Killing us softly...

Wednesday, July 02, 2008

NYTimes has a horror story about diabetes and how it creeps up on you and "eat(s) you alive,'' as one doctor described it. In addition to being the leading cause of blindness and amputation, diabetes also affects the afflicted in a myriad other ways from head to toe -- depression, sleep issues, stroke, dental and hearing problems, liver and kidney problems, *paralysis (!)* of the stomach, ulcers, and various sexual problems.

Cases of diabetes are growing -- 8 percent of the US population had it in 2007. And by 2050, it could be 25%, according to the Centers for Disease Control.

I'm fixating on this for two reasons. 1) I'm genetically predisposed to diabetes; my father was diagnosed in his mid-40s. 2) Our insurance coverage trends make it very difficult for people to maintain and keep this perfectly treatable disease at bay.

As more people (not us, mind you) advocate for more stripped down health plans, devoid of disease maintenance, it creates all kinds of barriers to getting the meds and seeing the doctor -- all necessities for a person with diabetes.

I'll do a quick, shameless plug for our SB1522 here, which not only would organize the individual insurance market, but also establish minimum benefits -- such as doctors, hospitals and preventive services. It's one of the ways we could begin to tame the unruly individual insurance market, which has been rapidly degenerating over the past few years.... unless we want a nation of diabetic zombies by 2050.

Labels: Insurers, InTheNews, Legislation, Steinberg, Underinsurance

posted by Hanh Kim Quach | Permalink | 10:34 AM


 

Deadbeat Insurers

Tuesday, July 01, 2008

David Lazarus at the LA Times had an excellent column last weekend about health insurers charging men and women different rates. When Blue Shield and other insurers admit they're charging women higher premiums because they are higher "risks'' (Read: more expensive), they're coming clean about the industry's already discriminatory practices against women. Though, in doing so, it further widens the gap between what women and men pay for health care. Women will wind up spending more, not only to *buy* care, but also to *use* care, as has been the case.

Since the steady increase of high-deductible health plans (and in the absence of stronger consumer protections such as community rating and minimum benefit standards) insurers have been permitted to passive aggressively charge women more based on the fact that women are trying to be conscientious about their health.

A Harvard Medical School study last year found women ages 18-64 with consumer-directed health policies wound up spending 218% more on health care than men. "High-deductible plans punish women for having breasts and uteruses and having babies,'' said Dr. Steffie Woolhandler, one of the authors of the study.

We require various gynecological exams. We need birth control pills (as a result of co-activities with men). Sometimes we have babies (as a result of said co-activities) -- though high-deductible plans don't cover maternity anyway. We go to the doctor when we hurt. We generally seek more preventive care than men. Hmmmm. And I thought I was just being responsible.

A world that allows high-deductible plans to proliferate -- as envisioned by John McCain -- is essentially a world that legitimizes deadbeat insurers, who want to thrust more and more costs onto women in the name of keeping prices low. But for whom?

Labels: Affordability, Insurers, InTheNews, Underinsurance

posted by Hanh Kim Quach | Permalink | 12:00 PM


 

"The choice is clear..."

The Sacramento Bee editorializes and says it well... Read the whole thing, but here's an excerpt:

Editorial: Budget deal will do real damage to health care

The choice is clear: Increase taxes or let the impact fall on children and the elderly

...Faced with a $17 billion deficit, the governor and state lawmakers are considering cuts that would likely drop tens of thousands of children from the Medi-Cal program, the state's version of Medicaid. They also are considering restricting adult eligibility requirements for Medi-Cal, hurting families trying to transition from welfare to work.

Elderly patients would also take a hit. As part of a 10 percent cut scheduled to take effect today, the state plans to reduce payments received by pharmacists who serve Medi-Cal patients. Pharmacists say it would force them to lose money on commonly prescribed drugs, and to choose between taking fewer Medi-Cal patients or cutting staff and limiting hours...

Legislators, particularly Republicans who have taken a vow not to raise taxes under any circumstance, need to consider the consequences.

Start with children. Currently, about 3 million children in California receive health care through Medi-Cal, and eligibility for the program is determined annually. To save $92 million in the budget, Schwarzenegger wants to reinstate a rule that families on Medi-Cal submit paperwork every three months to prove their eligibility, instead of every 12 months.

About 150,000 children are expected to lose coverage this year – and 470,000 eventually – because their families either fail to file the required forms or they can't meet the program's eligibility rules. The quarterly reporting requirement will also add to the burdens of counties, who will have to process all the extra paperwork.

For these reasons and others, the Assembly rejected the administration's proposal, while the Senate has come back with a "compromise" – requiring Medi-Cal recipients to file paperwork twice a year, instead of four times.

This is hardly a compromise. As senators and Schwarzenegger are well aware, kicking poor people out of the Medi-Cal program will only force them to go to the emergency room, or avoid treatment for diabetes, high blood pressure and other chronic diseases.

While campaigning for health care reform last year, Schwarzenegger often talked about the "hidden tax" that uninsured people impose on hospitals, businesses and local governments. It would be revealing for the governor to calculate the hidden tax he will impose on this state if these Medi-Cal cuts are fully enacted.

A better option would be a modest, broadly distributed levy – yes, a tax – to prop up this state's health care program for the poor. Consider it a down payment on a once-and-future goal: a more universal system of health coverage

Labels: Budget, InTheNews, MediCal, SCHIPHealthyFamilies, Schwarzenegger

posted by Anthony Wright | Permalink | 12:43 AM


 

So "never events" never happen...

Monday, June 30, 2008

Jordan Rau at the Los Angeles Times has an important article (with lots of links to primary source documents!) on the key issue of "never events"--those things that should never, ever happen when you get care.

It's a list that includes getting severe ulcers from bedsores, having equipment left in a person during surgery, undergoing the wrong surgery or having the wrong limb amputated, or being given the wrong medication or wrong dosage. Unlike other parts of the art of medicine, these are problems that are preventable if the systems are in place.

The number of these adverse events reported is over 1,000 in a 10-month period. It's a wake-up call--Many in the health care community would not have predicted such a large number. These medical errors are serious--in some cases, deadly serious. By definition, these are "never" events--not "sometimes OK" events.

The article highlights AB2146 (Feuer), an important bill supported by many consumer groups like Health Access California, AARP, CALPIRG, Consumers Union, as well as business and labor organizations. It would have California follow the federal government in not paying for these adverse events, as part of a shift to change the financial incentives in this category.

I would also add AB2967 (Lieber), which would add more transparency to the cost and quality of the care being provided in California. This information is valuable in its own right, and will have a impact in getting hospitals to prevent these errors, which will improve health outcomes, and save money too. Information shouldn't be the only tool, but it should be part of more aggressive oversight.

Read the article. It's worth your time.

Labels: Hospitals, InTheNews, Legislation, Prevention, Research

posted by Anthony Wright | Permalink | 1:32 AM


 

Follow along...

Sunday, June 29, 2008

Our report revealing the full magnitude of the health care budget cuts got lots of good response and press attention (such as from the Contra Costa Times, Ventura County Star, New America Media, and others) earlier this week.

For those following the budget, we have one-sheet on the proposed health cuts in the 2008-09 Health Care Budget on our home page.

The Budget Conference Committee is expected to come back on Monday, and perhaps close out in this week. Our website also has an often-updated Budget Cuts Scorecard where you can follow along to see--item by item--what the Assembly has done, what the Senate has done, and what the Conference Committee had done on a specific cut.

The scorecard answers the relevant question: where is the Legislature on the proposals that would deny coverage to one million Californians?

Our report details four cuts that lead one million Californians to be denied:
* One of the biggest and most direct cuts, to directly close eligibility for 430,000 low-income working parents, has been rejected by both the Senate and the Assembly.
* Two of the smaller cuts have been accepted by both the Senate and Assembly: the increase in premiums for Healthy Families, and the suspension of key reforms to streamline eligibility for children. Together, that potentially would prevent as many as 160,000 children (and some parents) from getting coverage.
* The Assembly rejected the other big cut, to impose paperwork requirements through quarterly status reports, which would by 2010 deny coverage to 470,000 children. The Senate, however, is looking at imposing the additional paperwork every six months, which would have from a third to half the impact, but it would still be significant. We'll see what they decide.

In short, the Legislature has indicated that, in the best case scenario, the budget will contain health cuts to leave roughly 150,000 more Californians without coverage. The Conference Committee will determine if that number could go to 300,000 or more... and if the "Big 4" negotiations between the Democrats and Republicans don't yield the necessary revenues to prevent these cuts, the number of uninsured Californians could grow by over one million.

Let's also not forget two other major categories of cuts: the provider rates, which were cut 10% and the Legislature is considering making some restorations; and the proposed elimination of dental and other key benefits to Medi-Cal patients, the impacts of which are detailed in this fact sheet, entitled "Vital Medi-Cal Benefits on the Chopping Block ".

Decisions made in the next weeks will determine the fate of care and coverage for hundreds of thousands, if not millions. The stakes are high.

Labels: Budget, InTheNews, MediCal, Research, Schwarzenegger

posted by Anthony Wright | Permalink | 1:37 PM


 

Patients, not paperwork!

Friday, June 27, 2008

Great editorial in the LA Times today: should we spend on healthcare, or on paperwork? That's the proposal in the Governor's budget, and while the Assembly rejected it, the Senate is still considering a modified version of the proposal. Read the whole thing, but here's the final paragraph:

The semiannual applications are projected to save California $25.6?million while taking medical coverage away from tens of thousands of children. Meanwhile, the costs of doubling the paperwork would erase much of the savings. The health of poor children is a vital social interest; more paperwork is not.

Labels: Budget, InTheNews, MediCal

posted by Anthony Wright | Permalink | 10:18 AM


 

It's called discrimination...

Sunday, June 22, 2008

The scrutiny on the inefficient, iniquitous individual insurance market continues, with David Lazarus' column in the Los Angeles Times.

We've explored before how women get discriminated against in the individual insurance market. They have to pay significant surcharges for maternity coverage. A recent NY Times story spotlighted how a C-section can be classified as a pre-existing condition that leads to higher premiums or a denial of coverage.

But now the California insurance marketplace had come full circle: Lazarus reports that three insurers: Aetna, Blue Cross, and now Blue Shield are charging men and women differently, and others are now looking to go there as well.

Where does it stop? As Lazarus says:

But parsing rates according to gender is a relatively new phenomenon. If women are more expensive than men to insure, and middle-aged women are significantly more expensive than middle-aged men, what about, say, older women with red hair? After all, they have fairer skin and thus are more susceptible to skin cancer.

How about if, statistically speaking, blacks are more expensive to insure than whites? Or Christians more expensive to cover than kosher-observing Jews?

How far will insurers go in determining risks?

This may be a standard insurance practice, but I think the public realizes that this is unacceptable social policy to have such discrimination, against women or any other group.

We should pass bills like AB1962(De La Torre) to require maternity as a basic benefit; institute guaranteed issue in the individual insurance market so that those with "pre-existing conditions" can get coverage; and fundamentally reform the health system to expand group coverage and shrink the individual market--where women and others are subject to discrimination, in multiple ways.

One last point: I keep reading that McCain is interested in appealling to women voters, but how can he explain to them his health plan, which would shift millions into the individual market, where they are likely to be discriminated against?

Labels: Insurers, InTheNews, Legislation

posted by Anthony Wright | Permalink | 4:57 PM


 

Buyer beware, indeed...

Our efforts to reform the individual insurance market got more attention this week, by John Howard in the Capitol Weekly and Aurelio Rojas in the Sacramento Bee, which both profiled SB1522, by Senator Darrell Steinberg, and sponsored by Health Access California.

SB1522 passsed the Assembly Health Committee this week, and is now pending in the Assembly Appropriations Committee.

The Bee has the story of the Mary McCurnin and Ron Bednar of Rancho Cordova, who unwittingly bought a plan that the insurer Mid-West National Life Insurance Company called "definied benefit" coverage.

McCurnin and Bednar said they paid a monthly premium of $600 for what they thought was comprehensive coverage. But in 2002, after she was diagnosed with breast cancer and he had open-heart surgery, they learned otherwise.

Their plan covered only 10 percent of his hospitalization, and the company rescinded her coverage because she didn't disclose on her application that she was given a prescription for an anti-depressant years ago that she never filled.

With more than $250,000 in medical bills, the couple filed for bankruptcy protection and now face the loss of their home.

"Health insurance companies will do everything they can not to cover you," McCurnin said. "Having good (individual) health insurance is a myth."

The wife of the couple was rescinded under that now-infamous practice; the husband got "coverage," but found it covered only 10% of his costs because the benefit was capped. Examples like this inform consumer advocates' deep skepticism about the individual insurance market, and any attempt to expand it, as President Bush and now Senator McCain seek to do.

With little bargaining power, the individual consumer trying to get coverage will be at the mercy of the big insurance companies. SB1522 (Steinberg) tries to set some minimum standards in terms of benefits (doctors, hospitals, preventative care), and to place a cap on out-of-pocket costs. Other bills this year deal with rescission, or making sure than premium dollars go to patient care. All are consumer protections that attempt to make the situation a little more fair in an inherently unfair situation.

Even if all passsed, more reform will be needed. Both stories put this bill in the context of reconstructing health reform.

As the Weekly describes it, "Although the governor's health-care reform plan died this year in the Capitol's political crossfire, critical pieces have been resurrected and are quietly moving through the Legislature. One of the most important--already approved in the Senate and opposed by HMOs--would force health insurers to give consumers uniform, clear and accurate descriptions of their policies to aid comparative shopping."

And in the Bee, Senator Steinberg himself not only makes the clear case for the bill on its merits, and but ends the article making the case that the bill as a foundation for future, and more comprehensive, reform.

"As we move forward to more comprehensive reform in the future, creating confidence that people know what they are buying will be a key element," he said.

Labels: Insurers, InTheNews, Legislation, Steinberg, Underinsurance

posted by Anthony Wright | Permalink | 3:17 PM


 

A great debate on the great divide...

Friday, June 06, 2008

There's few general-interest political reporters who get health policy and health issues like Ron Brownstein of the National Journal (and formerly from the Los Angeles Times). Now with the primaries over, he clearly and fairly lays out the choice between the plans of the presidential candidates, and it is stark.

His two recent articles in May, The Health Care Divide, and Going Solo, deserve to be read in full, but here are excerpts (the emphasis is mine):

The Health Care Divide
by Ronald Brownstein, National Journal, Sat. May 17, 2008

Countless details separate John McCain's health care proposal from those of the Democratic presidential contenders. But the most significant difference is fundamental and philosophical. The two sides are offering divergent visions about the basic role of health insurance in the nation's social safety net. The fork in the road could not be starker.

The plans unveiled by Barack Obama and Hillary Rodham Clinton encourage the sharing of risk between the healthy and the sick, even at the cost of requiring the former to subsidize the latter. McCain's proposal would maximize individual choice in obtaining coverage, even at the cost of reducing risk-sharing. This contrast, which reflects the broader divide between the Democratic emphasis on community and the Republican focus on personal freedom, is the wellspring from which all of the major differences in the candidates' plans flow.

Confused press coverage and McCain's shift to other issues have obscured the magnitude of his proposal. But he may be pushing for greater changes than the Democrats in both the way Americans pay for health insurance and how they buy it--changes that have potentially profound implications for the pooling of risk...

America subsidizes employer-provided coverage this way partly because it is administratively efficient, but mostly because it promotes the pooling of risk. By putting young, healthy workers into the same risk pool as colleagues who are older or sicker, employer-based coverage supports cost-sharing...

McCain's plan could threaten these arrangements, although how much is uncertain. He would eliminate the tax "exclusion," so that health premiums paid by employers would count as taxable income for workers. But he would replace the current exclusion with a refundable tax credit of $2,500 for individuals and $5,000 for families...

But almost all analysts think that without the economic incentive that the exclusion provides, some employers would drop coverage. The great unknown is how many. Even employers who want to maintain coverage might find it increasingly difficult to do so...

These dynamics could prompt a modest shift from group coverage to individually based insurance--or a massive exodus...

There's been a lot of heat about the debate at the federal and state levels around the idea of an "individual mandate." What Brownstein points to is a far more central debate: group vs. individual coverage. Since people want coverage, the issue was not so much the individual mandate, but the individual market.

When Health Access and other groups evaluated a health reform proposal here in California, one of the key barometers we looked at was whether it increased or decreased the number of Californians subject to the individual insurance market, the least efficient, most expensive way to get coverage, where the consumer is alone, at the mercy of the big insurers.

Schwarzenegger's original health reform plan expanded group coverage, but also expanded the individual market, but with some important improvements (guaranteed issue, medical loss rations, etc.) While consumer advocates supported many of those insurance reforms (like the insurance standards in this year's SB1522), we still preferred the benefits of group coverage.

The negotiated plan, AB x1 1, got support in part because the modelling showed that it shrank the individual market, while also attempting to fix it for those who are left.

McCain's plan does the worst of both worlds--it shifts millions into the individual market, as he deregulates the market as the same time!

Going Solo
by Ronald Brownstein, National Journal, Sat. May 24, 2008

Today, most Americans receive health insurance through large organizations (either their employer or the government). Only a small number of them (about one in 11) buy it on their own in the individual insurance market.

Almost all experts agree that the health care proposal that presumptive GOP nominee John McCain recently announced would shift that balance--perhaps substantially--toward individually purchased coverage. McCain wants to replace the tax benefit for employer-provided coverage with a personal tax credit of $2,500 for individuals and $5,000 for families. That trade would cause some companies to drop coverage, driving an unpredictable number of their workers from employer-based insurance to individually based plans...

That raises an obvious question: Could the individual market handle the load? A wide variety of experts, including some in the insurance industry, say that the answer, at least for today, is no.

For starters, the administrative costs of individual policies are at least triple those of employer-based policies. That means a worker shifting from a group policy to an individual one receives significantly less coverage for the same price, notes Kenneth Thorpe, an Emory University health policy professor. And although group policies share risk between the young and old, the healthy and sick, the cost of individually based policies varies enormously, depending on the person's health. Most important, people with prior health problems often cannot get affordable coverage--if they can get any at all. "If you are a 60-year-old woman with multiple chronic diseases, forget it," Thorpe says. "There is nowhere for you to go in the individual market."

America's Health Insurance Plans, the industry's trade association, insists that the individual market works better than Thorpe and similar critics believe. But, tellingly, even AHIP is not arguing for more reliance on individually based insurance. "We haven't advocated that," says Karen Ignagni, the group's president. AHIP has endorsed a McCain-like tax credit for the uninsured, but it opposes eliminating the tax break for employer-based coverage.

McCain would respond to the problems in the individual market by massively deregulating the insurance industry, a step that he argues would promote productive competition. Each state currently sets minimum standards for the health insurance plans sold within its borders. McCain would override that state regulation by allowing health insurers to sell in every state any policy approved in any state. That would mean states could no longer require insurers to pay for specific medical procedures (such as mammograms) or establish coverage requirements (such as maximum deductibles) if any other state set a looser standard. The state that regulates least would set the rules.

...many experts argue that McCain would be courting disaster by deregulating the insurance industry just as his plan drove more people into the already turbulent individual market. That could produce massive premium increases and diminished (or no) coverage for people in poor health. Again, it is revealing that even AHIP has not endorsed nationwide insurance sales.

While McCain would deregulate the industry, Democratic contenders Barack Obama and Hillary Rodham Clinton would restructure it by imposing new national standards. Each Democrat would establish government-organized purchasing exchanges for individuals and small businesses, and would require insurers participating in them to sell to all applicants at comparable prices, regardless of their health. The Democratic plans would face their own political challenges, but none may be as daunting as McCain's task of convincing Americans that the health care system will work better for average families if there is less regulation of the insurance industry, not more.

With the primaries over, I hope the medica coverage really focused on this clear distinction between the two candidates. It's never been as clear, or as important.

Labels: Insurers, InTheNews, PresidentialCandidates, YearOfReform

posted by Anthony Wright | Permalink | 10:49 AM


 

Pretty soon, the insureable will be a pretty exclusive club

Wednesday, June 04, 2008

The NYT had an interesting story on Sunday about women, of childbearing age, who are denied coverage on the individual market because they had previously had a Caesarean section. The rationale is that these women would be likely to have another expensive C-section should they get pregnant again.

If that were truly the case, most of the women I know who have had children would not be able to get coverage on the individual market, which seems horribly unfair -- as the story, and my friends point out -- many women don't go into labor wanting to have a C-section.

"Insurers are adding insult to injury. Not only are women feeling pressure
to have Caesareans that they do not want and may not need, but they may also be
denied coverage for the surgery.''

So women: If you haven't already been excluded from coverage for a rash, prescription, infection or allergy, having a baby will do it to you.

Labels: GuaranteedIssue, Insurers, InTheNews

posted by Hanh Kim Quach | Permalink | 1:54 PM


 

When medical debt attacks...

If you want to know more about the financial consequences of being uninsured, read yesterday's Wall Street Journal article by Sara Rubenstein.

In a move that consumer groups say could increase pressure on people with unpaid medical bills, some hospitals are trying out a new tactic to recoup patients' debts: They're auctioning the debt online.

Hospitals have long relied on outside collection agencies to go after debtors. Under traditional arrangements, these agencies receive a percentage of any money they get from a debtor; the more they collect, the more they earn.

Now, some of the same collection agencies, as well as other firms that purchase debt outright, have begun participating as bidders in online auctions, in which they buy the debt or provide guaranteed payments to hospitals for access to the unpaid accounts. Some experts say this gives them more reason to aggressively pursue patients in arrears. Auctions can drive up the amount paid for debt, meaning a collector must recoup more money from patients to cover its initial investment and turn a profit. And the winning bidders often get to keep all the money they collect on the auctioned debt.

Health Access California has talked to lots of Californians with medical debt, as we worked to pass AB774(Chan), to prevent hospitals from overcharging the uninsured. Invariably, the experience of these patients in dealing with the bill was worse after the bill was referred to collections, and much worse after the debt was sold. That's why AB774 included a moratorium on patients being sent to collections. There are other existing consumer protections against aggressive collections practices, but is it enough?

Winning bidders may "have to work harder" to make a profit from auctioned debt, says Michael Klozotsky, an analyst at Kaulkin Ginsberg Co., a collections-industry strategic-advice company. "Working harder means sometimes using strategies that are more aggressive.

"Many of the auctions of hospital debt have been done through Web site ARxChange.com1 -- shorthand for "accounts receivable exchange" -- owned by TriCap Technology Group. Another site is medipent.com2, run by Medipent LLC. The auction-site owners, both small companies based in New York, say their systems create safeguards that protect patients from potential abuse. Collection firms are vetted for their tactics and approach to patient needs and concerns before they are allowed to participate in auctions, the site owners say. The site owners also try to ensure that collectors comply with hospital rules -- whether they must record phone calls, for instance, or get the hospital's permission before initiating a lawsuit against a patient. Hospitals have final say over who bids on their accounts, and, on ARxChange.com, don't necessarily award the contract to the highest bidder.

Consumer advocates say patients are less likely to successfully dispute bills or negotiate them downward if they are dealing with a third-party collector rather than a hospital directly. Collectors also are further removed from hospitals' financial-assistance policies."The hospital is an institution in the community, has a reputation, in many cases has a nonprofit mission to uphold," says Anthony Wright, executive director of the consumer-advocacy coalition Health Access California. "Once it goes to collections, that starts a process that can get a lot more antagonistic, a lot more aggressive, and a lot more damaging to a family's credit history and financial future."

The federal Fair Debt Collection Practices Act and some state laws govern how debt collectors can treat consumers. For instance, debt collectors aren't allowed to harass consumers or make false statements, including implying they will sue if they don't intend to do so. Consumer groups say calling the medical provider or your insurer could help clarify any confusion about what you owe. The hospital also could provide information about financial assistance or charity-care.

A hospital bill is typically the biggest bill a person gets in their entire life. The first goal is to prevent these situations from happening in the first place: to make sure people are covered, or have other financial options that can help pay the bill. But in any case, patients with medical debt should have basic consumer protections. We don't want people to not go to the hospital for fear of the bill, or those who come to collect it.

Labels: Hospitals, InTheNews, MedicalDebt

posted by Anthony Wright | Permalink | 10:59 AM


 

The new/renewed conversation on health reform...

Friday, May 23, 2008

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

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

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

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

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

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

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

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

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

Labels: InTheNews, OtherBlogs, Uninsured, YearOfReform

posted by Anthony Wright | Permalink | 12:11 PM


 

It's worse than what you read...

Thursday, May 15, 2008

The news coverage of the budget, if anything, has downplayed the impact of the budget on health care. Let me focus on what we consider is the biggest of the cuts newly announced yesterday, that would impact the most number of people.

The San Francisco Chronicle mentions that the Medi-Cal eligibility cut would mean that "40,000 poor working parents, who now receive comprehensive Medi-Cal coverage, would have their benefits reduced if they earn more than about $12,000 for a family of three."

Actually, these parents, who would make roughly $10,736-$17,600/year for a family of three, would lose access to Medi-Cal coverage. Some might be eligible for other programs, but many would simply become uninsured.

More to the point, the 39,000 people impacted in the first year is only the beginning. In a few years, after full implementation, the cut would deny coverage to 439,000 Californians.

The Los Angeles Times described it in this way, that the budget would "Deny thousands of impoverished parents healthcare coverage that they now have through the state's Medi-Cal program. Under the change, a single parent with one child who earns more than $8,540 a year would no longer be eligible." Tha was correct, but downplayed the massive scale of the cut--that the impact was eventually deny *hundreds of thousands* of Californians.

The Sacramento Bee has an article that doesn't go into the specific horror of the cuts.

The sidebar that describes the budget "highlights" doesn't even mention this cut to Medi-Cal eligibility--even though it is the health cut with the biggest impact in the May Revise. That sidebar does list some of the bad cuts, but also neglects to mention a major-dollar proposed cut from January, that would also eliminate key benefits, like dental, optometry, and podiatry, for millions of adults on coverage. It's unclear why some cuts were included and other, bigger cuts were not.

Let's hope that future coverage of the budget goes into the full implications of what is being proposed here. The cuts are bad enough that they don't need embellishment, but they do need coverage, so Californians can understand the stark choices, and how they would impact our fellow citizens and our health system.

Labels: Budget, InTheNews, Schwarzenegger

posted by Anthony Wright | Permalink | 10:19 AM


 

Monetary Melancholy

Monday, May 12, 2008

Gov. Arnold Schwarzenegger is expected to release his May revision of the budget on Wednesday. In January, we had a $14.5 billion hole. By all accounts, it's at least larger than $16 billion now -- and possibly approaching $20 billion.

That's bad news for all of us. (See a list of health services cuts Health Access is tracking here.) Marty Omoto at the California Disability Community Action Network does a good job of laying out what's at stake here.

And San Francisco Chronicle has a story today about the big bad picture. California Progress Report also has an analysis.

Labels: Budget, InTheNews

posted by Hanh Kim Quach | Permalink | 11:29 AM


 

Healthcare Armageddon

Tuesday, May 06, 2008

The New York Times had an excellent article this weekend about workers, who have health coverage through work, feeling financially strained.

The reason: businesses - unable to absorb higher health care costs - have decided that workers need to absorb more of these costs. Businesses are buying crappier coverage (this doesn't mean cheaper premiums, just cheaper than more comprehensive plans, but still expensive) and asking workers to pay a greater share of the premium. So not only are premiums for workers increasing, but the plans that they are getting are getting worse, which means higher copays, deductibles, and less coverage.

It used to be that worrying about how to pay for health care happened mostly if you didn't have insurance. Then, it started creeping into the ranks of the insured -- but only those who bought insurance on their own, without the benefit of a group buying in bulk to negotiate lower rates. Now, though, health cost worries are hitting the employer market -- where most Americans get their coverage.

One *insured* worker said he was losing the equivalent of a month's worth of pay with the higher premium and deductibles. That's in addition to the fact that the coverage isn't very good.

The Times characterized these plans as "health insurance in name only.'' I like that: essentially people are paying to be uninsured under these plans.

My health plan colleagues would argue that having some kind of coverage is better than being uninsured. No?

But is it really? At what point does debt become so crushing that it doesn't matter if the number is $60,000 or $200,000 in debt, and accruing interest. Especially considering that families that are insured, earning more than 300% of the poverty level actually have negative (-$600) net financial assets according to the latest study by Health Affairs. On an annual income of $60,000, either way, you're screwed.

Labels: Employers, InTheNews, MedicalDebt, Underinsurance

posted by Hanh Kim Quach | Permalink | 2:01 PM


 

Look who's moving to Canada

Monday, May 05, 2008

The Associated Press reports that the Canadian Auto Workers have signed a three-year contract with Ford. Chrysler is next.

High health care costs have been a primary source of angst for automakers, who two years ago made headlines by appealing to Washington for some kind of help. Since 2005, though, automakers' health care costs have declined by $2.1 billion. The United Auto Workers agreed to some changes, that resulted in increases costs for retirees and workers.

Salaried workers have seen premiums increase as much as 30%, out-of-pocket maximums increase by 33% to $4,000, and a tripling deductibles from $500 to $1,500.

All this -- and automakers are *still* moving to Canada.

Labels: International, InTheNews

posted by Hanh Kim Quach | Permalink | 6:01 AM


 

The stars aligning again...

Wednesday, April 30, 2008

All week, we've seen signs that while health reform stalled, the need and the urgency--and the opportunity--has not.

* We have had a Field Poll showing broad support for the proposed California legislation that did stall, and even the broad provisions that any major reform is going to need to do.

* A Kaiser Family Foundation poll showed health as a major election issue this year, outpacing many other pocketbook issues--and the startling factoid, picked up by Ricardo Alonso-Zaldivar of the LA Times, that 7% of Americans said they made a decision about marriage based on the need for health coverage.

* A Robert Wood Johnson study, as reported by Lisa Girion in the Los Angeles Times, that laid out the bare facts about the rise in health care costs and the decrease in the number of jobs that now come with health benefits. Yes, the worry that the polls found is based on real trends-- people are appropriately more concerned about the status quo than the needed reforms.

* The playing field is set, the public is there, and so are many of the politicians. Governor Schwarzenegger made a strong commitment to revisit health care reform in the remaining years in his term.

The editorial board of the San Jose Mercury News may have cracked even the cynics, with their opinion piece today:

By all appearances, Gov. Arnold Schwarzenegger's plan for health care reform died an ugly death on the floor of the Legislature in January.

But as Billy Crystal's Miracle Max cracked in "The Princess Bride": "There's a big difference between mostly dead and all dead. Mostly dead is slightly alive."

Besides a great movie reference, the Mercury News also provided another key element to a new possibility: the need to get legislation passsed this year, to set the stage for 2009. We appreciate their spotlight on the Health Access California-sponsored SB1522 (Steinberg), and there are other key bills that can provide real help for people and patients as soon as possible, and lay the foundation for further reform.

It's not too late to resurrect the governor's plan. And even though it might take a miracle to reform health care in California, it's worth a shot in 2009.

That doesn't mean the subject can be ignored this year. The Legislature has work to do now to set the stage.

Next year Karen Bass will be Assembly speaker, Darrell Steinberg will lead the Senate and someone other than George Bush will be in the White House. If public support for reform remains strong, the stars will be aligned for the governor to make another run at passing his comprehensive package.

According to a Field Poll released Monday, a whopping 72 percent of voters said they generally favor Schwarzenegger's plan. And the need for reform continues to grow. Some 6.6 million Californians, 19 percent, are uninsured, and that number is certain to increase as the economy worsens. A Kaiser Family Foundation poll released Monday showed that every 1 percent jump in U.S. unemployment would cause the number of uninsured to rise by 1.1 million nationwide.

Two bills before the Legislature may give an early indication of the prospects for reform in 2009.

The first, Steinberg's SB 1522, would set up what consumer advocates call an apples-to-apples comparison for individuals seeking private insurance coverage. It's sure to draw intense interest from insurance companies, and it will test the governor's willingness to collaborate across party lines.

The second, Sen. Sheila Kuehl's SB 1440, would require insurance companies to spend a minimum of 85 percent of premium dollars on health care expenses. That's a concept from the earlier reform package that insurance companies hoped was more than "mostly dead."

Calling Miracle Max.

With all this momentum, I don't think we need a miracle to get comprehensive health reform in 2009-10, just our work and commitment. It would help to have some movement, as the editorial points out, by putting some of the legislative building blocks in place.

Labels: InTheNews, Sacramento, Schwarzenegger, YearOfReform

posted by Anthony Wright | Permalink | 9:44 PM


 

High-risk health reform...

Tuesday, April 29, 2008

John McCain is getting beaten by a woman, and it's not Hillary Clinton. It's Elizabeth Edwards.

In unveiling his health care plan, McCain seems super-focused on the fact that many more people could be denied coverage because of "pre-existing conditions," as he seeks to shift people from employer-based coverage to the individual insurance market, with some assistance from a tax credit.

Elizabeth Edwards pointedly has challenged McCain, saying that an American with her or his health history would be denied under McCain's plan in the individual insurance market. (To be fair, the Los Angeles Times made this point earlier.) She's absolutely right.

And because of this, McCain has a liability. He even has a "myth and facts" section of his website designed to counter exactly one, and only one, myth:

"MYTH: Some Claim That Under John McCain's Plan, Those With Pre-Existing Conditions Would Be Denied Insurance.

FACT: John McCain Supported The Health Insurance Portability And Accountability Act In 1996 That Took The Important Step Of Providing Some Protection Against Exclusion Of Pre-Existing Conditions.

FACT: Nothing In John McCain's Plan Changes The Fact That If You Are Employed And Insured You Will Build Protection Against The Cost Of Any Pre-Existing Condition.

FACT: As President, John McCain Would Work With Governors To Find The Solutions Necessary To Ensure Those With Pre-Existing Conditions Are Able To Easily Access Care."

The multiple "facts" don't really the answer the charge. The "myth" is a factual statement. Where do those those with "pre-existing conditions" go under the McCain plan? Some will get left behind. In the new twist to the slim pickings already on his website, McCain would now have states figure out how to solve the issue of the "uninsurables." .The New York Times coverage by Michael Cooper and Kevin Sack focus on this aspect. Bob Laszewski from Health Care Policy and Marketplace Review thinks McCain has opened a major liability for himself.

I think the Democratic rivals made good responses but didn't quite capture the central critique of this plan in their responses.

* Some of what they say is a criticism of what is *not* in McCain's plan, which indicates it lacks a certain ambition, but doesn't really say why the proposal is still not an improvement from the status quo. (Frankly, it doesn't take much.)

* Clinton appropriately criticizes state high-risk pools (and her statement--"virtually all high-risk pools today have waiting lists, high premiums, and scaled-back benefits"--is a dead-on description for California's MRMIP, Managed Risk Medical Insurance Program, which now has a waiting list, is underfunded, has high premiums and a $75,000 benefit cap.)

* But in our current system, the state high-risk pools are an essential lifeline to coverage for many. The problem is not the high-risk pool itself, but the major people who are denied in the individual market, that the high-risk pool provides some comfort.

* The real issue is not the high-risk pools in the state as a solution, but that his plan seeeks to make the problem much bigger. The more he accomplishes his goal of moving people from group coverage (like that of their employer) to individual coverage, the more he creates the problem that he seeks to solve.

Here in California, Health Access California supports AB2 (Dymally) and other efforts to improve and better fund our high-risk pool, so more people, denied for pre-existing conditions, can at least get some coverage.

We were more pleased to support AB x1 1, the negotiated reform between the Governor and the Speaker, that included not only guaranteed issue--so no insurers could deny for health status--but it would expanded group coverage enough that there was a net decrease in the number of people having to get individual coverage.

This was important, because the individual market is fundamentally a place where the individual has little market power against the big insurers, as opposed to when they at least have the purchasing power of a group. McCain would place more people in the individual market.

So the criticism isn't that McCain relies on state-based high-risk pools, it's that he would increase the need for them in the first place.

Labels: Insurers, InTheNews, OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 11:42 PM


 

From the World Health Care Congress...

Wednesday, April 23, 2008

Just wanted to spotlight some of the blog posts and reports from the World Health Care Congress, now at the World Health Care Blog.

Joe Paduda of Managed Care Matters has an excellent report, especially his commentary on the presentations by the presidential campaigns, as well as other panels. ChangeNow4Health also has notes from that panel. Notes are also taken by jenmccabegorman and ajfortin on Twitter.

With the Pennsylvania primary just past us, Richard Eskow at the Sentinel Effect has more opinion about the presidential plans.

Here's my basic gist: the Clinton and Obama plans are very similar, and very good. There's an important difference about the individual mandate, but it's one of emphasis, rather than actual implementation. But both plans are far from what McCain has put on the table, which simply isn't serious, and would actually do harm.

Labels: InTheNews, OtherBlogs, PresidentialCandidates

posted by Anthony Wright | Permalink | 12:50 AM


 

Bigger budget blues...

Monday, April 21, 2008

This isn't like every other year.

That's the budget message: it's worse than normal, and basic state services like health, education, and public safety are at major risk without significant action.

The deficit projections have grown significantly in just the last couple of months, reports Matthew Yi of the San Francisco Chronicle. The article goes on to quote several legislative leaders, that suggest that it's nearly impossible to fix the problem with a "cuts only" budget--and such an approach would be devastating if tried.

Ed Mendel of the San Diego Union Tribune blog also quotes Senator Denise Ducheny, chair of the Senate Budget Committee, about how bad it is. She thinks that cuts are going to happen--and that new revenues are need just to prevent the most severe.

Clearly, the optimism is at a low point as we approach May Revise, when the Governor puts out the new version of the budget...

Labels: Budget, InTheNews

posted by Anthony Wright | Permalink | 10:45 PM


 

More on rescissions

Friday, April 18, 2008

I wanted to follow up on Anthony's post with some more details about what Gov. Schwarzenegger's administration has laid out as his goals, this year, to tackle the rescission problem.

A quick recap: The state ordered the immediate reinstatement of health coverage for 26 enrollees who had their health policies retroactively cancelled in the past four years by Kaiser, Blue Cross or Blue Shield. Thousands more policies of consumers insured by the three named insurers, Health Net and Pacificare, could also be reinstated after review by an independent arbiter. These retroactive cancellations typically occured after a consumer started using lots of expensive health services -- triggering a second and very, very close look at their application by insurers.

As the system is now, said Daniel Zingale, one of the governor's health policy advisors, "If you use it, you lose it,'' of health coverage. To change this, the governor is supporting the following guidelines and principles to protect consumers:

1) A clear application process, which could help prevent mistakes and omissions
2) If there is no evidence of "willful misrepresentation,'' a policy cannot be rescinded
3) Plans must give adequate notice to consumers about the fact that they are investigating their applications. There would also be an established appeals process for consumers.
4) A prohibition on bonuses, quotas and other incentives for insurance company employees to rescind.

Of course, Zingale pointed out -- and we wholeheartedly agree -- this would all be moot had we passed ABx1 1. With health reform, we would have:

• Guaranteed issue: everyone receives coverage, regardless of pre-existing conditions,
• Guaranteed that everyone was paying into the system so insurers didn't go nuts about NOT being able exclude the really sick and expensive people,
• And guaranteed affordable health coverage and/or subsidies to purchase health coverage for 4 million Californians.

In the absence of that, though, this is a great place to focus reforms that would begin to help consumers feel more secure about the coverage they have.

Labels: BlueCross, Insurers, InTheNews, Rescissions, Sacramento

posted by Hanh Kim Quach | Permalink | 1:18 PM


 

Drug cost-sharing and other wonkery...

Thursday, April 17, 2008

Maggie Mahar and Niko Karvounis at Health Beat host this week's Health Wonk Review. In addition to a better-than-the-original summary of