The state of health reform....

Friday, December 29, 2006

Thanks to Matthew Holt of the good read and widely-read "The Health Care Blog", which links to both us and the debate over at Dan Weintraub's Crossroads.

He does make a snide remark about state-based reforms. I'm all for working for reform at the national level... but I think that's not going to happen if some states don't push the envelope, and California has been doing that for the last few years and is positioned to make a breakthrough.

That the states are taking the lead is actually the premise of TWO big articles in today's San Francisco Chronicle, that devotes more than a full page on previewing the 2007 health care debate.
http://sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/12/29/MNGUBN9SG91.DTL
http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2006/12/29/MNGUBN9SFJ1.DTL

It's the start of a series at the Chron. Another take-away message: we have a once-in-a-generation opportunity to make a major change here...
posted by Anthony Wright | Permalink | 12:43 PM


 

Out with the old title; in with the new...

Thursday, December 28, 2006

Outgoing Insurance Commissioner -- and incoming Lieutenant Governor -- John Garamendi spoke before the Capitol press corps today about his successes as Insurance Commissioner and what he hopes to continue in his new role.

Among his top four priorities: health reform.

Garamendi has been advocating for universal health since before I was born.

I actually watched him speak before a diverse group of small businesses in Contra Costa County a couple months ago on this topic, where he remembered speaking on the same issue in the same conference room 20 years ago.

In 2005, Garamendi published a paper called "Priced Out: Health Care in California'' spelling out 43 recommendations to fix the health care crisis, including expansion of public programs, use of evidence-based medicine and improving the use of technology.

As Lieutenant Governor, Garamendi doesn't have as much direct oversight -- as he did as Insurance Commissioner -- over aspects of the health care market. But we love the fact that he's continuing to use his position as a bully pulpit.

Labels: YearOfReform

posted by Hanh Kim Quach | Permalink | 2:35 PM


 

2006: It was a good year...

HEALTH ACCESS UPDATE
Thursday, December 28th, 2006


2006 for Health Consumers: Big Victories & Momentum for Major Reform
* Big Wins on the Overcharging of the Uninsured, for Prescription Drugs, Hospital Care
* Progress and Momentum for Coverage Expansions, for Children and all Californians
* Key Implementation Work: DRA, Medicare Part D, Regs at DMHC and DOI, Etc.


2006 was a watershed year for health care consumers, as the uninsured won significant relief from being overcharged for hospital services and prescription drugs. Major coverage expansions and reforms advanced further than they had before, and while stalled, this election year created a mandate setting up 2007 as a year for major action.

Below is a description of the 2006 year in review, of which a one-page flyer version is available at:
http://www.health-access.org/advocating/docs/2006%20Year%20in%20Review.pdf
A list of 2006 bills that made it to the Governor's desk, and their final fate, is available at:
http://www.health-access.org/advocating/2006_bills.htm

Health Access, the statewide health care consumer advocacy coalition, is gearing up for next year's effort, and needs your support. To make an online end-of-year individual contribution to assist our efforts, click on this link:
http://www.health-access.org/hafcontibution.htm
For your organization to join the Health Access California coalition, click on this link:
http://www.health-access.org/joinhac/organization_signup.htm

Major Victories, in Principle and Practice:
Those With the Least Should Not Be Charged The Most

Uninsured Californians had two major victories in 2007, the subject of multi-year campaigns by health advocates, that will provide real relief, while also establishing a key principle: The uninsured and underinsured, those with the least, should not be charged the most in our health care system. These two bills, on prescription drugs and hospital charges, where California leads the way with only one other state, are the most important and meaningful changes in health policy for the uninsured in years.

PRESCRIPTION DRUG PRICES: Americans without prescription drug coverage pay more for needed medications than anyone else in the world—40-60% more than Canadians or those in other countries that negotiate on behalf of the citizens; more than insurance companies purchasing on behalf of who they cover.

AB2911 (Nunez/Perata) was a landmark prescription drug law, allowing the state of California to use its massive purchasing power through the Medi-Cal program to negotiate lower prices for those without drug coverage. Up to 6 million uninsured, underinsured and senior Californians could benefit with a drug discount card that may provide 40-60% off needed medications. As the first large-scale implementation of a program modeled in Maine , the principle helps propel the national debate about negotiating for the best price under Medicare Part D, and shows that the prescription drug industry can be beaten, despite them spending $80 million to stop a ballot measure the year before.

The program will start to be implemented in 2007, and advocates will be watching to see if the Governor will include the appropriate resources in his budget proposal.

HOSPITAL CHARGES: Uninsured patients who go to the emergency room get a bill that is multiple times what insurers pay for exactly the same service. These inflated bills often send patients to collections, court and bankruptcy.

AB774(Chan) is a groundbreaking law, providing consumer protections for self-pay hospital patients. Hospitals will need to provide uninsured and underinsured patients with information about their consumer rights and financial options, provide a moratorium before sending patients to collections, and not place liens on patient’s homes. In particular, most uninsured and underinsured will not have to pay more than the Medicare, Medi-Cal, or worker’s compensation rate for hospital services. While this issue has gotten attention in national media, Congressional hearings, and class action lawsuits, California joins only New York in passing a bill this year to cap hospital bills. It takes effect on January 1st, 2007.

While neither law provides for actual coverage or free care, the new laws do ensure a fair price. These laws will provide real financial relief, and help millions of Californians get the care they need, and to avoid medical debt and even bankruptcy. A major 2007 challenge for health advocates is to make sure that Californians are informed about these new rights, protections, and opportunities.

Progress and Momentum for Coverage Expansions

UNIVERSAL CARE: Another historic advance was the legislative passage of SB840(Kuehl), the California Health Insurance Reliability Act, a proposal to create a universal, single-payer health care system to cover all Californians. The bill did not include a financing mechanism and was ultimately vetoed by Governor Schwarzenegger, but it clearly put universal health care in the political discussion, and advanced such a proposal farther than it ever has before. The vast majority of Democratic legislators endorsed a broad health care measure, some ran on it, and all who were up for re-election won. The legislature's endorsement of this and other measures helped force health reform as a major topic for 2007. After four years of sponsoring such legislation, Senator Kuehl has promised to re-introduce the measure in 2007, keeping the momentum alive and ensuring it is part of the conversation.

CHILDREN’S COVERAGE: The goal for universal children’s coverage inched closer to reality, as the issue was actively discussed in the legislature in the budget discussions. While it was disappointing that expanded children’s coverage was not included in the budget, and that Proposition 86--a tobacco tax that would have funded children's coverage among many other items--was defeated by the narrowest of margins of all the initiatives, the issue is very much alive. New legislative leaders emerged on the issue, and Governor Schwarzenegger took a major step when he voiced support for covering all children, including those that are undocumented. While he opposed both a bill and a ballot measure to accomplish the goal, he has reiterated his overall support for the goal.

SAN FRANCISCO: The passage of San Francisco's plan to provide access to care to all not only will provide real benefits to those who live and work in the city, but has implications far beyond the Bay Area. Tens of thousands of uninsured San Franciscans will get a medical home and a better ability to get needed care; Most San Franciscans will have better security in the private, employer-based coverage they benefit from now, and in a more financially sound safety-net of clinics and hospitals they they all rely on. California and the nation gets a model of how to set a standard for on-the-job health benefits, much like the minimum wage does for pay, and new spokespeople for the issue, in Mayor Gavin Newsom and Supervisor Tom Ammiano.

MOMENTUM AND A MANDATE: The top goal for health advocates this year was to keep health care in the campaign debate, and use the opportunity of the election to create a mandate for reform and action. Mission accomplished: both gubernatorial candidates pledged to take action on health reform in the first days of their new term. Governor Schwarzenegger displayed a new focus on health care, holding a health care summit in the summer, pledging to unveil a major health care plan in his 2007 State of the State, highlighting health care in campaign ads, hiring key staffers that indicate seriousness, and reconsidering previously-opposed issues that led to the signatures on the bills described above.

With the attention raised by the health reforms passed not just in San Francisco, but in other states and cities, including Massachusetts , Maryland , Illinois , Vermont , and New York City , the momentum for major reform is strong. The new Congress promises to focus more on health issues and health reform, that will both assist California efforts, which in turn can help the national debate.

Other Developments

INDIVIDUAL BURDENS: Advocates were successful in not just advancing good reform proposals through the legislative process, but also stopping bad proposals, most notably proposals for an “individual mandate.” Also stopped were efforts to use the tax code to subsidize underinsurance and high-deductible plans, through so-called Health Savings Accounts.

MEDICARE PART D: In the introduction and first year of the Medicare Part D program, California took a lead role in assisting low-income seniors and people with disabilities (the “dual-eligibles”), providing “emergency coverage of last resort” when these patients were not getting the drugs they needed. Unfortunately, legislative leaders and the Governor did not see fit to fix the ongoing problem for these dual-eligibles, the newly-imposed co-payments. The Governor did sign a bill to provide some additional oversight over Medicare Part D plans, but vetoed a bill to provide seniors with a report card to evaluate the myriad of choices before them.

KEY REGULATIONS: Medicare Part D wasn't the only law that needed significant work in the implementation. One defeat for health and low-income advocates was the federal passage (by only a few votes) of the Deficit Reduction Act, which left advocates struggling to figure out and to mitigate the onerous documentation requirements for Medicaid patients. At the state level, the Department of Managed Health Care moved along in its consideration of key rules around cultural and linguistic access to care, as well as timely access to care. The Department of Insurance also considered both new rules on language access, and tightening up rules on medical loss ratios, so more money goes to patient care rather than administration and profit.

INTEGRITY OF INSURANCE: While health advocates won battles with the drug companies and hospitals, insurers were successful in killing a range of bills to ensure their plans provided value to consumers. In particular, AB977(Nava) and AB2281(Chan) would have provided consumer protections and oversight on high out-of-pocket costs and underinsurance. Other failed bills attemped to ensure that there were adequate providers in managed care networks, and to ensure a specific amount of a premium dollars goes to patient care. As we consider health reform in 2007, better oversight over the insurance industry will continue to be a goal.

Labels: Updates

posted by Anthony Wright | Permalink | 2:04 PM


 

Get well soon, Governor...

Sunday, December 24, 2006

Governor Arnold Schwarzenegger seems to have broken the femur in his right leg, when skiing on vacation at Sun Valley. He made need surgery when he gets back.

Beyond his ability to boogie at the inaugural ball, the obvious connection made by some reports, like the Sacramento Bee, and by blogger Dan Weintraub, is how this incident ties in with the push for health care reform in 2007.

As someone who had an ankle injury earlier this year, I can attest: having a medical problem causes major setbacks and stress on one's lives, in small ways and large: Governor Schwarzenegger is lucky (as was I) that his job does not require him to be on his feet.

So the test with health care reform is to make sure that a medical problem, caused accident or age, does not also turn into a financial problem. If Arnold was uninsured or underinsured (say, with a high deductible plan), this incident will cost him thousands of dollars, at a minimum, from the immediate care to stabilize the situation, to the follow-up surgery. For most people who have some debt and live paycheck-to-paycheck, that's enough to face serious financial harm or even bankrtupcy. Even for the insured (like me), the co-payments for the needed follow-up care can either discourage such care, or cause tough choices for California families.

As the press reports indicate, the Governor--somebody as proud of his fitness as anyone--has had a couple of medical incidents in the past year. The goal of next year is that Californians can get similar care without the negative financial consequences for ourselves, our families, and our communities.

Here's to a happy, healthy, and hopeful new year.
posted by Anthony Wright | Permalink | 6:35 PM


 

What I want for Christmas...

Friday, December 22, 2006

Maybe it's just the holiday season, but I am hopeful about 2007 with regards to health reform. Governor Schwarzenegger, Senate President Pro Tem Perata, and Speaker Nunez have prioritized the issue, and are engaged in the policy in a significant way. And we have seen the legislature pass major coverage expansions in the past four years, for children, workers, and all Californians, so we know the political will is possible for bills to pass.

But given Schwarzenegger's opposition to those efforts for this first term, can we be hopeful about his role in the next year?

George Skelton of the LA Times seems to think so. The blog Calitics seems to agree.

Of the good health reform items he vetoed (which we at Health Access supported), only SB840(Kuehl), the California Health Insurance Reliability Act, was something he vetoed idelogically, stating his straight, out-and-out opposition.

The other efforts, most notably expanding public insurance programs for children, and employer-based coverage for workers and their families, Governor Schwarzenegger has usually made his opposition situational. Now most politicians always have a stated reason about why they would oppose something popular, and you always wonder if they are just opposed, or if just this one thing were fixed, they'd actually be supportive.

On universal children's coverage, he vetoed AB772(Chan) because of lack of funding, even though its relatively cheap. He opposed Prop 86 because he didn't like the tobacco tax that would have provided the funding. But he has continued to say he supports the goal. It's now up to him. One way to help meet the goal is to have more employers provide family coverage, which is how most children get coverage...

On SB2 and Prop 72, as blogger Bill Bradley has pointed out, he opposed a requirement on employers "because the economy was then weak." As KQED's Jon Myers and other reporters have pointed out, he said on the campaign trail earlier this year that he didn't like the 80-20 split, but that he could support some other mix. And as he has said all thoughout the year with regard to health reform, it needs to be a mix of individuals, employers, and government. Dan Walters of the Sacramento Bee thinks this language could be a "code phrase for some kind of employer mandate." Finally, when he has critiqued all these proposals before, he said he doesn't like to have a solution that only focused on one part of the health problem, but that suggests he might consider these policies as part of a overall plan. (Health Access supported many of these efforts, not as the whole solution, but as a part, understanding that other efforts--specific proposals and comprehensive ones--were underway.)

So given the statements and the build-up, if the Governor does not put forward a plan to cover all children, if he does not put forward a standard for employer-based health care, it will be a disappointment. But maybe he will.

Or maybe I'm drinking too much nog. Merry Christmas, and best wishes for a happy and healthy new year!

posted by Anthony Wright | Permalink | 2:36 PM


 

Update: Speaker Nunez's Proposal...

Thursday, December 21, 2006

HEALTH ACCESS UPDATE

ASSEMBLY SPEAKER RELEASES HEALTH CARE PROPOSAL

• “Pay-or-play’’ model, with employer and employee buy-in required
• Focus on covering *all* children; affordability for workers
• Individual market oversight and reforms; benefit package uniformity and cost containment

New on the Health Access blog: New Senate chairs; Defending the young; New studies, etc.


It may be the holiday season for most of California, but Sacramento is working away on the health care debate. Governor Arnold Schwarzenegger had press events on Monday and Wednesday to discuss health care issues, not revealing anything about his plans but setting the stage for his State of the State on January 9th. The video of these events are available at the Governor's website, at:
http://www.gov.ca.gov/index.php?/press-release/4950/

Today, Assembly Speaker Fabian Nunez unveiled an outline for his health care proposal. The proposal, called “Fair Share Health Care,’’ views our health care system as "a three-legged stool," with employers, workers and government all supporting the load.

While the language still has not been drafted, health advocates appreciated the framework proposed, including:

• Building on the existing system of employer-based coverage;
• Insisting on affordability for working families;
• Expanding public programs, including a focus on covering *all* children;
• Reforming the insurance market, which would make it harder for insurers to deny coverage based minor pre-existing conditions.

Nunez’s announcement comes a week after Senate President Pro Tem Don Perata unveiled broad concepts for his plan. There are some common elements, most notably the requirement on employers to provide coverage for their workers, or pay into a purchasing pool. Workers would be required to participate in the employer's plan, but there is no overall individual mandate, enforced through the tax code--a major difference with Perata's approach. "I don't like the concept of an individual mandate, I want a fair share approach. Everyone has an obligation, a responsibility to be a part," said Nunez.

While his plan isn’t the single-payer approach, which Sen. Sheila Kuehl is expected to reintroduce this year, Nunez referenced he supported the bill this past year. But the reality, he said, is that most Californians receive insurance through their workplace and don’t want to disturb that. "You cannot overlook the fact that 71 percent of employers already offer health insurance to their employees..." He also cited the politics. "Clearly, single-payer is something that Governor Schwarzenegger will never support."

Instead, Nunez said, he preferred to focus on pieces that are broken – the high cost , and the uninsured population--"bringing them into the system."

COVERING ALL CHILDREN

What Nunez emphasized most in his Thursday morning press conference to Capitol reporters that covering all children was his top priority, saying “When it comes to children, the only document I care about is a clean bill of health.’’ By July 1, 2008, Nunez’ plan calls for covering all children in families at or below 300% FPL ($60,000 for a family of four.) "Diseases don't discriminate, and neither should we."
While Nunez has not spoken with Gov. Arnold Schwarzenegger directly about his plan, he believes “we are moving in the right direction. We have a lot of common ground,’’ including, the desire to cover all children.
“That’s one thing I’m not walking away from,’’ said Nunez. he also outlined a broader commitment to expand public programs to parents and adults without children at home.

NUTS AND BOLTS

Health Access is still reviewing the proposal to provide analysis in the coming week. There are many elements that the consumer, health and community groups have supported in the past – including an employer mandate, limits on health costs for workers and universal children’s coverage.

It’s unclear, at this point, how much Nunez’ plan would cost. The speaker did not have an estimate, but argued that various elements could save general fund dollars.

Here’s the outline of his plan, to be dropped into his reform bill AB8(Nunez):

PAY-OR-PLAY: Employer Mandate

• Employer mandate. Pay for coverage or pay a fee, based on a "fair share" percentage of payroll. Exemption for small businesses with fewer than two workers and less than a $100,000 payroll.
• Worker responsibility to accept health insurance when it’s offered – as long as it does not exceed a “reasonable percentage’’ of their income. (This would catch 87,000 of California ’s 6.6 million uninsured -- making more than $60,000 for a family of four – who are declining coverage that they’re offered. The rest are either not offered, not eligible or too poor to get benefits.)
• State purchasing pool. Creation of a California Cooperative Health Insurance Purchasing Program (Cal-CHIPP) through MRMIB to negotiate and purchase health insurance for businesses and employees who want to buy into this system.
  PUBLIC PROGRAM EXPANSION
• Expansion of Medi-Cal and Healthy Families for those below 300% of poverty ($60,000 a year for a family of four.)

MARKET REFORMS

• Standardizing applicant screening and placing oversight into what pre-existing conditions are used to deny people coverage.
• A surcharge on health insurance premiums to provide coverage for people who are denied based on pre-existing conditions.
• Uniform benefits making it easier for everyone to make apples-to-apples comparisons when shopping for coverage.

COST CONTAINMENT

• Ensuring coverage of preventive care and disease management
• Moving toward electronic personal health record
• Promotion of healthy lifestyles

Labels: Updates

posted by Hanh Kim Quach | Permalink | 5:59 PM


 

New Senate Commitee Chairs!

Lots of news for the holiday season. Today, Senate President Don Perata announced the new chairs of key Senate committees. Here's the news for health advocates:

On the policy committees:
* Senator Kuehl will chair Health Committee. A champion of universal health coverage, she has also been a smart and effective legislator getting a range of bills passed in the health field.
* Senator Machado will chair Banking, Finance, and Insurance Committee. As the previous the chair of the Revenue and Taxation Committee, he took an appropriately skeptical view of Health Savings Accounts.

On the fiscal committees:
* Senator Torlakson will chair Appropriations. Previously chair of Transportation & Housing, he has a record on health from his days as a Contra Costa county supervisor, where he was supportive.
* Senator Ducheny will chair Budget. She previously served as chair of the budget subcommittee on health, and so is well versed in the details of everything from the hospital financing waiver to Healthy Families funding formulas.
* Senator Alquist will chair the Budget Subcommittee #3 on Health and Human Services. She carried key health bills and has been an active member of the Health policy committee, and so is familiar with the broad issues that she will now impact from the budget perspective.
posted by Anthony Wright | Permalink | 4:16 PM


 

First take on the Nunez proposal

We'll post a further summary soon, but here's our first take on the Speaker Nunez's proposal.

While we look forward to the details, the plan sensibly builds on what works, to strengthen and extend employer-based health benefits and public insurance programs, while placing needed oversight over insurers.

We particularly appreciate the focus and assurances on affordability for patients and families.

It's helpful that the plan brings together many ideas that have been vetted and have received considerable legislative and voter support, including expanding coverage for all children, and to workers and their families, as well as insurance market reforms. This will make it easier to act in 2007.

While the details of the solution are not fully fleshed out, the Speaker’s plan gets the problems of the uninsured in our current system (or non-system) right: they don’t get coverage on the job; they don’t qualify for public insurance programs; and they find individual insurance either unaffordable or unavailable. The ideas put forward attempt to address each of these points.
posted by Anthony Wright | Permalink | 12:43 PM


 

Close yet far

Wednesday, December 20, 2006

With the new analysis by the Field Poll about the fate of Proposition 86, a comment. The analysis suggests that voter turnout mattered. If it were during a presidential election, with more young, first-time, low-income and other voters, the measure may have won--despite the $60 million in advertising the tobacco companies through against it.

It's remarkable that the two of the closest ballot measures in the last five years are the ones that would have expanded coverage: Prop 72, which got over 49% of the vote, and Prop 86, which got 48%. It suggests that we are very close to geting majority voter support for major health reform.

ONE OTHER TAKE: The failure was not about children's coverage: few knew the specifics of what the tax would fund; It wasn't even against the concept of increasing the tobacco tax! Even the tobacco industry's own ads that said, "I want to raise cigarette taxes, but.." and then went on with various objections. The last time an industry ran that type of campaign was last year with Prop 79 ("The drug industry wants to provide discounts, but only voluntarily...") As it happens, by accepting the premise that drug costs needed to be lowered, they won the battle but lost the war. Similarly, could we see a tobacco tax in the mix next year, to help fund health care reform?
posted by Anthony Wright | Permalink | 11:30 PM


 

Only 5 shopping days until Christmas...

This morning, Governor Schwarzenegger held a press event, participating a health care roundtable with a handful of businesspeople, consumers, and providers. No real news on what he will propose, but more tea leaves to read:
http://gov.ca.gov/index.php?/press-release/4950/

Tomorrow morning, Speaker Fabian Nunez will talk about his plans for health care reform. We'll have a report then.

At this rate, we'll have a few more proposals to analyze, in betweeen wrapping presents and counting down with Dick Clark.
posted by Anthony Wright | Permalink | 7:07 PM


 

Young Californians, Unite! More on the Manifesto...

Tuesday, December 19, 2006

Over on the Sac Bee Crossroads blog on Healthcare, I refute the much-cited argument (by many, not just by Assemblyman Richman) about young people not caring about being insured:


So let me be the one confront one of my pet peeves, blaming young people to provide justification for an individual mandate: Here’s this quote from the opening essay by former Assemblyman Richman: “Young healthy adults, 18-34 years old, are the largest single demographic segment of the uninsured and account for about 40% of uninsured adults. This population with low health care needs collectively believes it is not economically worthwhile to purchase costly insurance.”

He’s right that young people are more likely to be uninsured, but wrong about the reason. It’s simply not supported by the data, which shows:
* Young people are more likely to be low-income, just starting out their careers.
* They are more likely to work at jobs that do not provide health coverage to their workers (McDonald’s, Wal-Mart, etc)
* They are more likely to be in the first several months or years of employment, and thus not qualify for their employer’s health benefits.
* They are less likely to qualify for Medicaid, since they are less likely to have dependant children at home.

These are the reasons young people are more likely to be uninsured, not because they don’t want it. The most recent CHIS (California Health Interview Survey) data shows that when offered, young people take up coverage at the same rate as older people. They have similar rates of uninsurance if you account for income and job type.

Yet the mythical problem of the “young invincible” leads policy folks to propose an individual mandate, which as we have written (in a paper on the Health Access website) is not just unwarranted, but unworkable and unwise. (http://www.health-access.org/expanding/docs/access.project.Ind.Mandate120406.pdf)

Most importantly, miscasting the problem leads to unfortunate solutions. We should be focused on systemic changes to extend dependent coverage, get more employers to provide health coverage, to expand public insurance programs, or to create a universal system like Medicare or the VA. Young folks get this: they overwhelmingly supported Prop 72, because they see themselves or their friends working but not having coverage, and the consequences, even for those that are healthy. Young people aren’t the problem, they are the solution.


Twenty-somethings are the base support for any health reform, and they need to be engaged and active in this debate.

Part of a young people's health agenda would be extending dependent coverage. Speaker Nunez sponsored such a bill in 2005, one that Health Access California supported, with some interest from groups like Rock the Vote. Other states, most recently New Jersey and Massachusetts, have raised the age that a dependent child can stay on their parents' health insurance. With young folks seeking more education and otherwise staying at home longer, it's a small but important step.

Our 2005 bill summary shows the fate of the bill, AB1698(Nunez): it was vetoed by Governor Schwarzenegger. We'll see if this is another idea that he may reconsider, as part of a broader package.

Labels: YoungAndUninsured

posted by Anthony Wright | Permalink | 10:19 PM


 

Leave it open a crack...

Clea Benson's Sacramento Bee article on Gov. Arnold Schwarzenegger's hospital tour yesterday suggests that while the governor will not introduce his own tax to fund health coverage expansion, he wouldn't rule out proposals that did.

"I'm not telling you now what I would or would not consider," the Republican governor told reporters at a Los Angeles hospital when he was asked whether he would approve a solution that included a tax increase.

Reporters Jordan Rau at the LA Times and Dan Weintraub, also at the Bee, came away with the same impression.

That's certainly welcome news.
posted by Hanh Kim Quach | Permalink | 8:05 AM


 

Everything on the table?

Monday, December 18, 2006

Gov. Schwarzenegger spoke before a Los Angeles emergency room today about the importance of covering the uninsured. Our woman on the street -- Norma Martinez-HoSang -- was able to listen to the governor from *outside* the press bay.

His thrust, "hidden taxes'' -- the shift in costs from the uninsured to those with private insurance -- will cost Californians $1,186 in premiums in 2006, according to this new paper by the New America Foundation.

Again, he reiterated his goal to "insure everyone in California.'' Schwarzenegger praised Perata's efforts and welcomed proposals from Republicans and Democrats.

At one point, Schwarzenegger said, "We have to debate all the issues. Mandates for individuals. Mandates for employers. Taxes. Redoing the whole system. Everything is on the table.''

As for his own plan, taxes were not included.

Schwarzenegger said details of his plan were still being "fined tuned'' and that it would not include a tax because, he did not believe Californians should be "punished'' twice -- once with a hidden tax, and a second time with a government tax.

One reporter specifically asked whether the governor feared undocumented immigrants would be covered by his plan.

The governor said that undocumented immigrants "now are insured. They can walk into the ER right now and get care. ERs are right now required to treat everyone. No one is allowed to be turned away.''

It's important to note that while federal law (EMTALA) requires emergency rooms to treat the uninsured, it is also the case that the uninsured get 40% less care than the insured -- as referenced in the New America Foundation paper cited by Schwarzenegger -- and face the health and financial consequences for receiving less care.
posted by Hanh Kim Quach | Permalink | 10:38 AM


 

The Governor starts...

Governor Arnold Schwarzenegger is holding a press conference this Monday morning on health issues... It will be broadcast live on the web (and presumably archived there later) at the Governor's website at:
http://gov.ca.gov/

I believe this is his first press event on health issues and his health reform push since the election. We suspect there may be others leading up to the January 9th State of the State. He's had many offhand comments on health policy, but normally as part of broader interviews or events on other matters. Many will be carefully watching to see if it provides any clues to what he may do...
posted by Anthony Wright | Permalink | 9:27 AM


 

A Smidge Better...

Friday, December 15, 2006

Shortly before adjourning, Congress passed the "Tax Relief and Health Care Act of 2006" legislation that would fix some of the technical errors in the Deficit Reduction Act of 2005. President Bush is expected to sign the legislation into law.

California, in the meantime, still has not implemented the Deficit Reduction Act.

More analysis from groups like the Center on Budget and Policy Priorities to come, but here is a quick take.

Medicaid Citizenship Documentation

"Scrivener's error(s)'' created mass confusion and consternation among advocates and states tasked to implement the new rules. The original law said that every single one of 50 million Medicaid recipients would have needed to show proof of citizenship by providing a birth certificate or U.S. passport, resulting in the loss of benefits for up to 4.6 million low-income, U.S. born citizens, according to this CBPP paper.

The new law will not require citizenship documentation for the following citizens who are:

• receiving Medicare
• receiving Supplemental Security income
• receiving Social Security Disability Insurance
• in foster care
• receive adoption assistance payments

Cost Sharing

Secondly, the new legislation clarifies that states may not increase premiums, co-pays or other cost sharing for Medicaid recipients at or below poverty level ($20,000 for a family of four). That means the copayment limit for this population will remain at $3, indexed to inflation.

The legislation also caps cost sharing at 5 percent of a family's income -- and is assessed on a monthly or quarterly basis.

Health Savings Accounts

A sore spot for those of us who dislike high-deductible plans -- changes to Health Savings Accounts, those tax free shelters for medical expenses.

First, the new law allows people to transfer money from their flexible spending accounts and Health Reimbursement Accounts to their HSAs until 2012. It also permits a one-time transfer of money from their IRAs.

Additionally, the law used to limit contributions to HSAs to the amount of the health plan deductible. So if a person purchased a minimum qualified plan with a $1,050 deductible ($2,100 for families), they would only be permitted to contribute that amount. The new legislation increases that threshhold to $2,700 annually ($5,450 for families.)

Only about one-third of people with HSA-qualified plans actually put money into their accounts, but you can guess who this is helping.

posted by Hanh Kim Quach | Permalink | 2:03 PM


 

Never mind.....

Longtime Medi-Cal director Stan Rosenstein WON'T be leaving state service next month after all, according to news reports. Rosenstein, who had announced his resignation last week, intended to be a consultant in the private sector.

Instead, Health and Human Services Secretary Kim Belshe asked him to stay, and bumped up his salary (though not as much as he'd have made consulting, I bet).

Rosenstein's decision to stay put is likely a positive for Medi-Cal, as he has sincere affection for the program.
posted by Hanh Kim Quach | Permalink | 12:51 PM


 

Yogi: Nobody goes there anymore, it's too crowded

With the center-right dialogue going on at the Sacramento Bee Crossroads/Healthcare blog, moderator Daniel Weintraub invited participants to critique employer-based healthcare. He got several folks to weigh in, and then added another jab of his own recently.

The conversation sounded a little like the great Yankee catcher and policy wonk Yogi Berra, who said of a local restaurant, "nobody goes there anymore, it's too crowded." The employer-based system, for all its flaws (and there are many--more later), does cover almost 19 million Californians, more than half of the population. I prefer and strongly advocate for a universal system, like SB840(Kuehl) or Medicare for all, but it seems important that reformers also should be mindful that many consumers want to protect the coverage they have now. It's worth noting that several other European countries with universal systems rely on some form of employer-based coverage.

Employer-based coverage does three things well:
1) It is the system we have now, so people are familiar with it.
2) It captures the financing of employers and brings those funds into the mix, alongside taxpayer-generated funds.
3) It pools people together to share the risk and cost of health care, to better negotiate for the best price, and to allow us to broaden the risk so that when I have a major emergency, I don't have to face that burden alone.

#3 is the core value, and this is common to group coverage, whether through public insurance programs or employer-based coverage. As a group, it is harder for insurer to try to pick us apart based on our age, gender, geography, or health status, to deny anyone of us health coverage, or to charge discriminatory rates.

But like the popular restaurant, now we seem to have many proposals that includes at least the concept of an employer mandate. Why? Because it makes sense to build on what works in the health care system. And when you are looking for money in the system, it makes the most sense to see if everybody is paying their fair share. We all pay more if some pay less, including employers that don't provide health coverage to their workers.

SB2 and some of the current prosposals try to deal with the issues of group coverage through employers. Many "pay-or-play" models offer employers the ability to choose to join an even bigger pool, which for smaller employers would likely provide more choices for their workers, and remove the burden of administering the benefit. Having a statewide insurance plan that workers are in (like a CALPERS or Healthy Families) would also provide more opportunities for portability, allowing a person to keep coverage when switching jobs.

Let me be clear: it order for this to work, the employer requirement can't be simply a token amount, such as the $295/worker that the Massachusetts plan imposes. It really needs to set a standard for on-the-job benefits, much like the minimum wage does for pay. If there is an amount required, it needs to be similar to the actual amount it would cost to insure their workforce. Otherwise, the system doesn't work. That's one of the things we'll be looking for in the various proposals for next year.

Watch for other Yogi lessons soon...
posted by Anthony Wright | Permalink | 12:51 AM


 

Paying more, getting less

Wednesday, December 13, 2006

One-fifth of Americans are paying 10% of their disposable income -- not total, disposable -- toward health care annually, according to a new JAMA study.

The study details how -- no matter how you get your insurance -- you're paying more and getting less.

The study covers the period between 1996 and 2003 -- just as employers were beginning to shift more premiums one to workers, and insurance plans were increasing deductibles and annual out-of-pocket costs, so it doesn't even capture the more recent trend.

The JAMA study fills an important gap. First, it tracks the percentage of family income devoted to medical care and insurance. Secondly, it documents the increase of this burden over time, and breaks it down by:

• how people get covered (through work, on their own)
• how the increase in costs affects people with certain health conditions (diabetes, heart disease).
  

Also important -- the study details that people who buy their insurance as individuals (if you're self-employed, or unemployed and purchasing coverage on your own) -- pay the most. While to many, this information may be self evident, the study provides powerful evidence against individual policies at a crucial time when lawmakers are increasingly considering these types of policies to cover the uninsured.

Some factoids. You're more likely to spend at least 10% of your disposable income on health care if you:

• Are an adult between ages 55 and 64 (30.6%)
• Are a woman (20.6%)
• Live further from an urban area (24%)
• Have diabetes (39.1%)
  

And before anyone thinks that high health costs only afflict the poor, 22.7% of middle-income families (between $60,000 and $80,000 for a family of four) spent 10% of their income on health care -- a 7% jump. (sorry for all the numbers.)

So, you'd think that with all this money that some people are throwing at health care, patients are getting stellar access. Wrong. JAMA says,

"It is somewhat surprising that persons who experienced high total burdens were also more likely to report problems accessing medical treatment.''

Now that's really adding insult to injury.
posted by Hanh Kim Quach | Permalink | 10:14 PM


 

Blaming the individual won't work

Two health care proposals floated yesterday – one by Senate Leader Don Perata, the other by Kaiser CEO George Halverson – include an individual mandate.

Health Access has explored this idea – especially through the lens of the Massachusetts plan. Our conclusion is simple: An individual mandate in California is unwise, unwarranted and unworkable.

Read our full paper on the differences between Massachusetts and California.

An individual mandate is not only impractical, we don’t believe it’s the direction that health care should go – cleaving people apart as individuals, rather than pooling people together as a community.

Neither Kaiser nor Perata’s plan even bring California to the same level as Massachusetts before its new law was passed – particularly with respect to funding for county hospitals and Medi-Cal. California would need to spend up to $30 billion more in its public infrastructure to get to the same level as Massachusetts.

Another flaw: Perata’s individual mandate does not make any exemption for workers if coverage is not affordable. Massachusetts’ new law does.

To read more see our paper on individual mandates, and a one-pager explaining the difference between Massachusetts and California *before* Massachusetts passed its law.

More comments on the proposals to come.
posted by Hanh Kim Quach | Permalink | 1:42 PM


 

Sutter settlement sealed

Patients who were overcharged by Sutter Health will finally be relieved the burden according to this Sacramento Bee story. A court yesterday approved the nearly $300 million settlement.

Sutter is one of two hospital chains that have settled this year for overcharging patients. Find information about both settlements and how to submit a claim at:
http://www.health-access.org/providing/classaction.html

Each hospital system settlement also has its own website:
Sutter: www.uninsuredsettelement.com
Catholic Healthcare West: www.CHWsettlement.com

Labels: Hospitals

posted by Hanh Kim Quach | Permalink | 11:19 AM


 

First Take on the Perata Plan

Health Access Update
December 12th, 2006

SENATE PRESIDENT PERATA UNVEILS HEALTH CARE PLAN COMPONENTS

• "Pay-or-play" model, with individual mandate, expansion of Medi-Cal & Healthy Families
• Goal to workers & their families, 2/3rds of uninsured; Workability issues raised
  

Senate President Pro Tem Don Perata on Tuesday unveiled a broad outline of his health care proposal, which he estimates may cover up to 2/3rds of uninsured Californians. His proposal requires employers and employees to contribute to the financial cost, while also expanding some public programs. His sponsorship of the plan signified the Senate's priority that this will be "our primary issue in the upcoming year."

You may also hear audio from his press conference.

Perata's proposal is limited to concepts, but provides the most detail on what leaders may be discussing in health reform next year. On the first day of session last week, Assembly leaders introduced several placeholder bills stating their intent to provide affordable coverage to Californians, but few details have been released. With Senator Sheila Kuehl's universal single-payer health care proposal, there looks to be over a half-dozen bills for major health reform. Gov. Arnold Schwarzenegger is set to release his plan to add to the mix during his State of the State Address on January 9th.

Perata spoke about "shared responsibility'' on the part of both businesses and workers. Immediate reaction included concerns voiced by both business and consumer advocates. Perata's not surprised. "Once fleshed out, I'm fully confident that there will be something for everyone to oppose,'' he said.

Reporters and bloggers at Senate President Perata's press conference summarized the tenor of the conversation, including:
* Clea Benson at Sacramento Bee
* John Myers at KQED
* Tom Chorneau at SF Chronicle

* Frank Russo at California Progress Report
* Donald Lathbury at California Majority Report

Few details were revealed about how much patients would have to pay, who would be impacted, and how and and whether the plan would work.

Health Access is reviewing the proposal to provide an analysis in the next several days. While there are components that consumer, health and community groups have supported, such as serious efforts to protect on-the-job coverage, and the expansion of public insurance programs. At the same time, there are other components that may not be workable or desirable, such as an individual mandate enforced through the tax code; insurance reforms and rules to govern some but not all products in the market; the exclusion of some California populations; and the lack of guidelines without regard to affordability for consumers.

Here is a broad outline as presented by the Senator:


Who is included?
The proposal focuses on working Californians and their families. It would also expand public programs, using federal matching dollars, to cover more (but not all) children and parents up to 300% of the federal poverty level ($49,800 for a family of 3). For example, Perata estimates their plan would cover 58,000 out of the 316,000 uninsured children who currently aren’t eligible for Healthy Families or Medi-Cal.

Where does the money come from?
Perata estimates his plan would cost between $5 billion to $7 billion annually – all state dollars (before federal match) but none out of the general fund. Employers, employees and the federal government should all be kicking in enough to pay the tab. As for specifics – how much each population is supposed to pay – that hasn’t been determined that, but Perata has asked the California HealthCare Foundation for technical assistance.

Any exemptions?
At this point, anyone who is working would be required to pay into the system – businesses and employees alike. Perata said he is modeling his plan after State Disability Insurance (SDI). To that extent, a buy-in would be voluntary for the self-employed.

How would it work for employers?
Perata’s "pay or play" plan would set a minimum requirement for what employers should spend on health coverage. If they don’t, they’d be required to pay an equivalent amount into a Trust Fund. Money in the Trust Fund would buy health coverage for Californians through a “Connector,’’ run by the Managed Risk Medical Insurance Board. MRMIP already administers Healthy Families, Access for Infant Mothers and the program for the medically uninsurable (people with pre-existing conditions).

How would it work for workers?
The "connector" would be expected to set coverage standards and negotiate rates (like CalPERS) using economies of scale. Small employers and individuals that wanted to buy insurance through "the Connector" would be permitted. Employers could choose from three types of plans, and contracting health plans

More information and analysis to come on this and the many other proposals being crafted.

Labels: Updates

posted by Hanh Kim Quach | Permalink | 9:23 AM


 

Could being uninsured kill you?

Another sad story about how being uninsured can make health problems worse. Belinda Bradley succumbed to pancreatic cancer earlier this year. She could not continue working as a health care aide due to an injury, and was therefore uninsured.

"I hurt so much," she said. "My stomach hurt before I came to the hospital but I
ignored it. I was scared they weren't going to treat me like they would somebody
with money, and they was just going to let me die.

...

"It's heartbreaking," said her daughter. "If people had health care, they'd
definitely come when they first had symptoms, instead of waiting because they're
afraid of being pounded with large bills."

By the time Bradley was rushed to the hospital in severe pain last November, it was too late, said Dr. Andre Campbell. "If we found it earlier, the prognosis would have been better," said Campbell, General's chief of medical staff.

As the governor and lawmakers look at health care reform next year -- we hope
they take into consideration voices like Belinda Bradley.
posted by Hanh Kim Quach | Permalink | 8:31 AM


 

Ill Effects of Consumer Driven Health Plans

Tuesday, December 12, 2006

A new study, jointly authored by the Employer Benefit Research Institute and Commonwealth Fund show that the public is still wary of consumer-driven and high-deductible health plans -- and with good reason.

Consumer-driven and high-deductible plans were defined as plans with deductibles of at least $1,000 (individual) and $2,000 (family). These plans also had two savings options -- the Health Savings Account or Health Reimbursement Account.

The study shows that:

• nearly 10 million individuals had such plans last year -- approximately 8 percent of the population. Nearly 90% of those had deductibles high enough to qualify for a Health Savings Account, but did not have one.
• many consumers could not afford to contribute to Health Savings Accounts.
• nearly half (44%) of adults with CDHPs/HDHPs spent more than 5 percent of their income on health care -- double the amount of people in comprehensive plans.

The study also echos other academic research on the health and behavioral impacts of those who have high-deductible plans, in that they delay care because of cost.

Another important point is that few resources were available to people with these plans to make good cost and quality choices.

This report, coupled with this Fitch prognosis for for-profit hospitals in 2007 (the next blog) provide very interesting insight as policymakers in California -- particularly Gov. Arnold Schwarzenegger -- explores the option of consumer-directed health plans.
posted by Hanh Kim Quach | Permalink | 4:41 AM


 

Part Two: Ill effects of consumer-driven health plans

Increasing numbers of people with consumer-driven health plans could cause problems for a hospital near you.

Fitch, the credit rating agency, says this about the impact of consumer-driven health plans on for-profit hospitals in 2007, "Bad debt will continue to be driven primarily by the growing uninsured population and secondarily by increasing deductibles, co-pays and co-insurance among policy holders. "

While "bad debt'' -- the term used to describe a consumer's defaulting on debt -- is still primarily driven by uninsured, the growth of consumer-driven plans is a significant problem because "it is more challenging for hospitals to collect payment from individuals than from managed care providers, resulting in a potential for increased bad debt if these plans become more prevalent. Since these plans are still relatively infrequent, the impact in 2007 should be limited...However, CDH represents a significant trend to monitor in the coming years."

Why? Fitch describes what much of the academic literature describes: "...participants often delay medical care and may put themselves at risk for severe health events for which they will shoulder a large portion of the responsibility to pay.''

As California explores options to cover the uninsured, particularly looking at Steve Burd's consumer-directed Safeway plan model, the impacts and strains on the existing system must be weighed as well.
posted by Hanh Kim Quach | Permalink | 4:19 AM


 

Holiday health reform...

A press advisory indicates that Senator President Pro Tem Don Perata will have a press conference at 11:00am to unveil his health care reform plans. We'll post some quick (hopefully immediate) reaction and analysis later today, on this blog, as we get the info.

And you thought this would be the "quiet season."

I heard Senator Sheila Kuehl give a talk in front of the California Association of Public Hospital last week, where she committed to reintroducing her universal, single-payer plan (the plan formerly known as SB840). But as the presumptive head of the Senate Health Committee, she also committed to working on the range of plans proposed by her colleagues, and working with Senate President Perata on an approach.

So that's two more that we expect to add to our growing list of major health reform proposals, on our main website. From our point of view, the more the merrier...
posted by Anthony Wright | Permalink | 2:14 AM