Around the blogosphere in 24 minutes...

Wednesday, February 28, 2007

In addition to my ongoing debate with Daniel Zingale of the Governor's office on the LA Times' Dust-Up online opinion feature, a few other items to note:

* Julia Rosen at Working Californians (cross-posted on Calitics) comments on both our online debate and the re-emergence of SB840. She has been as passionate as anyone in the blogosphere on the inequities of the individual mandate.

* Randy Bayne, the Bayne of Blog, has his own report on the re-launch of SB840, and some direct testimony from health care consumers. Frank Russon at the California Progress Report has his own reports of Senator Kuehl's statement and give-and-take with reporters.

* The new, one-year anniversary edition of Health Wonk Review is out, hosted by Julie Ferguson at Workers Comp Insider, and has some really interesting links, about presidential candidate John Edwards' plan, and other national health policy issues.

* The blog Healthcare Economist has a interesting review of literature that shows that increased co-pays for things like prescription drugs may actually increase medical costs, since that will discourage some from taking their medication and leading to hospitalizations and the like.

* The opinion journal The American Prospect has a ongoing discussion among many writers and thinkers about what are progressives' core demands in a health care reform debate. While it is focused at the national level, it provides food for thought for those looking through the California debate. I'll write more about my thoughts on this later...
posted by Anthony Wright | Permalink | 2:17 AM


 

"The gold standard"

HEALTH ACCESS UPDATE
Wednesday, February 28, 2007

HUNDREDS OVERFLOW CAPITOL HEARING ROOMS IN RE-LAUNCH OF SB840
* Crowd of SB840 supporters fill up hearing rooms; spill into Capitol hallways
* Sen. Sheila Kuehl fields questions from reporters, committee members

New on the Health Access WeBlog: SCHIP Update, Governors Attack in DC, Blogs Away
Bonus Blog This Week: Wright vs. Zingale on Gov's Health Plan at LA Times "Dust-Up"


After five years, Sen. Sheila Kuehl’s efforts to pass a single-payer health system continues to see support grow. The senator unveiled SB840 -- again – on Tuesday, with more than a dozen lawmakers as co-authors, many standing by her side. The list of supporters include Speaker Fabian Nunez and Senate President Pro Tem Don Perata, even though they each have their own health reform measures on the table this year.

Longtime supporters of the effort, such as the California Federation of Teachers, California Nurses Association, California School Employees Association, Health Access California, Health Care for All, League of Women Voters, Service Employees International Union, and many others also stood with the senator, as she fielded questions from reporters. Many groups, including American Medical Student Association, California Alliance for Retired Americans, CNA, CSEA, Gray Panthers, Health Care for All, SEIU, Older Women's League and others brought dozens of people.

THE REINTRODUCTION OF SB840

Sen. Kuehl’s bill would create a single, universal, health insurance pool. Every California resident would receive a card and be allowed to see a doctor.Private medical groups and hospitals would continue to exist, but be reimbursed from the universal system, rather than dozens of private insurance companies and public funds, all with their own rules and paperwork. This change would provide savings from thus reducing the money that goes to duplication, administration, and profit.

The system would be financed through a tax system that replaces all the dollars currently paid into the health care system today, including premiums (from employers and employees), copays, and deductibles, and the money now spent on government programs such as Medicare and Medi-Cal.

For health advocates, single-payer in California is "the gold standard for affordable health reform" to evaluate other proposals, as Senator Kuehl put it, allowing the state to eliminate $20 billion administrative and profits of private insurers, save money by buying in bulk, using health technology to eliminate expensive errors and provide everyone in California with the health care they need with they need it.

But Kuehl was frank with the press. She recognized that the Governor may not sign this bill if it passes. But for every year that this bill continues to be introduced, it helps bring the conversation about health reform further along, she said. “I welcome the debate because I think we win this debate. We win it because the facts are on our side… We win it because, unfortunately, the decomposing health system is on our side,’’ Kuehl said.

BOOSTERS BRAVE COLD AND RAIN

SB840 and Kuehl supporters, including health advocates – but also, school secretaries, nurses, uninsured residents, teachers, shop stewards, doctors, medical students, retirees and many others -- arrived early for the 1:30 p.m. hearing, lining up outside the hearing room more than three hours in advance and crowding out many regular Capitol lobbyists.

Those who didn’t fit in the hearing room, watched on the flat-panel TVs in the hallway as Kuehl gave succinct testimony and showed a documentary about why California needed a single-payer system.

LAWMAKERS ASK EXACTLY HOW IT WOULD WORK

Assemblymembers – many of whom have voted for the bill and stood with Kuehl -- questions were wide ranging and tested Kuehl on the exact mechanics of a single-payer plan.New

Assemblywoman Fiona Ma asked whether she’d still have a choice of providers, as she does now with her private insurer. Yes, said Kuehl. All doctors would have the option of contracting with the state system. However, should a particular doctor choose not to, then their patients would have to pay in cash, just as is done now.

Assemblywoman Patty Berg feared there might be an exodus of medical providers in the state should such a system be enacted. Kuehl asked, where would they go?

“Physicians are not in a cushy place these days,’’ said Kuehl, pointing out that physicians are having a difficult time getting paid – not only by public programs such as Medi-Cal and Medicare – but private insurers. The problem is so bad that a cottage industry of attorneys has sprouted to help physicians recover money. The Wall Street Journal and New York Times' Paul Krugman wrote about it this month. A single-payer system may be an improvement.

Assemblyman Alan Nakanishi, an ophthamologist and the only Republican to speak up on Tuesday, asked how the system would hold down costs, and adequately compensate physicians. Kuehl said Medicare and Medi-Cal both take care of the sickest and most expensive populations in the country – the elderly and the poor and disabled. And Medicare rates, it has been reported, pays for the cost of treatment. Aside from that, the system would hold down costs because it would eliminate administration and profits (also allowing higher reimbursements), take advantage of economies of scale and new technologies and the ability to plan, rather than having each medical group and hospital have to scrimp and save to buy its own systems.

Kuehl noted that in Russia, after the collapse of their health system for seniors, the average life expectancy for a man declined from 79 years two decades ago to 59 years now. “I don’t know if anyone can imagine this country without Medicare now. The seniors would be in the emergency rooms,’’ she said.

Nakanishi continued to counter that Medicare was inadequate. Kuehl replied: “If you way Medicare is inadequate, let’s make it adequate. Not say SB840 won’t work.’’

Assemblywoman Loni Hancock asked how Kaiser Permanente would shake out. Kuehl, who said she had been a Kaiser member since the 1960s, said the self-contained medical company would remain intact but its role would change. It would no longer be an insurer, but its cadre of physicians, hospitals and medical services would contract with the state as a large medical group. She said she believed such legislation would be a “boon for Kaiser’’ and said she relied on Kaiser’s model and innovation in health delivery systems to serve as the basis for many parts of her legislation.

Health Committee Chairman Mervyn Dymally asked how the unemployed would be covered. Kuehl said they would also be covered, but also pointed out that in California, most people aren’t chronically unemployed. In fact, 80% of those who are uninsured are in jobs where they are not offered, or qualify for health insurance.

Dymally also asked whether non-traditional services, such as acupuncture and chiropractic would be covered. Kuehl said they would.

THE LARGER PICTURE

In addition to the mechanics, Assemblywoman Patty Berg asked what core principles should be in a health reform package – as an interim step -- should SB840 not pass.Kuehl listed three notions: Shared responsibility, market reforms, and expanded risk pools.All the current proposals rely on the idea of “shared responsibility,’’ Kuehl said. But it means "different things to different people."

As for market reforms, Kuehl cautioned that market reforms did not mean stripping away benefits to make packages “cheaper,’’ what she called “race to the bottom.’’ To her, it meant not only banning the practice of denying applicants based on health conditions, but also ensuring insurers did not have incentives to delay patient care.

And lastly, Kuehl cautioned against the trend to segregate the market, putting less healthy people into one pool, and healthier people into another.

SUPPORTERS FILE THROUGH

Because of the large number of supporters, Dymally limited testimony, but organizations who showed up to support SB840 included:California Nurses Association, Health Care for All, California Federation of Teachers, California School Employees Association, Service Employees International Union, Californians for Racial Equality, Health Access California, California Physicians Alliance, California Universal Health Care Organizing Project, Unitarian Universalists, Neighbor to Neighbor, Older Women’s League, League of Women Voters, Friends Committee on Legislation, California Alliance for Retired Americans along with many single members and interested people – from organic farmers, school bus drivers, school faculty and hundreds more.

The committee meeting was only an informational hearing, the second part of a hearing from last wek that considered other health reform proposals. The bill is expected to go through the legislative process once again, starting with the Senate Health Committee, chaired by Senator Kuehl herself.

Health Access will continue to follow SB840 throughout the year. Please tune into our website and blog (at www.health-access.org/blogger.html) for more updates in the future.

For more information, contact the author of this report, Hanh Kim Quach, policy coordinator, Health Access California, hquach@health-access.org.

Labels: Updates

posted by Anthony Wright | Permalink | 2:06 AM


 

Sheila Kuehl, Rock Star

Tuesday, February 27, 2007

Sen. Sheila Kuehl barely clears five-feet, but among health care activists, she is a giant who has dedicated a large part of her legislative career to fighting for universal health coverage. Today - for the fifth year in a row - she presents her single-payer legislation at an informational hearing with the Assembly Health Committee. Hundreds of groupies of the senator and her SB840 started lining up in front of the Capitol hearing room at 10:30 a.m for a hearing that wouldn't begin for three hours.

She defended her plan to Capitol reporters an hour ago, "This is not a faith-based initiative, it's a reality based initative.''

We will have a full report of the hearing here later.

Labels: Kuehl, Legislation, Sacramento, SB840

posted by Hanh Kim Quach | Permalink | 1:37 PM


 

Attack of the Governors...

Monday, February 26, 2007

Robert Pear of the New York Times has this article about Governors of both parties splitting with the White House over child health coverage:
http://www.nytimes.com/2007/02/27/washington/27govs.html?_r=1&hp&oref=slogin

Key graphs:

WASHINGTON, Feb. 26 — Governors clashed with the White House on Monday over the future of the popular Children’s Health Insurance Program, an issue that some members of both parties said was as important as money for the Iraq war.

Governors said the Clinton and Bush administrations had encouraged them to expand children’s coverage and had granted waivers allowing them to cover parents and even some childless adults.

Having successfully expanded the health insurance programs in their states, some governors now suggest that the Bush administration is pulling the safety net out from under many children....

And yes, the last paragraph...

Gov. Arnold Schwarzenegger of California, a Republican, said federal aid was essential to his $12 billion plan for universal health coverage. Mr. Schwarzenegger said that in a private meeting he told the president, “We need the federal government’s help.” He did not say whether he got a commitment.

Labels: Bush

posted by Anthony Wright | Permalink | 10:19 PM


 

Redux

Sen Sheila Kuehl will hold a Capitol Press Conference commemorating the fifth year of her SB840, single payer legislation. The Q&A will Capitol reporters will be followed by a hearing before the Assembly Health Committee Tuesday at 1:30 p.m.As many of you know, SB840 is Kuehl's single-payer bill that was vetoed by Gov. Arnold Schwarzenegger last year.

The Lewin Report estimates that SB840 would save the state the most money of any proposals out there. Even though insuring all Californians would cost an additional $25 billion in services, it would save $33 billion in expensive health costs because more poeple would seek less expensive preventive care. That's a net savings of $8 billion.
posted by Hanh Kim Quach | Permalink | 6:05 PM


 

Opinions 'R Us

The Los Angeles Times has just initiated a new online Opinion feature, "Dust-Up," where they invite two people to debate a topic for a week. Last week, the topic was immigration. Now that they have dispensed with that, they have moved on to health reform.

To discuss the Governor's health reform proposal, they have invited me to debate Daniel Zingale, senior advisor to Governor Arnold Schwarzenegger and chief of staff to First Lady Maria Shriver. In full disclosure, we have worked with Daniel in the past, most notably when he headed the Department of Managed Health Care in the previous Administration. But he ultimately works for the Governor, with whom we have had significant disagreements. We started our volleys today:
http://www.latimes.com/news/opinion/la-op-dustup26feb26,0,1228016.htmlstory?coll=la-opinion-center

Hopefully the Sacramento Bee online opinion blog Crossroads won't think I am cheating on them.

Speaking of newspaper blogs, San Francisco Chronicle reporter Tom Chorneau reports on new ads by the California Nurses Association against the Governor's plan.
posted by Anthony Wright | Permalink | 5:52 PM


 

SCHIPS without Ponch and Jon

Saturday, February 24, 2007

On Friday, the California HealthCare Foundation held a convening on SCHIP (State Child Health Insurance Program) reauthorization--the technical term for the Congressional debate this year on how much money should be allocated to the federal program that funds 2/3 of California's Healthy Families program. HHS Secretary Kim Belshe and MRMIB Director Lesley Cummings were there, as were policy wonks and advocates.

As Belshe said, this is the biggest health care policy issue on the federal agenda this year. She not only extolled the program's worthy goal of covering children, but also its "operational success"--an important part of the case for additional funding is the fact that it works, and that it has actually served to decrease the number of uninsured children. We'll report on this issue more throughout the year, but a few quick points from the meeting:

* Cummings stated that the next few years will be the first real test of the "block grant" nature of the program; up until now, it has been sufficiently funded, but some states have started to run out of funds, and depending on the funding debate this year, California may follow, with creating waiting lists or even dropping children off of coverage.

* The President's proposal is woefully inadequate: $25 billion over the next 5 years would mean hundreds of thousands of California children being dropped from coverage. In the choice between having stable funding or increased funding to keep up with growing demand, President Bush took the third and worst option, which is to under-fund children's coverage.

* The SCHIP reauthorization can't be less than $60 billion over the next 5 years, in order to have the funds to meet the goal of covering all California children. The policy people are still refining the numbers, in order to account for variables such as different formulas to distribute funds between the states, or the impact of declining employer-based coverage, or different take-up rates. But that's the general figure.

My comments at the forum focused on how this fits into the broader policy debate.

* First, those of us who will advocate for $60 billion or more to fund children's coverage will also need to take another step, to support the revenues or offsets needed. Under the new "paygo" rules, where both tax cuts and new spending need to be balanced with other budget items, the proposal by Rep. Rahm Emmanuel and others to do more in collecting capitol gains taxes is welcome, as a way to show that children's coverage is important enough that we have to pay for it. There's lots of ways to raise the money we need: we just need to provide support for those who properly prioritize children's coverage, and who take the harder but necessary step of finding the money.

* Secondly, this debate is fundamental to the broad conversation on health reform here in California. Whether you support the Governor's plan, or the ones by the Speaker, the Senate President Pro Tem, or Senator Kuehl, they all would be better financed and more feasible and workable with full SCHIP funding. The less funds there are for kids, the harder it is to find the resources to cover their parents.

* Third, all these debates are intertwined. SCHIP is a key priority, but not the only one for the cause of children's coverage. For example, there's been a big drop in employer-based coverage for children, as employers start scaling back benefits with dependent coverage. The recent report on Safeway shows that for new employees, the waiting periods to get individual coverage is 18 months, and for family coverage it's 30 months. That's a trend, especially at big fast-food and chain restaurants and many retailers. Healthy Families was wildly successful at picking up the slack and preventing a dip in the rates of children's coverage, but broader reforms will be needed to truly get universal children's coverage.

We'll be talking about SCHIP reauthorization throughout the year here on this blog.

Labels: Bush

posted by Anthony Wright | Permalink | 12:40 AM


 

A discussion the size of Hoover dam

Friday, February 23, 2007

HEALTH ACCESS UPDATE
Friday, February 23, 2007


LITTLE HOOVER COMMISSION EXAMINES COVERAGE PROPOSALS
* Costs, price controls, high deductibles, public program reforms discussed
* Also: Update on Deficit Reduction Act & Documentation Requirements

New on the Health Access WeBlog: Disembodied Heads of BlueShield, Viva Las Vegas


On a parallel track from the health debate raging in the legislature, the Little Hoover Commission continued its examination of state’s health landscape on Thursday, calling academics and advocates to talk about health proposals on the table. Since last year, the Little Hoover Commission, which is charged with examining ways to make state government more efficient, began looking at different aspects of the health care system late last year.

The Little Hoover Commission materials are linked here:
http://www.lhc.ca.gov/lhcdir/healthcare.html

The Health Access blog features an update reporting on a previous hearing, linked here:
http://www.health-access.org/2006/11/little-hoover-takes-on-big-issue.htm

The three-hour conversation on Thursday was slightly different than the other commision hearings in that it reviewed health reform through a wide lens – not just limied to public programs, even though its focus is state government.

Panelists on Thursday included:
* Peter Harbage, senior program associate for the Health Policy Program for the New America Foundation.
* Gerald F. Kominski, Associate Director of the UCLA Center for Health Policy Research
* Glenn Melnick, Professor and Blue Cross of California Chair in Health Care Finance; School of Policy Planning and Development at the University of Southern California
* Anthony Wright, Executive Director of Health Access California

After each presenter provided an overall statement, there was a wide ranging question and answer session with the Commissioners. There were many topics of discussion and interest. Below is just a smattering of the conversation:

On the "hidden tax":

One of the elements discussed was Gov. Arnold Schwarzenegger’s pitch about the $1,186 "hidden tax." The New America Foundation’s recent report by Peter Harbage, “A Premium Price,” is widely cited by Gov. Arnold Schwarzenegger’s administration, when arguing that a “hidden tax’’ of $1,186 is paid by insured Californians to make up for uncompensated care.

When questioned about the savings, Harbage reiterated his case that the report put forward a "conservative" estimate. Some of the panelists agreed that doctors and hospitals would be better paid under the Governor's plan because more people would be insured and Medi-Cal payments would be higher. But Professor Melnick stated, “I’m a little less optimistic that we’re going to see doctors and hospitals charge lower prices. They very quickly can figure out ways of spending that money without passing on the discount,’’ to insurance companies, which may or may not pass savings on to consumers. Professor Kominski agreed, but said that it would be up to insurers to negotiate the lower payment rates.

Additionally, with more people insured, there would be additional use of services, said Melnick. While that would cost money up front, those services used would likely be preventive services, which would save much more money in the long run, stated Wright and other panelists. But Wright also challenged the notion that the uninsured are to blame, or that they simply get free care, pointing out they often are charged more than anybody else for medical services, and often face medical debt and bankruptcy.

On price controls and transparency:

The discussion included all active proposals, including SB840(Kuehl), the universal, single-payer proposal which Gov. Schwarzenegger vetoed last year. Quoting a Lewin Group report, Kominski said that initial costs would increase by $25 billion for medical services, but that efficiencies would save the state $33 billion. Those efficiencies include the use of price controls, reduced fraud, bulk purchasing and $20 billion less spent on private insurance company administration and profit. Like SB840, Kominski said Medicare – another single-payer program -- has done a good job keeping down costs through price controls.

The commissioners discussed both price controls and transparency, allowing consumers a better idea of how much things cost. “It doesn’t occur to people to ask price,’’ said Marilyn Brewer, a former Orange County Republican legislator. “None of this will work if there’s not cost containment. Maybe we need universal pricing and universal cost.’’ Kominski stated that in spite of its success with Medicare, price controls have not been a serious debate for more than two decades “and somewhat out of favor.’’

Commissioner Mitch Mitchell also commented, “no individual is going to negotiate a price. Discussions about transparency and price shopping are absurd,’’ he said. Harbage argued that transparency of prices has its uses in certain instances, such as with prescription drugs.

On benefits and high-deductible plans:

Such consumer-driven/high-deductible health plans rely on consumers to “shop around’’ for the best price for care. But the commissioners and panelists discussed that pricing out medical services is impossible because it is not public, and it varies from place to place and from person to person.

Mitchell asked what the minimum basic benefit package should be – and what did panelists think of the $5,000 deductible minimum plan the governor proposed, for those who would not qualify for subsidized coverage. Kominski laid it out. Such a plan would cost a family about $200 a month -- $5,000 a year. On top of that, the families would still have to pay $5,000 deductible. That’s $10,000 before they even see a dime of coverage. “If these policies were so desirable, why don’t we all have them?’’ he asked.

Anthony Wright said such policies caused families to have to “pay to be uninsured," paying premiums but still facing worse health outcomes and the possibility of medical debt and financial ruin. The other danger of high-deductible plans, he said, is cost-conscious consumers would have to decide which procedures were “necessary’’ and which were not. Half the time, they guessed wrong and forgo preventive treatments that end up making them sicker and costing more money to treat. Some may not also have the cash necessary to pay up front for doctor’s visits.

Mitchell asked why it would not be sufficient to have a high-deductible plan that also covered preventive services. While some high-deductible plans do allow for preventive services, they’re limited, said Wright. And if a consumer has a chronic disease, such as diabetes, asthma, heart disease, which require regular doctors visits and medications, such a plan would not work for them. Chronic diseases are also the largest cost drivers in health care, and to exclude such coverage would just make matters worse, experts said.

On affordability for consumers:

Commissioner Eloise Anderson, however, questioned why some consumers with the means couldn't just save their money for routine visits, rather than be told by government to buy a certain kind of health policy.

Kominski stated that even routine procedures -- such as one he had in 1982 when he was 28 years old, which ended up costing him $28,000 at that time -- are so expensive, and thus it is unfeasible for most to feasibly save enough for a major medical care. But he also critiqued the individual mandate proposal: the cutoff defining consumers "with means'' and those "without means'' in the governor's proposal is 250% of poverty -- about $52,000 for a family of four. Such a requirement to purchase high-deductible plans, and save money in a health savings account, would unfairly burden those middle-income families, who would be barred from subsidies. For those on the edge, they'd essentially be paying about 20 percent of their income for healthcare.

Melnick said subsidies were an essential part of any system. He shared an analysis, showing that on average, people end up spending about $450,000 in their lifetimes on health care. Without subsidies, that would mean more than half of the lifetime income for a $10-an-hour workers (who would earn $800,000 over 40 years). A more reasonable spending obligation would be the current average of about 8.2 to 8.5 percent for families at around 300% of poverty, said Kominski, citing an Urban Institute study.

On public programs:

Commissioner Mitchell criticized Medi-Cal's enrollment mechanisms, which often makes it difficult for low-income to become enrolled. "Medi-Cal is a barrier to progress, set up to be a disincentive for people to get in,'' he said. "When you talk about the uninsured and Medi-Cal, why hasn't the state made progress?''

The reason, said Peter Harbage, who worked as a health official in the Gray Davis administration, is because Medi-Cal is "overworked and underfunded.'' Many of the challenges could be fixed if the system simply had more money. Wright added that the fact that 6.7 million of the sickest and poorest Californians can actually rely on the program means that Medi-Cal is a success "in spite of itself," especially providing such coverage "at a lower cost than the private sector and a lower cost than any other Medicaid program in the nation." He said much remains to be done to streamline and ensure government doesn't make it more difficult for people to enroll and stay on coverage.

Mitchell said Medi-Cal was an area that warranted attention because it could create a positive domino effect, "Health care can be lifted up by lifting Medi-Cal."

On employer contributions:

Panelists roundly agreed that the employer requirement in Gov. Schwarzenegger plan -- 4 percent of payroll -- was too low. Because most firms that provide insurance already spending between 8 to 12 percent of payroll on healthcare, they would still end up subsidizing those that do less, and creating similar fairness and cross-subsidy issues as in the current system. Kominski recommended a graduated tax for small businesses, with tax breaks for start-up companies.

On immigrants:

Kominski said he thought the Senate Republican plan to bill the federal government $2.2 billion for state expensives on undocumented immigrants was an interesting notion. "Good luck collecting on that. You can send a way the bill, but i'd like to see [Center on Medicare and Medicaid Services'] reacion to the bill,'' he said. He said providing services to the undocumented was a good policy decision, given that the undocumented contribute more in taxes than they use in services, according to an Urban Institute study.

On single-payer

Near the end of the hearing, Commission Chairman Michael Alpert asked "why not national health care?" and described the components of the "essence of a single-payer system." Panelists talked about the prospects for national reform, but also suggested the opportunity to take action at the state level.

The commission also took one public comment, along similar lines. The California Nurses Association, as on Tuesday at the Assembly Health Committee hearing, reiterated its strong support for a universal, comprehensive single-payer system, as proposed in SB840(Kuehl), to fix our healthcare crisis.

The California Nurses Association also said it was dismayed that the Governor and the New America Foundation blamed the health care cost and access crisis on the "uninsured." They stated that the blame should be placed with the insurance companies, with their rationing of care and their waste of 30% of premiums in administration and profit. They stated that all the health proposals that provide more money to the insurance companies--"the real source of the problem"--are thus flawed. They also warned that "a bad deal is worse than no deal", and reliance on market forces might lead the state down the same path at the failed energy deregulation debacle.

For more information on this process and these issues, contact Hanh Kim Quach, policy coordinator, Health Access California, at 916-497-0923 or hquach@health-access.org.


UPDATE ON DEFICIT REDUCTION ACT CITIZENSHIP REQUIREMENTS

On February 22, 2007 The Department of Health Services (DHS) convened a public hearing in Sacramento to solicit feedback on the state’s latest revision of their implementation instructions to the counties on the new requirements for Medi-Cal eligibility.

The new policy, narrowly passed last year by Congress as part of the federal Deficit Reduction Act, requires citizens to submit proof of citizenship and identity when applying for Medi-Cal or in order to remain eligible for that program. Both advocates and DHS stress these new proof requirements do not apply to non-citizens. In addition, certain other groups do not have to submit proofs (for example, anyone receiving Supplemental Security Income (SSI), Medicare, or children receiving foster care payments.)

However, much of the content of the comments at the hearing related to how to make these new rules clearer for new applicants and beneficiaries, the counties, and advocates who assist them. Because of the complexity of the new rules, DHS was not willing to commit to an implementation date or the release date of the instructional letter.

The Good News

The state has worked to build in as much flexibility as possible into the new policy, which they argue is as much as federal law and interpretation permit. For example, the state has run a computer data match of Medi-Cal beneficiaries’ information against the California ’s register of birth records. DHS was able to locate birth certificates for slightly more than half of the 3.3 million records in the test. This means that those beneficiaries would remain eligible for Medi-Cal without interruption. The fact that DHS was able to electronically locate such a significant percentage of birth records would also save the state and the counties both time and money in administering this new law.

The Bad News

Advocates continued to point out language in the instructions and outreach materials that were unclear, misleading, or just plain wrong. Many advocates expressed concern that this very confusing law has recently received media coverage that contained incorrect information that everyone had to submit proofs (however, these new rules do not apply to non-citizen legal immigrants.) Advocates also expressed concern about the potential that counties would apply inconsistent interpretation of the new rules and offer different levels of assistance to Medi-Cal applicants and beneficiaries, resulting in different outcomes for people living various parts of the state. Advocates urged DHS to conduct extensive training, provide multiple language outreach materials, and track county-specific data to ensure correct application of the law.

While not a focus of this meeting, there is continued discussion about ways to potential have Congress revisit the original law. Advocates and others contend that even with the state's attempts to mitigate its impact, there will be signficant number of Californians who will lose access to health coverage, as well as significant cost to federal, state, and local government and providers, because of this onerous law.

For more information in DRA proceedings or other administrative activities, contact Elizabeth Abbott, Health Access, at 916.497.0923 x 201 or eabbott@health-access.org.

Labels: Updates

posted by Anthony Wright | Permalink | 10:58 PM


 

The Man Behind the Curtain

Thursday, February 22, 2007

Blue Shield wants to know why your health plan sucks.

Actually, the real pitch is that they want to hear all your insurance experiences -- "the good, bad and the unbearable -- Don't hold back. We can take it,'' their ad says.

Well, they must be suckers for abuse. They have collected about 2,000 stories so far from their "chatbox'' which was out in front of the Capitol on Wednesday. In the course of a day, hawkers heard from people denied, overcharged, or just plain patronized by insurance companies (the identities of the offending health plans were kept confidential so as not to malign insurers too much.)

Both the tactic and the story-collecting apparatus were brilliant. (View a picture of the chatbox here.) Essentially, you poke your head in a gigantic box (that kinda looks like a clothing collection box for WEAVE) and speak to a television screen, where the disembodied head of the interviewer asks you about your bad experiences. The Max Headroom-like "director" is actually sitting inside the box on the other side of the TV camera.

On the one hand, it's really nice that Blue Shield is saying they care. They asked questions about how they felt about customer service. They probably will get a lot of people wondering with increasing deductibles and co-payments, what the real value of health coverage is. (They said they will feature many of these "disembodied heads" on their website.)

But it's unclear if this is actual consumer outreach and feedback, or if it just marketing. Along with the mock hospital ID bracelets and cheekily-labeled bottled water, they were also giving out brochures describing the various Blue Shield products.

It could also be a tool for policy action: for a few years now, Blue Shield has had its own plan for health reform. At least they have supported the goal of universal coverage, and been a constructive contributor to the debate, even if we at Health Access often have significant policy disagreements with them.

But on the other hand, if they cared about universal coverage, such action could start at the street level. Some of the hawkers who were paid to peddle Blue Shield's sympathy should have been in front of the camera themselves. They were uninsured.
posted by Hanh Kim Quach | Permalink | 8:00 AM


 

Viva Las Vegas

Caught a glimpse of C-SPAN and the various Democratic presidential candidates presenting in front of an AFSCME crowd. Health care came up a lot.


What Governor Schwarzenegger is proposing, and what actually gets done in California, will have an impact on the debate. Maybe health care was part of the conversation in Las Vegas with the Governor's NBA All-Star game seatmate Wayne Newton. What else would they have talked about? (Thanks to LA Times Political Muscle for the hat tip to the delightful photo. Credit: Lisa Blumenfeld / Getty Images)

The health care policy debate is likely to go on beyond the Nevada or California primaries, but probably not as long as Newton's Vegas show.
posted by Anthony Wright | Permalink | 1:16 AM


 

The Assembly weighs in...

Tuesday, February 20, 2007

HEALTH ACCESS UPDATE
Tuesday, February 20, 2007


ASSEMBLY HEALTH COMMITTEE REVIEWS MAJOR HEALTH PROPOSALS
• Governor’s Plan Put in Hot Spotlight; Plans of Speaker and Senate President Reviewed
• Assemblymembers Ask About Affordability & Examine Cost Savings


The Assembly Health Committee, chaired by Assemblyman Mervyn Dymally, on Tuesday held the first of two informational hearings, titled “Health Care Reform: What Are the Choices?” They will examine the different approaches to health care that have been proposed this year.

Tuesday's hearing reviewed Gov. Arnold Schwarzenegger’s proposal, as well as those of the two Democratic leaders. Dymally said he had also invited Senate Republicans, who have announced their own plan, but reported that they declined the invitation. Senator Kuehl's proposal for a universal, single-payer health system will be the subject of next Tuesday's hearing.

THE OPPORTUNITY THIS YEAR

After introductory remarks to welcome the new Assembly Health Committee, Assembly Speaker Fabian Nunez said he was encouraged by the momentum this year. He cited the several comprehensive proposals including his own, as well as those by the Governor, by Senate President Perata, and by Senator Kuehl. He mentioned the effort of passing Kuehl's legislation last year, and his continued support for the bill this year, even with his own proposal. “We have a very rare opportunity to do something fundamental. We have to do it right. We can’t waste this chance,” said Nunez, who reviewed the elements of his plan to expand public programs, require employers to contribute, create a state health purchasing pool and restrict insurers from denying potential policy holders based on minor health conditions.

As in the Senate Health hearing last Thursday, California Health and Human Services Secretary Kim Belshe reiterated that the administration was flexible about the final approach – so much that they do not currently have, nor are they seeking, an author for their proposal at this point. “We want to start with a process focused on principles,’’ she said. “We must create a functional, competitive health care market with complementary proposals.... What is the proper balance between strategies?’’

The other main presenter was Senate staffer David Panush, representing Senate President Pro Tem Don Perata and his proposal. All three mentioned an interest and the real possibility of action this year.

AFFORDABILITY, FEDERAL FINANCING AND THE SAFETY NET

Questions by assemblymembers were wide-ranging, although Republicans also weighed in more heavily this week with their thoughts.

Assemblyman Dave Jones, D-Sacramento, picked up on questions asked by Senators last week about whether health coverage will actually be affordable to people above 250% of poverty, which is the cut-off for Californians in the Governor's plan who would received subsidized coverage through a state purchasing pool and those who would need to buy coverage on their own. For instance, a single man earning $27,000 is above 250% of poverty, yet that person could ill afford the $3,200 annually for health coverage, Jones said.

Belshe, again, reiterated that the administration is still studying the issue of affordability, but that she believed the combination of expanded coverage (which she stated would lower costs), a bare bones $5,000-deductible plan, and the 15 percent cap on administration and profit would help drive costs down. “We are endeavoring to promote a far more functional healthcare system. By bringing up the bottom, we’ll be relieving pressure from the top,’’ she said.

Belshe also addressed critiques levied by the Legislative Analysts’ Office last week that said the administration’s anticipation of $5.4 billion in federal dollars was too optimistic. She said conversations with the previous U.S. Health and Human services administration secretary said their estimations were sound, although, they did not have that guarantee on paper.

Another area of contention is nearly $2 billion that the state would take from counties, in anticipation that fewer uninsured would be flooding the emergency rooms of public hospitals. Counties, however, would still be the place where many uninsured and undocumented immigrants received care. Assemblyman Hector DeLaTorre said this approach was like Wimpy in Popeye saying, “I’ll gladly pay you Tuesday for a hamburger today.”

Belshe acknowledged that “issues have been raised,’’ but said the counties were worked in as part of the solution because the governor’s proposal was an attempt to be comprehensive, rather than patchwork.’’ She said she understood that legions of uninsured would not be suddenly insured overnight and seek primary and preventive care away from emergency rooms. Because of that, the administration would be willing to talk about timing and implementation to make sure counties and patients did not suffer.

REPUBLICANS VIEW PLANS WITH SKEPTICISM

Republicans took the opportunity to question whether any of the plans could really bank savings predicted.

Republican Assemblyman Alan Nakanishi, the vice-chair of the committee and a Lodi ophthamologist, focused in on the Medi-Cal expansion proposals. He questioned Speaker Nunez whether or not state costs would actually decrease if there were more people in the system – needing and acquiring – more services. Nakanishi may as well been referring to the Governor’s, Senate Leader Perata’s, and Sen. Sheila Kuehl’s single-payer plan as well, as all of them include an expansion in programs and coverage.

In response, Speaker Nunez said that coverage – public program, or private health insurance – would force people to get preventive and primary care, which is cheaper than getting care at the last minute through the emergency room. Even though there will be more people covered, those patients will be using health care more appropriately – seeking care earlier and more cheaply -- and that will save money.

Assemblyman Bill Emmerson, R-Redlands, followed Nakanishi’s cue and asked Health and Human Services Secretary about “overutilization’’ because there are more people insured, and his belief that many of the costs would be driven by new and expensive technologies. “Then, do we need to start rationing care?’’ he asked.

Belshe echoed Nunez’ previous comments, saying the state needed to take the opportunity to “drive people to primary and preventive care and keep people out of the ER.” By having people take care of their health needs more cheaply, there would be more money to go around for everyone. She noted that there needed to be a shift in attitude, toward preventive care and maintenance on the front end, rather than episodic care on the back end. As it is now, in addition to the uninsured who get care in the Emergency Room, so do Medi-Cal patients, who end up in the emergency room because there aren’t enough primary care physicians to take care of them.

Republican Ted Gaines, from the foothills, repeated Emmerson’s and Nakanishi’s concern about too many people using too much health care. But he took a different angle. “The white elephant that no one’s talking about is the middle class who can access care easily and services will be overutilized by folks with health care,’’ said Gaines. He went a bit further, also, implying that the individual mandate portion was a backdoor to getting “socialized medicine’’ advocated for health savings accounts and said he wanted to allow market forces to prevail and drive down prices.

Belshe said the administration sympathized with middle-income Californians who have been jolted by higher and higher premium and health costs in recent years. But it requires a two-pronged approach. The administration believed in covering everyone – that means through an individual mandate, and regulatory controls. Part of that was also getting to cost drivers, which in the administration’s view, was chronic disease and lifestyle choices.“We need to do more on prevention and wellness,’’ said Belshe. She said the administration did propose conforming state tax law to federal law in allowing for health savings accounts.

Republicans also questioned why certain groups were being targeted. Nakanishi questioned why all providers were being asked to pay up. “The 2 percent to 4 percent fee is unfair. There are a lot of providers who don’t provide to Medi-Cal patients,’’ said Nakanishi, who is one of the founders of the Delta Eye Medical Group in San Joaquin County. Nakanishi suggested limiting the provider “dividend’’ payments to just the Medi-Cal providers, who already operate on very thin margins, or in the red. His view – they are the ones who will be getting increased Medi-Cal reimbursements, they should pay. The Medi-Cal rate increase proposed would be the first in several years.

Belshe acknowledged, “Not all providers are the same…But we would hope to see more physicians provide to Medi-Cal patients.’’ The administration, though, justified imposing the provider fee on everyone because everyone would be benefiting from the extra $10-$15 billion that will flow into the health budget as more patients are insured. The requirement that plans dedicate 85% of premium dollars to health care should also help compensate providers better.

Bill Emmerson stated that he didn’t like the employer mandate, requiring employers to pay 4 percent of payroll for health care. He said it was too expensive, but also said that it might create an exodus of employers who already provide more health care, but see 4 percent as a cheaper option.

Belshe said that MIT economist Jonathan Gruber – who has been helping the administration work through the issue – did not see as much leakage in employer-sponsored plans because many businesses who offer coverage do so for recruitment and retention. She also said the administration was working to discourage employers from dropping their health coverage.

OTHER ISSUES

Assemblywoman Karen Bass, D-Los Angeles, feared that the enforcement of the individual mandate would be too punitive. For instance, if schools were asked to verify if children had health coverage – as the do with immunizations – would children be turned away from school if they are not insured.

Belshe said the goal is not to “criminalize health coverage’’ but more to encourage and facilitate enrollment. Schools could help identify children who qualified for public programs and enroll them. Bass hoped that meant children would just be asked to fill out paperwork and not deterred from school.

During Speaker Nunez’ presentation, Assemblywoman Loni Hancock from Berkeley, asked if his plan would limit insurance administrative and overhead costs. Nunez replied sheepishly that the governor’s proposal was actually stronger on that front, but that Nunez would be putting that idea into his proposal also.

Assemblyman Jones also asked whether small group market reforms would be extended to mid-size businesses. The administration said it was still examining the issue.

STAKEHOLDERS LINE UP

The committee took testimony from stakeholders, who mostly said they were eager to be part of the solution. Among the stakeholders who spoke were SEIU, California Labor Federation, Planned Parenthood, CALPIRG, California Nurses Association, Western Center on Law and Poverty, Health Care for All/Health Care Organizing Project, California Pan-Ethnic Health Network, Older Women’s League, League of California Cities, California Association of Counties, the California Medical Association, California Hospital Association, and the California Restaurant Association.

Among the comments:

• SEIU said that employer mandates were not sufficient – particularly in light of the fact that workers have to wait months – even years – before coverage kicks in. In the meantime, they’d still be subject to the individual mandate.

• Dovetailing with that sentiment, the California Labor Federation noted that more than 50% of retail clerks are now uninsured as a result of the Southern California grocery contract from three years ago. The Labor Federation also noted that the workers compensation compromised reached a couple of years ago was not acceptable. Since then, even though employers saved $9 billion, injured workers have suffered while insurance company profits have soared. For every premium dollar that comes in, only 31 cents goes to benefits. Lobbyist Angie Wei urged that a health care deal do better than what came out of worker's compensation talks.

• CalPIRG’s Emily Clayton, sporting the consumer-health campaign sticker “It’s Our Healthcare’’ enumerated three guiding principals for lawmakers to consider in the coming year, including: 1)Tackling problems with access, allowing Californians to get coverage they need when they need it, taking away the ability for insurers to cherry-pick only healthy patients; 2) Dealing with rising costs, ensuring that money going into the system is spent on health care. To that end, a strong medical-loss ratio is recommended, and 3) Focusing on quality and preserving the HMO Patient Bill of Rights, because health insurance does not help anyone if it they must pay thousands in out-of-pocket costs and are unable to get care when they need it.

• California Pan Ethnic Health Network urged lawmakers not to forget health disparities plaguing communities of color. Any comprehensive reform must also address inequities in health delivery that affect different minority groups.

• Planned Parenthood said family planning – which can be a big cost saver -- must also be factored into health reform.

• The California Restaurant Association explained the slim profit margins many small restaurants live on and any employer mandate would negatively impact them.

Next Tuesday, the the Assembly Health Committee will be dedicated to examining Sen. Sheila Kuehl’s SB840 single payer proposal.


For more information on this report or on other issues, contact the reporter of this udpate, Hanh Kim Quach, policy coordinator, Health Access, 916-497-0923 x206, or hquach@health-access.org.

Labels: Updates

posted by Anthony Wright | Permalink | 11:45 PM


 

Just before the Tower Bridge, the peloton caught up to the breakaway...

Sacramento was abuzz today. I wish I could say it was about the Assembly Health Committee holding its first hearing on health reform, listening to presentations about the proposals by Speaker Nunez, Senate President Pro Tem Perata, and Governor Schwarzenegger. (Hanh will provide a full report here later today; Next week, they will hear Senator Kuehl's single-payer proposal.)

But the talk of the town was that the Capitol was circled today by some of the best cyclists in the world, as part of the Tour of California. The finish line for today's stage was just outside our offices here at 11th and L in Sacramento. As a regular watcher of the Tour De France, I was excited to see the preparation and the energy of the crowd, and to get a glimpse of these racers going at incredible speeds.

posted by Anthony Wright | Permalink | 12:53 PM


 

Dilbert-Care

For an amusing and pithy comment of so-called "consumer-driven" care, and other cartoon critiques of our health system, check out this post and links by Michael Millenson at The Health Care Blog:
http://www.thehealthcareblog.com/the_health_care_blog/2007/02/health_policy_a.html

Labels: Funny

posted by Anthony Wright | Permalink | 11:06 AM


 

Sunday reading: no articles about spanking or light bulbs?

Sunday, February 18, 2007

Important article today in the Los Angeles Times by the reporter and erstwhile Political Muscle blogger Jordan Rau, vividly describing the biggest concern in the Governor's plan: the proposal that many Californians would be required to buy private insurance without regard to ability to pay, without a defined and meaningful benefit, and without assistance from either an employer or a public program. There's lots of good components of the Governor's plan, but this is the major element that ends up being a burden, rather than a benefit, to many California consumers. It's something that we will expect to be changed by the end of the process.

Another article of note is a column by Jim Boren in the Fresno Bee, which cyncially starts by stating that the health care crisis "will never get fixed," because of the various interests that will oppose any specific proposal. The article attacks not one political party but the Sacramento establishment, "a weak-kneed bunch that could be dubbed the Status Quo Party." It rightly goes on to say why reform is necessary and beneficial, talks about the plight of the uninsured, and the flaws in the health system that impact all Californians.

But the tone of the column is so negative that it actually enables the status quo that it attacks. Rather than exhorting Californians to engage in the debate and keep the Governor and legislators accountable for action this year, it simply says "don't be surprised if nothing happens." He doesn't acknowledge that the Legislature has passed major reforms in the last four years--to expand coverage to workers, to children, and to all Californians--but only to have them blocked by this Governor. Now that the Governor, to his credit, has put forward his ideas, we have the opportunity for debate and action--and that's the news story. Boren is right that there are lots of reasons why we haven't had reform in the past, but the response should be active to demand more from our political leaders, rather than be resigned to expect less.
posted by Anthony Wright | Permalink | 3:03 PM


 

They asked the right questions...

Friday, February 16, 2007

HEALTH ACCESS UPDATE
Friday, February 16, 2007

SENATE COMMITTEE REVIEWS GOVERNOR’S PROPOSAL
* Senators grill Administration on affordability of health coverage for consumers
* Optimism expressed on passage of reform this year
* More information released on modeling of new proposal
More on the Health Access Weblog: Of Pirates and Snowboarders...


The state Senate Health Committee took its first crack at drilling down and exploring the interlocking components of Gov. Arnold Schwarzenegger’s health proposal on Thursday. The four-hour hearing, based essentially on a 10-page fact-sheet proposal that still has not been written in bill format, indicated that much still needs to be done – both on by the Legislature and the Administration side – before a health reform plan is to be passed.

Committee members and the administration all expressed appreciation at the intense focus on health care and the urgency to do something this year. Senators from both parties, including Republicans Senators Cox and Aanestad, and the introductory remarks by Senate President Pro Tem Perata, expressed the desire and overall optimism about passing major reform this year.

But as a caution, Sen. Sheila Kuehl, chair of the committee and a longtime advocate (and author for five years) of legislation for a universal, single-payer system, displayed the sign “Do No Harm’’ at the dais to remind all policymakers that any changes must not make Californians worse off than they are now.

In the meantime, Governor Schwarzenegger was speaking on his health proposal at the "National Pay for Performance Summit." His comments are available on his website here:
http://gov.ca.gov/index.php?/speech/5425/

The Governor's Office also released a new paper, "Modeling Health Care Reform in California," by MIT professor Jonathan Gruber, which reveals some of the assumptions behind the Governor's plan and the assumed impact, on individuals, employers, and the state government:
http://gov.ca.gov/index.php?/fact-sheet/5428

Back to the hearing, it started with a presentation by Health and Human Services Secretary Kim Belshe, with substantial give-and-take from the members of the committee. A second panel featured LAO analysts and academics, and a third panel featured quick response from selected stakeholders.

AFFORDABILITY AND THE INDIVIDUAL MANDATE

Most notable was the discussion between the lawmakers and Administration officials, which mostly focused on the impact of the individual mandate on California consumers. The governor’s plan calls for an individual mandate, combined with rules on insurers such as guaranteed issue and modified community rating, to assure individuals can get covered. It’s unclear, though, how much the plans would cost under the proposal.

The biggest issue raised by the Senators was the issue of whether health coverage was affordable for consumers, either to buy it, or to use it. Their questions indicated that reform plans would not be helpful if all Californians were forced to buy plans – through an individual mandate -- that were too expensive or that didn’t provide much coverage – like high-deductible plans.

Sen Sheila Kuehl started out by saying that she agreed with the broad concepts of the Governor's plan, including "universality," "shared responsibility," and "affordability." However, she "worried about whether Californians can afford it," both those Californians with subsidized coverage--she called the 6% of income that many would have to pay "a lot"--and those who would have no subsidies. She was concerned that there were "no limit of premiums." She also wanted to make sure that consumers received valuable and meaningful coverage for their premium dollar. “There’s a tension between what people have to pay and the level of benefits that will be provided,’’ said Kuehl, who added that she was “not confident that affordability will be achieved.”

The Administration’s theory, said Administration official Richard Figueroa, is that with double the number of people buying health insurance in the individual market (from the current nearly 2 million to around 4 million Californians) prices would either go up 1.2 percent – if new enrollees were of “average’’ health -- or come down by 1.2 percent – if the newcomers were younger and healthier.

Belshe summoned the oft-used analogy to auto insurance, which Kuehl pointed out, also was not universal. In California 14 percent of motorists remain uninsured and policyholders pay an uninsured motorist premium. This analogy is also not apt because auto insurance is priced, in part, based on the vehicle that you choose to drive (ie can afford.).

There were no assurances that any reduction in health premiums for individuals would actually result from the governor’s plan. Kuehl alluded the now-infamous California energy crisis six years ago, where the “market’’ was supposed to behave and lower prices. As history now tells us, that never happened and California and its 37 million electricity consumers suffered higher prices, and rolling blackouts.

“We need to hire a pirate to tell us how the system could be gamed," Kuehl said, noting that such expertise would have been helpful in the crafting of energy deregulation as well.Many senators chimed in with the same concerns about taming the market.

WILL THE MARKET WORK?

Sen. Leland Yee requested data sets that would show how market assumptions worked.
“How does the economics of this work?’’ asked Sen. Elaine Alquist. “How do you ensure that premiums will be kept at a reasonable level?’’

Administration official John Ramey argued that by "putting money at the bottom of the system," with many uninsured patients covered and Medi-Cal provider better reimbursed, "the market will become more functional" which is intended to "relieve pressure at the top." Ultimately, he said, “we’re placing confidence in the market.’’

Belshe said the administration’s directive to put a 15% on non-medical expenditures should help funnel more money to patients. Currently, HMOs already have to meet that mark, but PPO plans do not. Some spend as little as 50 cents of every premium dollar on health care. Belshe added that all of the changes in the market taken together, including the influx of new enrollees, fewer people using high cost care, more money from employers, would serve to drive down cost.
WHAT IF WE'RE WRONG? WHO BEARS THE RISK?

Sen. Darrell Steinberg followed up, seeking to understand the consumers’ recourse if things didn’t go as planned. He did call the plan an "elegant proposal" and congratulated the Governor for putting forward "a vision."He also said: “we know there are no guarantees in life. You’re counting on a better market. In some ways, this debate comes down to ‘who bears the risk?’

The market may work in the way that you describe. But has the administration addressed whether or not the mandate should be modified or eliminated if we are wrong?”More to the point: “If the premiums do skyrocket, is there going to be any failsafe way for the individual who won’t be able to afford the insurance?” he asked.

Belshe said the administration was building in a “review mechanism’’ to assess how things will shake out in the coming years.

Steinberg indicated that wasn’t enough. While waiting for the “review mechanism” to kick in, consumers will still have suffered the unaffordability of insurance if the market fails. He propose, a “trigger,’’ which would be activated if premiums and out of pocket costs increased above 5 percent (or some benchmark), then there would be some kind of relief from the mandate.

AFFORDABILITY BEYOND PREMIUMS

Aside from the issue of affordable premiums, Sen. Elaine Alquist also asked about the affordability of the plans themselves, once consumers were enrolled. “How do low income people meet the high deductible?’’ she asked, referring to those families who are just above 250% of poverty, and therefore would not be eligible for subsidies and low-cost comprehensive coverage in an insurance pool run by the state.

Belshe said the Administration drew the subsidy line at 250% because most uninsured Californians earn less than that. But, she said, “It’s a balance we’re trying to find.’’

The concerns about the individual mandate and its workability and affordability were also expressed by several stakeholders, including Health Access California, SEIU and the California Nurses Association, and others. Belshe did state that "an individual mandate doesn't work on its own," but many of these presenters indicated that the Governor's proposal for insurance market reforms and subsidies was not sufficient.

Health Access indicated that while it did not oppose the notion of an individual contribution to health coverage, but couldn't support a mandate to buy coverage along as an individual without consideration for ability to pay, without a defined and meaningful benefit, without the power of group purchasing, and without shared risk with an employer or public program.

Professor E. Richard Brown, director of the U.C.L.A. Center for Health Policy Research later testified that he believed the subsidies should be increased to 400% or 500% of poverty and that anyone in the state should be permitted to buy into the state insurance pool. He also said the out-of-pocket ($10,000 for a family) limits drawn by the administration were high and “seems like excessive risk."

OTHER ISSUES

Because Belshe’s time as a witness was limited, other issues were not explored in great depth. Senator Mark Ridley Thomas asked about long-term care. Senator Cedillo asked about care to the undocumented, which if left as a county responsibility under the Governor's plan. Senator Steinberg and Kuehl talked about the intersection of health care reform with worker's compensation.

Senator Aanestad asked where the provider rate increase was in the Administraton's budget. Belshe responded that the health care plan was self-contained and self-financed as a package, and thus not included in the budget.

Here are some other comments and ideas that the administration and other panelists traded on these issues.

Employer mandate: Some advocates said that requiring employers to provide coverage was a good start but the 4%-of-payroll requirement was too low, as many employers (who provide coverage) provided more than twice that level already.

Professor Brown said that the way the employer mandate was structured could cause employers to drop coverage – or reduce it to the level required. Employees would have no leverage because they would still be required to buy insurance through the individual mandate. Brown proposed that the administration require all employers provide coverage – including those with fewer than 10 employees, which are currently exempt under the governor’s plan. For those smaller businesses, he recommended a lower contribution rate – starting at 2%. But he also would require a higher contribution -- around 7% -- from larger companies with higher paid workers.

Local governments: There was a concern among lawmakers and some presenters, including Harbage, Health Access, and Yolo Country Supervisor Helen Thomson, that local governments would be left holding the bag and public hospitals – in particular – would be unable to afford to stay around and meet the ongoing demands. The governor’s plan would take $2 billion away from public hospitals, but these providers would still be the safety net and be expected deliver health services to the undocumented adult community.

Belshe, however, said “public hospitals and counties would have ‘significant funding’ to assure” that they could met their obligations.

Federal government: The Legislative Analysts’ Office said many of the assumptions were "plausible," but believed the administration’s reliance on $1.4 billion from the federal government was too optimistic. They will be putting out their analysis on the Governor's proposal next week.

Belshe characterized their critique as a “difference in opinion.’’ Both agreed that the bulk of the money from the federal government was from straight matching funds that did not require addition negotiation, but there was dispute about the impact on existing waivers and agreements.

Peter Harbage of the New America Foundation applauded the Administration for identifying new ways to bring in federal funds, but raised the need to be active in federal budget debate, especially around SCHIP reauthorization.

Doctors and hospitals: Providers said they were concerned about the “dividends’’ that the administration was going to ask them to pay (2% for doctors and 4% for hospitals).But Senator Steinberg did not believe that the “dividends’’ were either a “fee’’ or a “tax’’ because of the administration’s estimates that providers stood to gain $10 to $15 billion more dollars because of higher insured and paying patient loads, higher Medi-Cal reimbursements, and fewer uninsured patients seeking uncompensated care.

A public option?: Presenter Peter Harbage suggested that Californians in the individual mandate could be given the choice to join the purcahsing pool, to have a public option that could compete with the private sector. Senator Steinberg followed up with Secretary Belshe at the end of the hearing, noting the Governor's opposition to a single-payer system, but asking if the Governor would consider a statewide or regional public plan that could be something that competes with the private plans. Secretary Belshe did not reject the notion, stating that competition and market solutions were values that the Governor supported.

MORE HEARINGS TO COME

There were lots of issues raised: For example, the Chamber of Commerce representative, spent twice her allotted time simply reading off a list of questions about the reform proposal. Senator Steinberg, however, boiled the major questions down to two: 1) the affordability for consumers, and 2) the need for sustained funding. He noted that the employer contribution was only $1 billion of the $12 billion, and that most of the financing came from the federal government and the fee on providers.

Kuehl’s hearing is only the first of many in the coming weeks. Belshe said she was “very encouraged’’ by the discussion and the ‘clear recognition that we have a significant set of problems for the uninsured and insured alike.’’ The sense of urgency gave her confidence something could be accomplished this year.

Perhaps the most important thing she said was that the administration would remain flexible. “We need to talk about different policies before we put pen to paper. We need to identify the paramount principles and policies.’’

Stay tuned next week, on February 20th, when the same cast of characters – and more – reconvene before the Assembly Health Committee.

For more information, visit the Health Access website at www.health-access.org, or contact Hanh Kim Quach, Health Access, at 916-497-0923, or hquach@health-access.org.

Labels: Updates

posted by Anthony Wright | Permalink | 1:18 AM


 

Of pirates and snowboarders...

Thursday, February 15, 2007

I testified today at the Senate Health Committee's hearing, chaired by health care champion Senator Sheila Kuehl, on Governor Schwarzenegger's health proposal. My colleague Hanh will post a more full run-down of the discussion, but here's my first take:

I was impressed that the Senators zeroed in on the right questions about health reform: What is affordable for consumers? Who ultimately bears the risk?

The legislators seemed to get the point of health reform is to provide a benefit, not a burden, to individual patients and families. If voters continue to remind them and hold them accountable, the prospects of positive reforms this year are good.

The two most vivid images invoked by the Senators was of insurers as pirates, and of 23-year old surfboarders as slackers.

My point in testimony was that as we define the problem, that