” said Uwe Reinhardt, a professor of
economics at
Princeton University. “The spillover effects could have been incredible.” (Uwe Reinhardt, by the way, is also very interesting and entertaining when speaking of health policy and economics...)

Ok. We're worried there's going to be lots of pain everywhere. Lots of people with investments aren't going to have as much anymore. Lots of people, who have been paying for insurance, on the case that their factory goes down in flames would be SOL if their factory went down in flames after AIG declared bankruptcy. It's very sad when people lose their money. I don't like losing money, ESPECIALLY when I've played by the rules. It took regulators a couple days, but the came to the table and said they said, "We have to do this. It's too important not to do.''
The public is annoyed, but gets it. We don't want the economy to get any worse. We want to be number 1 again.
By contrast, the issue of whether to insure children -- with roughly the same amount of public resources (Again, i recognize it's a totally different process and comes from a totally different fund) remains a subject of intense debate. Ten million children, the majority of whom are in working families who play by the rules, need health coverage. But there is no rush to their side. I would argue that the "spillover effects" of uninsurance are just as tragic as a fallen market.
Children can't see a dentist to get cavities filled. They get abscesses and die. Children can't get to an eye doctor. They can't see the chalkboard. They get behind and frustrated in school. They can't live up to their intellectual potential. Children get asthma. They can't see a doctor. They can't get an inhaler. They miss school. They get behind. Schools lose money.
I'm not saying that money used to rescue AIG should be redirected to children's healthcare. I'm just miffed at the level of frenzy surrounding financiers, and I'm not sure why that frenzy and drive to take action is not as strong when it comes to those born to families that can't afford health insurance.

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posted by Hanh Kim Quach | Permalink | 4:56 PM


Veepy views on health care

Thursday, September 04, 2008
The Wall Street Journal today contains an analysis of Rep. Veep candidate Sarah Palin's policy record. Here are the relevant health portions:
Gov. Palin didn't make health care one of her top priorities, but where she did take a strong stand on health, it was for the free market.
"Health care must be market- and business-driven, rather than restricted by
government," her office said in a January statement.
Her overall approach is much like Sen. McCain's -- loosen government regulations to allow for greater competition, along with more information for patients to make good
Addressing the uninsured was less of an issue for Gov. Palin, much as it is less significant for Sen. McCain. She was reluctant to support a significant expansion of the state's version of the Children's Health Insurance Program, called Denali KidCare. She signed a bill that raised eligibility to allow families with incomes up to 175% of the poverty level -- stingy compared with other states.
Great. So she doesn't *really* think addressing the uninsured is an issue. Yet, Alaska, according to the latest Census Report, her state (and it's teeny tiny population of 664,000) has nearly the same proportion of uninsured as California -- 17.3 percent (to our 18.6 percent). The number of uninsured in her state could populate the entire town of Costa Mesa -- home to South Coast Plaza and 113,955 Orange Countians. (AK's uninsured is 115,000).

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posted by Hanh Kim Quach | Permalink | 11:03 AM


"Voila! Problem solved!"

Thursday, August 28, 2008
There's been lots of quotes regarding the latest Census data, including our comments in Victora Colliver's article in the San Francisco Chronicle.

But the one that has gotten the most attention are those of John Goodman, speaking to the Dallas Morning News.

California still has the highest number – not percentage – of uninsured residents at 6.7 million, compared with 5.7 million Texans. The Texas number is up from 5.5 million in 2006.

But the numbers are misleading, said John Goodman, president of the National Center for Policy Analysis, a right-leaning Dallas-based think tank. Mr. Goodman, who helped craft Sen. John McCain's health care policy, said anyone with access to an emergency room effectively has insurance, albeit the government acts as the payer of last resort. (Hospital emergency rooms by law cannot turn away a patient in need of immediate care.)

"So I have a solution. And it will cost not one thin dime," Mr. Goodman said. "The next president of the United States should sign an executive order requiring the Census Bureau to cease and desist from describing any American – even illegal aliens – as uninsured. Instead, the bureau should categorize people according to the likely source of payment should they need care.

"So, there you have it. Voila! Problem solved."

Amazing...a McCain advisor wanting to simply define away the uninsured... in a just world, that should get a public rebuke worse than Sen. Gramm suggesting that America was only going through a "mental recession."

Some commentators have already pounced, including Ezra Klein and Joe Klein (no relation).

But even these rebukes don't actually explicitly refute the misconception that Goodman's comments are based on--so I will. Yes, Health Access California was founded 20-years ago, from a coalition working for a law that people are not turned away from emergency rooms based on insurance status. The eventually-passed federal version of that law, EMTALA, is important, but let's be clear what it does, and doesn't do:

* The law only requires emergency rooms to stabilize patients, not treat them. If you just had a car crash or heart attack, they will treat you, but if have cancer, asthma, diabetes, or any other long-term illness, there's no obligation by the hospital.

* Even in an emergency situation, there's no prohibition on what the hospital can charge. And in fact, the uninsured is often charged 2-4 times what insurance companies and public programs pay for the exact same service. That's the bill they get.

So even our EMTALA law does not ensure access to care, and certainly not *coverage* for care. People need care, and they need coverage to pay the bills. And the Census figures show a staggering number of people who have neither.

The irony is that the Census figures do have a "voila" moment. It shows that policy matters: states like Hawaii, Massachusetts, and Minnesota--that have set standards for employer based coverage, or have expanded public programs--have significantly lower uninsured rates in comparison to other states.

We know what we need to do to say "Problem solved!" But it's not by sweeping it under the rug.

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posted by Anthony Wright | Permalink | 3:25 PM


Getting a sense of the landscape...

Tuesday, August 26, 2008
It's useful context to look at the broad numbers:

Out of nearly 300 million Americans, 253.4 million (85%) have coverage, nearly 45.7 million (15%) do not. 202 million (67.5%) have private coverage: About 177.2 million (59%) have employer-based coverage, and a relatively small 26.7 million (9%) buy coverage as individuals. 83 million (28%) have coverage through public programs: 39.6 million (13%) have Medicaid, 41.3 million (14%) have Medicare, and 11 million (4%) have coverage through the military.

California's uninsured rate inched up, to a 3-year average of 18.6%, up from 18.4% and 18.5% earlier in the decade. The Census figure pinpoints the number at 6.7 million uninsured. There are other figures, such as those from the California Health Interview Survey of the UCLA Center for Health Policy Research, which have different survey technique, and ask some different questions (Are you uninsured now? vs. Have you been uninsured in the past year?) Even with those differences, the Census data is important to indicate scale, trends, and baseline comparisons with other states.

Only six states have a higher percentage of uninsured residents than California: Texas, New Mexico, Florida, Arizona, Louisiana, and Mississippi.

The states with the lowest rate of uninsured are Massachusetts, Hawaii, and Minnesota, which suggests that state policy matters: you can you could look to the policies and reforms in the states to see how they have been able to reduce the uninsured rates.

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posted by Anthony Wright | Permalink | 10:17 AM


Go Medicaid....(!?!)

The Census released its annual report on Income, Poverty and Health Insurance Coverage for 2007 today. The good news is that there are fewer uninsured Americans -- 45.7 million as opposed to 47 million the previous year.

But lest anyone think this means we can sit and twiddle our thumbs and not do anything about our rapidly degrading health care system, think again. More Americans are falling into our public safety net -- the ones that are *always* in jeopardy during bad budget years.

The report shows:
  • Private insurance: DOWN (67.5% from 67.9%)
  • Employer-based insurance: DOWN (59.3% from 59.7%)
  • Public insurance: UP (27.8% from 27%)
Medicaid (Medi-Cal here) increased by 1.3 million Americans.

Also of cheer -- the number of children who were uninsured nationally also declined from 11.7% to 11%.

Of course, the gains of the past year that can be attributed to California could be wiped out as our budget impasse continues. Already, the Conference Committee budget would leave nearly 300,000 children without public coverage -- such as Medi-Cal and Healthy Families -- by the end of three years.

Other cuts could also resurface, totalling more than 1 million uninsured by the end of the Schwarzenegger administration.

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posted by Hanh Kim Quach | Permalink | 9:17 AM


For the children....

Monday, August 25, 2008
The state budget impasse is nearing the end of its second month and shows no signs of abating. For every day that California goes without a budget, we get anxious because it means that more cuts are possible.

The May Revise budget contained nearly $1 billion in cuts to health services, which would have translated to more than one million additional uninsured Californians by the end of the Schwarzenegger administration. The Conference Committee restored many cuts, but the Conference Committee budget would result in the loss of health coverage for nearly 300,000 children by the the Schwarzenegger administration. The LA Times had a story this weekend.

As the budget debate drags on, and Republicans refuse to agree to increased revenues to fund our state's basic needs, more lives will be on the line. There have been rumored mutterings of more cuts -- meaning more children will be unable to get eyeglasses, teeth cleanings and basic health services that would keep them healthy and in school for years to come.

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posted by Hanh Kim Quach | Permalink | 10:33 AM


This is interesting...

Wednesday, August 06, 2008
The WSJ Health Care Blog today reports that ER visits are at an all time high at a time when the number of emergency rooms is *shrinking.*

What's going on?
While conventional wisdom suggests that the uninsured are crowding the ER, the data suggest that’s not what’s going on. The uninsured (comprised in this survey of those who paid themselves, and those who didn’t pay) accounted for between 17% and 18% of ER traffic in both 1996 ( see this report) and 2006.

A recent study in the Annals of Emergency Medicine noted a similar trend, and found that the biggest rise came from well-off people who typically get their care at a doctor’s office. The real problem, the authors suggested, isn’t the lack of care for the uninsured, but the inability of the insured to get prompt care at the doctor’s office.

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posted by Hanh Kim Quach | Permalink | 10:59 AM


If only...

Wednesday, July 30, 2008
The National Federation of Independent Business this week unveiled their campaign to promote health reform from a business perspective. What I really liked was their "Faces of the Healthcare Crisis,'' a compilation of stories/testimonials of small businesses struggling with health care costs. The stories, not surprisingly, sound a lot like some of the consumer stories we get.

One guy, whose employees largely receive health care through their spouses, did not have insurance of his own. When he had chest pains, he delayed going to the ER. When the pain became excruciating, he finally relented and found he was having a heart attack, leaving him with $200,000 in hospital bills.(!!) Sounds like something out of our story database: uninsured, delayed care, high hospital bill.

We certainly empathize with many of the small businesses who want, very badly, to provide health care for their workers. It's expensive, and we have bills that can help:

  • Transparency (a la AB 2967 - Lieber, and which NFIB is supporting) allows health care buyers can gravitate toward providers that are effective and efficient.

  • Standardizing and organizing the individual market, a la SB 1522 (Steinberg), would cap out-of-pocket costs, ensure that every plan has doctors, hospitals, and preventive care. This would help give small businesses, who are worried about how much their workers can afford, more peace of mind.

  • Public insurer (SB 973 - Simitian) would allow small businesses to buy coverage from a public system that competes for business with private companies.

  • Anti-rescission (AB 1945 (De La Torre) and various other bills) would make harder for insurance companies to yank coverage from paying policy holders willy nilly.

Of course, (here's our 'I told you so' moment) what would have *really* helped was the 1993 Clinton Health plan, which was defeated with lots of help from NFIB. Through Clinton's plan, smaller businesses would have only had to pay up to 3.5 percent of payroll costs toward healthcare rather than the 20-plus percent they are now paying in a virtually unregulated market.

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posted by Hanh Kim Quach | Permalink | 1:35 PM


Healthy Food

Tuesday, July 29, 2008
High gas prices, a sputtering economy, global food shortages the obesity epidemic and countless other apocryphal trends make the headlines and have spurred interest in locally grown goods, farmers markets and "Slow Food" (I'm still trying to figure out what the heck that is.)

I really love food. I love the farmers' market. I plan my weeks and weekends around the farmers market. I feel really fancy, wholesome and healthy buying my food directly from the Hmong and Latino farmers, and I prefer the taste of farmers' market food to Safeway (sorry, Steve Burd.) But the small family farmers who are raising goats, planting tomatoes and picking cherries are doing this at risk to their own financial well being and health. The Boston-based Access Project recently published a paper about the health care burdens that California's farmers face.

Farmers tend to be wealthier than the average citizen and are more likely to be insured. On average, they spent nearly $9,000 annually on premiums and out-of-pocket expenses, which constitutes between 9 and 44 percent of the family's income. High health care expenses:
  • Made it hard for farmers to pay other bills;
  • Meant farmers delayed investments in their farm;
  • Took time off farming/ranching.

According to the report author, Carol Pryor, "The survey shows that most farmers and ranchers are trying to do the right thing by getting coverage, but they aren't finding products in the (individual) market that are affordable and that provide them with financial protection if they get sick. This is a case of product failure.''

If not for moral reasons, wouldn't the like-minded food obsessed want to keep our farmers healthy?

I'll do a quick shameless plug for a few of our bills here that would start us down the track of easing health care burdens for farmers:
  • SB 1522 (Steinberg) would organize the individual insurance market, where family farmers need to buy their coverage, and establish a minimum benefit package that includes doctors visits, hospitals and preventive care;
  • AB 2967 (Lieber) woudl require insurers and healthcare providers to provide better data on the cost and quality of care, and create pressure to drive down rapidly escalating health care costs;
  • SB 973 (Simitian) would create a public insurer that would enable farmers to buy in to a system that is publicly run and competes with private insurers;
  • Rescission bills (AB 1945, AB 1150, AB 2549 and AB 2569) rein in the insidious insurer practice of retroactively cancelling coverage of people who have been paying premiums and believed they were covered.

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posted by Hanh Kim Quach | Permalink | 11:32 AM


One million more uninsured, just to begin with...

Wednesday, June 25, 2008
Earlier this week, Governor Schwarzenegger called the number of uninsured in California a "moral crisis"--and he was right, both about that and the need for concerted action on health reform.

Unfortunately, the Governor's cuts-only budget goes in completely the opposite direction, making our health care system even more broken, and leaving more people uninsured. Today, we are releasing a report that reveals the full magnitude of the cuts the Governor proposes--with over one million more Californians uninsured. While the Legislature has adopted some of these cuts and rejeced others, all of these proposals are on the table until a budget solution is agreed to. There's early press from Aurelio Rojas at the Sacramento Bee and Jordan Rau of the Los Angeles Times.

Thursday, June 26th, 2008

New Analysis Reveals Full Impact of Governor’s Health Cuts:
One Million More Californians Would Lose Health Coverage

* Permanent Policy Changes, Not One-Time Cuts, Would Hinder Reform
* Magnitude of Cuts Would Have Ripple Effects Through System
* Health Consumers and Providers Urge Alternative to Cuts-Only Budget

Over one million more Californians would lose health coverage, with significant impacts throughout the state’s health system, if the Governor’s budget and health cuts were passed, according to a new analysis today.

The study, by the health care consumer advocacy group Health Access Foundation, uses information from the Schwarzenegger Administration, but shows a much greater magnitude than earlier estimates, which only looked at the impact of the cuts for less than a year, and not at full implementation.

The report is available on the front page of the Health Access California website, and directly at:

The study shows that these health care budget cuts are of a magnitude that will impact every Californian, as they place huge burdens on the health system we all rely on. These are permanent, not just one-time cuts, to leave more than one million more Californians uninsured, and over three and a half million having to pay more and get less.

Previous summaries of the Governor’s budget proposals, including the May Revision, show the impact of the cuts in only the first year – with tens of thousands losing coverage or being barred from enrollment. But the impact is much greater, in three ways:
  • The Governor’s budget is not proposing one-time budget savings, but lasting policy changes and coverage reductions for the health care system.
  • A snapshot of the savings in the budget year does not reveal the full impact in the following years, once the reductions have been enacted and all the administrative changes have occurred to continue the reductions.
  • Finally, the cumulative impact of all the proposed cuts, when added up together, suggests that the magnitude of the cuts—with more than a million more uninsured—will have impacts not just on specific programs but on the entire health care system on which we all rely.
The permanent policy changes reflected in the budget will be in place long after the 2008-09 budget year comes and goes. Of note, these policy changes are contrary to health reform proposals the governor previously put forward.

The cuts include:
* A roll-back of eligibility for basic Medi-Cal coverage for low-income working parents to well below the poverty level. (429,000);
* Additional paperwork burdens for children and adults, requiring reports every three months in order to avoid disenrollment (471,500);
* Suspension of already-passed legislation to streamline child enrollment (97,000)
* Increased premiums for children’s health coverage, leading to decreased enrollment (60,000).

The cuts represent a reversal for the Administration, reducing programs that just a few months ago were being considered for massive expansions to provide coverage to millions more people. Rather than shrinking the number of uninsured, the Schwarzenegger budget would increase the number of uninsured substantially.

The report includes appendices that include:
* a county-by-county breakdown indicated the increase in the uninsured by county by 2010, the last year of the Schwarzenegger Administration;
* a chart comparing the policy changes in the Governor’s budget that would restrict coverage, to the health reform proposal supported by the Governor earlier this year to expand coverage; and
* a further detailing of the populations that under the proposed cuts would be forced to pay more or get less benefits, totaling 3.5 million Californians.

Allowing one million more California children and parents to go uninsured creates ripple effects throughout the entire health care system. It includes:

  • an increased burden on “safety net” providers, from emergency rooms to hospitals to community clinics—many of which are dealing with direct cuts of their own;
  • a cost-shift, from both the uninsured and reduced Medi-Cal provider payments, to private purchasers of health care—which likely means increased premiums; and
  • worse health and economic impacts for California communities, from the destabilizing impact of more children uncovered and getting sicker, to more families facing medical debt and bankruptcy for being uninsured.

As a result, all Californians—not just the million more uninsured—will be impacted these cuts. The report makes clear the stark choice the budget debate this summer presents for California policymakers, between allowing these devastating cuts to move forward and to make these structural policy changes to our health care system, or to find the revenues needed to prevent these cuts.

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posted by Anthony Wright | Permalink | 6:57 PM


An Unhealthy Trend

Tuesday, June 10, 2008
75 million adults -- that's 42% of working age adults in the US -- had no insurance or really bad insurance (the kind that makes you pay up the nose anytime you sneeze) in 2007.

That's up from 35% of working age adults that were uninsured or underinsured in 2003, the first time Health Affairs did this analysis. A new analysis -- out today!-- updates the study from five years ago.

Among the findings:

  • 25 million people who were technically "insured'' actually have really crappy insurance (that amounts to one-fifth of the entire "insured'' population)
  • The number of adults earning between $40k and $60k who were underinsured nearly tripled from 5% to 13%.
  • The number of adults earning more than $100k and were underinsured (meaning that they spent more than 10% of their income on out-of-pocket medical expenses) increased from 1% to 7%.

The series of studies is important because until recently, most analyses only tracked the number of people without coverage and how lack of coverage impacts a person's ability to stay healthy. Just as important now, though, is this tracking the number of people with inadequate insurance. High deductibles, high co-pays, high co-insurance and high out-of-pocket costs cause patients to behave in similar ways to a person who is uninsured -- they forgo care because of the expense.

Insurance companies like to argue that these low-quality, low-premium plans are at least a backstop to keep people from going into bankruptcy. But as our previous study has shown, people don't have much in the way of assets -- and a $5,000 deductible would wipe out the savings of 40% of Americans. Health Affairs (obviously a nerd's must-read publication) also recently published a study that showed uninsured families earning more than 300% of the poverty level had less than $4,000 in liquid assets. (Here's our blog post on that study).
From our perspective, being underinsured means you're paying premiums to be functionally uninsured. All in all, we don't really buy the insurance company logic on this and think they should be labeled and limited (and the most egregious ones banned) -- as SB 1522 would do.

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posted by Hanh Kim Quach | Permalink | 11:32 AM


Dressing up the Individual (Market)

Monday, June 09, 2008
As we continue to struggle with how to get more people coverage, I'd suggest a look at this Kaiser Family Foundation report from February. The study looks at people who can't get public coverage and aren't offered insurance through their jobs.

Among the findings:
  • At 400% of poverty, the outer limit of an income that could qualify for subsidies in California (under last year's health reform discussions), only 25% of family purchased coverage on the individual market.
  • At 1000% of poverty, fewer than half (49%) of families purchased coverage.

Self-employed families, who receive tax credits on the premiums took up coverage at ever-so-slightly higher rates:

  • At 400% of poverty, about 30% purchased coverage
  • At 1000% of poverty, 58% took up coverage

The study, however, did not take into consideration the regulatory atmosphere -- whether individuals *wanted* to buy coverage, but were denied because of pre-existing conditions, or priced out because of their health histories -- all important factors as we go forward.

So the upshot is this: health coverage on the individual market isn't that attractive to lots of people and policymakers are going to have to find a way to make it more so, including subsidies that "may need to extend higher up the income scale than some policymakers may prefer.''

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posted by Hanh Kim Quach | Permalink | 11:46 AM


We knew her when...

Sunday, June 01, 2008
The effort to win national health care reform is heating up: lots of planning meeting and activities to ensure that there is a mandate for a new President and Congress to take this issue on, and to be ready to roll in 2009.

Consumers Union (a Health Access California board member) is spearheading a Cover America Tour: an RV that will criss-cross the country for four months, collecting stories about the issues that people have with the broken health care system.

The effort has a website and blog of interest, which includes a video of the launch of the Cover America Tour from Consumers Union's Yonkers headquarters, being cheered by staffers from the labs that test all those products that are evaluated in Consumer Reports. It should be an interest and informative trip, that I urge folks to follow along on the web.

The video prominently features the energetic Meg Bohne (pictured above, crouching), a Health Access alumnus, who has told me she give us partial credit (or blame) for her current assignment. On the website page that describes the whole enterprise, Meg Bohne cites her experience as a "a seasoned community activist, advocate and organizer, Meg has come to specialize in on-the-road campaigns in vehicles that have spanned a bus, an ambulance and, now, an RV." At left is the ambulance she drove up and down the state of California for Health Access, in the cause of lower prescription drug prices.

We wish Meg and the whole crew at Consumers Union luck in their trip and their effort. We look forward to hearing the stories, the personal health care experiences, and the adventures on the road!

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posted by Anthony Wright | Permalink | 2:02 AM


Why today matters...

Friday, May 30, 2008
Later today, both the Assembly and Senate budget committees will be considering and making decisions on many of the health care cuts proposed by Governor Schwarzenegger. And with that, the budget debate goes into full gear.

This is still an early stage: any decision made at this point can still be reversed. Given the massive deficit, and the major effort it will take to raise revenues, it is likely that cuts that the both the Assembly and the Senate agree with the Governor on are close to final. Yet the rejection of those cuts does not mean we can breath easy. Unless there are revenues or taxes to fill the gap, those cuts still loom as possibilities. So this is a day where we can't win, but we can surely lose.

However, while these are not final decisions, the actions made today in the Assembly and Senate are hugely important. The decision to reject health care cuts will set the stage for the budget negotiations. It will send the clear signal: some cuts are too severe, and we need to raise revenues to prevent those cuts. And then we have the debate, with those legislators who want a cuts-only budget, rather than a budget solution that includes some revenues or taxes.

It's important that the majority of legislators make this stand, so that the choice is clear, between denying children and parents health coverage, defunding doctors and hospitals, eliminating dental and other benefits, etc... and raising the revenues needed to prevent those cuts.

To follow along, here's a health budget cuts scorecard, which details the cuts impacting access to health care, and what their status is with the Governor, the Assembly, and the Senate. We'll update it after today.

We'll be posting through the day on the action.

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posted by Anthony Wright | Permalink | 9:44 AM


The new/renewed conversation on health reform...

Friday, May 23, 2008
“When you come to a fork in the road, take it,” said Yogi Berra.

It’s a lesson that health reformers can take to heart after reading the May issue of The American Prospect, which has a special section on “the path to universal health care.” The articles reflect heated debates, some spanning decades, on the preferred type of health reform; the best strategies and messaging; whether to pursue reform at the state or federal level; and how prevention can be a cornerstone for reform. My sense is we need all of the above: multiple efforts on different tracks and different venues—to meet this challenge.

There’s agreement on a couple of things, including the absolute urgency for reform. Many people are uninsured, or concerned their coverage won’t be there for them when they need it. Lack of adequate health coverage has direct health and financial consequences. The uninsured—and underinsured—live sicker, die younger, and are one emergency away from financial ruin.

A couple of the articles debate the kind of health reform to pursue and point out issues with experiments like the Massachusetts reform and Medicare. I was privileged to contribute an article on some of the lessons learned from the debate in California, and about how we can be ready for the next round.

We have a new window of opportunity in 2009 to confront these issues, with a new President and new Congress. While California had a health reform effort stall recently, there is enough support and momentum that the window for comprehensive reform will re-open at the state level as well, with new legislative leaders and a Governor who still wants to pursue big reform in his last two years. In California we have an opportunity to pursue state reform, to both bolster and shape federal efforts, alongside our own direct pursuit of a national solution.

So will we be ready? Yes, if we learn lessons from our multiple-year experience in California, and help educate our friends around the nation. We Californians have much to tell: no other state has had such a robust discussion of health reforms in the past five years. Our legislature has advanced multiple reforms—expansions of job-based coverage, universal children’s coverage, a single-payer system, and a comprehensive “shared responsibility” approach—and all these ideas are still on the table.

To be ready, we need to lay the foundation this year. Proposed budget cuts would take us backwards in terms of access to health care. The budget—and current programs like Medi-Cal and Healthy Families--are the foundation on which health expansions will be built. While shoring up the budget with new revenues, we can also pass other policy reforms that are building blocks toward universal coverage.

Most of all, we need to plan and prepare for the next stage of the great health debate—as previewed in The American Prospect. We have a real opportunity in the next year or two and we need to take it.

(Cross-posted at Bob's Blog, as a guest post on the new and renewed conversation on health reform, at the website of The California Endowment, an important funder for the Health Access Foundation and many key health programs and organizations in our state.)

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posted by Anthony Wright | Permalink | 12:11 PM


Senate Committee says No to Prescription Drugs

Wednesday, May 21, 2008
The Senate budget subcommittee that oversees the state's health budget voted to eliminate funding that would have implemented the California Discount Prescription Drug Program.
By eliminating the $5.8 million in funding for this program, the work that state officials have done the past two years in negotiating lower rates will go to waste.

As many may recall, health advocates went through a bruising battle against Big PhRMA in 2005 ($80 million spent against us) on the ballot, and then won a year later when Gov. Arnold Schwarzenegger signed the bill and even had a fancy signing ceremony in the Capitol Rotunda.

The discount drug program would have allowed the state to negotiate discounted drug prices from pharmaceutical company, helping approximately 5.4 million uninsured families -- the people who now pay FULL PRICE for prescription drugs -- buy drugs at fairer prices. If drug companies did not give satisfactory discounts, then the state could have used the purchasing power of Medi-Cal to leverage lower prices.

Californians below 300% of poverty ($63,600 for a family of four) would have been able to buy drugs at 40-60% off the sticker price. While that's still more than many of us pay for our drugs (insured Californians often pay a fixed co-pay), it's still a lot less than what they pay without the program.

So that means middle-income and low-income Californians, who are already seeing the substantial reductions in their health benefits through public programs for their children, and schools, will now have to pay more for drugs.

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posted by Hanh Kim Quach | Permalink | 11:22 AM


Find the solutions, not blaming the victim...

Tuesday, April 15, 2008
"Don't Blame Crowded ERs on the Uninsured" is the pitch-perfect headline of an article by Suzanne Bohan in the San Mateo County Times and other papers.

The articles reports on a UC-San Francisco study that reports that asks "Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?" and answers "no." In fact, the "proportion of adult ED visits by persons without insurance was stable across the decade," roughly in the 14-15% range.

Despite the belief that the uninsured are the majority of those crowded in our emergency rooms, I note that this figure is a bit lower than the overall percentage of uninsured people in the country, which is around 16%.

This is consistent with other findings, such as a 2004 Urban Institute report by researchers Zuckerman and Shen on ocassional and frequent ER users. That paper concludes, in part, "The uninsured and the privately insured adults have the same risk of being frequent users... It seems hard to blame the overcrowding of EDs on the uninsured."

MISSING THE MESSAGE: Some conservative commentators will use this research to attack the notion that of a "hidden tax" that we all pay in our premiums for having such a large uninsured population, and to attack the notion of health reforms and coverage expansion generally. I get a very different lesson from the study.

I too have been a skeptic of the Governor Schwarzenegger's "hidden tax" rhetoric, because it led people to blame the uninsured for high health costs, rather than the reverse.

If the uninsured go to the emergency room, they have only a right to be stabilized. But even then, they get a bill--typically the biggest bill they will see in their lives, and often one that is inflated well above what an insurer would pay for the same service. No wonder they may actually go to the ER less.

LOTS OF FACTORS: That said, there's nothing inconsistent with saying that the uninsured, when they finally do go to get care, are in a worse condition since they let their conditions linger and mestatisize, costing the health system more money in the long run. Or that the uninsured get the bill, but some face bankruptcy not being able to pay, and as a result leave the hospital unpaid.

In other words, I think the real world in health care is more complicated than one cause. Some uninsured get the care they need. Others go without and simply die. And in between, some uninsured wait until the problem gets worse. And some of these factors end up costing the health system. So reforming health and increasing coverage is needed and urgent, even for the regular, insured California.

SOLUTIONS: So how much is the "hidden tax?" I don't know, but it's real. But I think the focus should be on fixing the system, not the victims of that system:

* We all pay when McDonald's, Wal-Mart, or Applebee's don't, when some employers don't pay their fair share. Those who are uninsured are those who fall through our health system that relies on voluntary employer contributions.

* We should ensure that those who are uninsured are not overcharged and thus discouraged from getting needed care. California passed a fair hospital pricing law in 2006, and other protections would be helpful.

* We who are *insured* would not go to the emergency room as much if we had the ability to get timely access to care to primary care and specialists. There's pending regulations for insurers and providers at the California Department of Managed Health Care.

Our health care system doesn't have just one problem, and doesn't have just one solution. The new research helps us understand that.

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posted by Anthony Wright | Permalink | 10:45 PM


Fake Plans

Monday, April 14, 2008
One of the bills Health Access is watching that's up in Senate Health Committee this week is SB1603 (Calderon), which would authorize the state to license and regulate so-called discount health cards.

We question the very existence of these things. Not only do they annoyingly clog up the fax machine (you've seen those strange health "insurance'' offers), but they rely on consumer naivete to make money.

Their sin is that they're incredibly deceptive and provide questionable -- if any -- value to consumers. Discount health plans entice consumers with words like "no pre-authorization,'' "no pre-existing condition denial,'' and "no waiting period." They exaggerate their value, promising low prices -- discounts of as much as 80% -- at a vast "network'' of providers.

But often, neither is true. Consumers have no idea what the price for which the "discount'' is based on, rendering the discounts essentially meaningless -- and often, they could have received the discount anyway if they told the provider they were uninsured.

Mila Kofman, health policy expert formerly of Georgetown University, also tested out some cards and found that nearly three-quarters of providers contacted did not even realize they were part of the "provider'' network. Complaints filed against these cards in California show a similar patern.

Kofman's research also finds that the monthly cost for the identical card can range from $54.95 to $120 because of the pyramid-esque marketing for these products. Cancelling the cards can also be tricky, as many continue to charge a former subscriber's credit card even after they consumer quit the service.

Sadly, SB1603 would create a way to allow these fake plans to operate legally and continue to bilk consumers.


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posted by Hanh Kim Quach | Permalink | 10:27 AM


Only in LA?

Friday, April 11, 2008
For those who were not able to witness Senate Health Committee in person, this week, it's not always as boring as you might think.

Committee Chair Sheila Kuehl and Sen. Dave Cox had an interesting exchange during testimony of our bill SB1522, which would help organize the individual insurance market and place caps on out-of-pocket costs. Most importantly, it would help weed out junk coverage and require at least mimimum coverage of doctor's office visits and preventive care.

Kuehl shared a story of a caller on a radio show who had ambulance workers lay a bill on her chest as she was being wheeled into the hospital emergency room.

"Surely,'' snorted Sen. Dave Cox, R-Fair Oaks, "they would do no such thing.''

Responded Kuehl: "Yes, Sen. Cox. And a hospital in LA would surely not dump patients on Skid row in the middle of the night.''

"Well...'' grunted Cox. "Maybe in Los Angeles.''

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posted by Hanh Kim Quach | Permalink | 2:12 PM



Tuesday, April 08, 2008
An interesting comment from Medi-Cal director Stan Rosenstein at the budget subcommittee hearing yesterday on the elimination of adult dental benefits for Medi-Cal recipients.

“…People could go to the emergency room if they’ve got dental pain,’’ he

And they will.

Is that really the best place for a toothache?

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posted by Hanh Kim Quach | Permalink | 9:56 AM


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