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


 

Where does our money go?

Friday, June 27, 2008

The most exciting thing this week (other than Health Access' report release) was the release of the California Medical Association's annual "Knox-Keene Health Plan Expenditures Report,'' which replaces my old dog-eared copy from a couple years ago.

The report gathers data reported by health plans to the Department of Managed Health Care to show which ones spend the most on medical services for their enrollees (and which ones spend the most on administration and profit). This is called the "Medical Loss Ratio,'' you know, because plans ''lose'' money when they spend it on health care for you. The percentage of premium dollars spent on patient care is an important (though not the only) measure of a plan’s value.

Sadly, there is not similar data publicly available for PPOs, which are regulated -- more loosely -- by the Department of Insurance. Not having the data on the Department of Insurance side creates a huge hole for advocates, because 40 percent of insured Californians now buy the less robust insurance products regulated by the Department of Insurance. These plans are required to spend 70% of revenues on patient care and are among the worst offenders on the market. Low-value products are marketed to consumers for their low premiums. Patients do not have the actuarial expertise, or information to assess whether a particular low-premium product will actually provide them value – meaning it would pay for physician visits, drugs and other health costs when they need it. Products that have low medical-loss ratios often do not have maternity coverage, do not cover prescription drugs, have high deductibles, high co-insurance, and lack caps on how much consumers need to spend out-of-pocket for their illnesses. Such flimsy coverage causes consumers to defer care, or leaves them saddled with medical debt. Low-value health plans have dedicated as little as 51 cents of every premium dollar toward on what patients need. Meanwhile insurers spend 49 cents of every dollar consumers pay against consumers -- fighting bills for patient services, scouring health records in order to retroactively rescind policies, and other administrative costs—or to the profit of the insurer.

CMA is the sponsor of SB 1440 (Kuehl), which Health Access also supports. The bill would require health plans spend 85 percent of revenues on patient care (also called Medical Loss Ratios -- 'cause to insurers, they ''lose'' money when they have to spend it on you.) That is different from the current law, which only caps administrative costs at 15 percent (which means profits layered on top of that eat into the amount spent on patient care.) A nice feature of the latest version of this bill is that it will require plans to report the Medical Loss Ratio by product, rather than averaging them across the insurer's entire book of business, allowing the really awful products to be lumped in and hide behind better ones.

Okay, on to the report.

For-profit plans that spent the least on patient care in 2007:

1. Great-West Healthcare of California: 69.4% patient care; 11.5% admin; 11.3% profit
2. Blue Cross: 79% patient care; 11.1% admin; 6.1% profit
3. Aetna: 81.4% patient care; 8.7% admin; 6.3% profit
4. Molina Helathcare of California: 84.2% patient care; 15.5% admin; 0.2% profit

Non-profit plans that spent the most on patient care (not including public health plans)

1. Scripps Clinic Health Plan Services: 95.3% patient care: 4.5% admin; 0.1% income
2. Partnership Health Plan: 94% patient care; 6.1% admin; -0.4% income
3. Western Health Advantage: 90.8% patient care; 8.7% admin; 0.6% income
4. Kaiser Foundation Health Plan: 90.6% patient care; 3.6% admin; 5.8% income

Labels: Insurers, Kuehl, Legislation, Research

posted by Hanh Kim Quach | Permalink | 4:24 PM


 

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

Wednesday, June 25, 2008

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

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

HEALTH ACCESS UPDATE
Thursday, June 26th, 2008


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

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

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

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

The report is available on the front page of the Health Access California website, and directly at:
http://www.health-access.org/preserving/Docs/HACoverageImpactReporto6-25Final.pdf

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

Previous summaries of the Governor’s budget proposals, including the May Revision, show the impact of the cuts in only the first year – with tens of thousands losing coverage or being barred from enrollment. But the impact is much greater, in three ways:

• The Governor’s budget is not proposing one-time budget savings, but lasting policy changes and coverage reductions for the health care system.
• A snapshot of the savings in the budget year does not reveal the full impact in the following years, once the reductions have been enacted and all the administrative changes have occurred to continue the reductions.
• Finally, the cumulative impact of all the proposed cuts, when added up together, suggests that the magnitude of the cuts—with more than a million more uninsured—will have impacts not just on specific programs but on the entire health care system on which we all rely.
  

The permanent policy changes reflected in the budget will be in place long after the 2008-09 budget year comes and goes. Of note, these policy changes are contrary to health reform proposals the governor previously put forward.

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

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

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

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

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

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

Labels: Budget, MediCal, Research, SCHIPHealthyFamilies, Uninsured, Updates

posted by Anthony Wright | Permalink | 6:57 PM


 

Evidence for Reform

Thursday, June 12, 2008

A national report released today confirms what many health advocates already knew: California's individual health insurance market is a big mess.

The individual market is where consumers to go buy health insurance if you don't get it at work (where you have a group going in to buy coverage together and spreading out the risks) or through public programs.

California's feeble -- or lack -- of protections leaves consumers extremely exposed. Here's how we fared:

• Requiring insurers to sell coverage to all applicants (also called guaranteed issue): No Credit.
• Requiring affordable coverage alternatives for uninsureables -- people with pre-existing conditions: Partial Credit. (California has the Managed Risk Medical Insurance Program, which allows this population to buy coverage at above-market rates. Without this program, these consumers would be denied coverage. MRMIP, however, is unable to accommodate all who need coverage. They do not advertise, yet have 8,101 enrollees and 339 applicants on a waiting list.)
• Prohibiting higher premiums based on health status: No Credit.
• Requiring advanced review of proposed premium rates: No Credit.
• Requiring insurers to spend at least 75% of premiums on health care: No Credit. (Actually, HMOs in California are required to spend at least 85% of premiums on health care. PPOs, which are regulated by a different department, are required to spend 70% of premiums on health care, though some insurance products spend as little as 51% on health care)
• Limiting how long coverage can exclude pre-existing conditions: Partial Credit.
• Limiting look-back period: Partial Credit
• Using objective standard to define pre-existing conditions: Full Credit (the first!)
• Requiring medical underwriting to be completed during application: Full Credit (We're not completely convinced this is the case -- otherwise, why the need for some insurers to rescind insurance later?)
• Reviewing insurers' requests to revoke coverage: No Credit (The Department of Managed Health Care Services has restored coverage to more than 1,000 patients and is in the process of reviewing more than 5,000 cases where patients have had their insurance revoked since 2004. )
• Accepting appeals when coverage is revoked: Full Credit
• Reviewing denials for all state-licened carriers: Full Credit
• Making external reviewer decisions binding: Full Credit
• Offering free external reviews regardless of claim size: Full Credit

Pretty sad. But there's hope! Fortunately, we're actually trying to do something about our abysmal performance.

• SB 1522 (Steinberg) INSURANCE MARKET STANDARDS & PREVENTING "JUNK" INSURANCE. The bill would set a minimum benefit standard for coverage, and weed out "junk" insurance that still leaves people exposed to bankruptcy. It would require coverage to have an overall cap on out-of-pocket costs, and cover doctor, hospital, and preventative care. It would sort health insurance policies into five coverage categories, ranging from “comprehensive’’ to “catastrophic.’’ Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing, and assist consumers in making apples-to-apples comparisons between plans.
• SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT. It would set a minimum medical loss ratio – requiring every insurer to spend at least 85 percent of premiums on patient care.
• AB 1945 (De La Torre) INDEPENDENT REVIEW OF RESCISSIONS. It would require health plans to seek approval by an independent review panel under the Department of Managed Health Care or Department of Insurance for each individual rescission. It would also standard the process and questions used in any underwriting. Also up in the Assembly is AB 2549 (Hayashi) that would impose a six-month time limit in which insurers have to rescind individual health care policies once consumers’ applications are approved.

Labels: GuaranteedIssue, Insurers, Legislation, Rescissions, Research, YearOfReform

posted by Hanh Kim Quach | Permalink | 11:49 AM


 

Field Poll: strong opposition to the health cuts...

Tuesday, June 10, 2008

The coverage of today's Field Poll is broadly about the budget, but has lots of specific information on health care.

On the broad take, it's clear that the voters' top two priorities in the budget are education ("the public schools") and health care, with 80% and 77% of the public opposing to making cuts in these areas. The budget reflects the will of the voters: around half of the budget is education, and a third is health and human services.

The terrifically high support for health care could actually be an underestimate, given the question (about making cuts to "health care programs for low-income Californians and the disabled.") It's true that Medi-Cal, the main health program, serves 6.5 million low-income children, parents, seniors, and people with disabilities. It's also true that Medi-Cal is an essential funding base for the entire health care system on which we all rely.

The poll in fact did ask about specific health areas: here are the proportions reporting being very or somewhat concerned about each of the five health program areas measured.
• hospital emergency rooms and trauma centers (86%)
• health care programs for low income Californians and the disabled, like Medi-Cal (80%)
• staffing for nursing homes (76%)
• immunizations and prenatal care (72%)
• public health and bio-terrorism preparedness (60%)

The public is clear about rejecting these health care cuts. The polls also tests a range of taxes to prevent those cuts, with some getting majority support, and some not. It's up to our elected leaders to figure out exactly the mix of revenues to prevent these cuts. But that's the job of our leaders now.

Labels: Budget, MediCal, Research

posted by Anthony Wright | Permalink | 11:52 AM


 

An Unhealthy Trend

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

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

Among the findings:

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

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

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

Labels: Research, Underinsurance, Uninsured

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


 

Dressing up the Individual (Market)

Monday, June 09, 2008

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

Among the findings:

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

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

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

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

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

Labels: Affordability, Insurers, Research, Uninsured, YearOfReform

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


 

Rebuilding our muscle

Thursday, May 08, 2008

American manufacturers pay more than twice as much per hour for health benefits as the manufacturers in countries we regularly trade with, according to a new report by the New America Foundation that found for every $2.38 an hour paid for benefits by US manufacturers, others pay about $0.96. It's a losing proposition all around that:

1. Makes our products more expensive -- read: less competitive. (ie. an American-made car costs $1,500 more due to health costs versus $900 more by foreign competitors.
   
2. Results in American businesses trying to ratchet down what they pay in health care costs, and resulting in crappier coverage for their workers. (for more money, I might add)


3. Results in jobs going overseas -- like Ford going to Canada as reported earlier this week.
   

The report runs through a litany of interesting stats, including:

• In 1960, health benefits were only 1.2% of payroll. Now, it's more like 9.9% (averaged across all businesses, including those that *don't* provide coverage).


• Since 2000, fewer employers are offering coverage (from 69% to 60%). But for workers that *do* get coverage on the job, it's costing more -- 102% more (from $135 to $273 monthly premium).

It also acknowledges that not all costs can be shifted to workers, either in higher premiums and out-of-pocket costs or lost wages, because it would affect a business' ability to be competitive in hiring good quality employees -- something all businesses must grapple with in order to stay competitive. And that the cost of health care can't depress wages -- particularly for those already making minimum wage ($5.85 or $8 in CA), or in cases where a labor contract acts as a backstop.

Labels: Employers, International, Research

posted by Hanh Kim Quach | Permalink | 2:24 PM


 

A cuts-only budget harm knows no party...

Monday, May 05, 2008

The California Budget Project has an excellent resource on its website, showing the local impact of proposed budget cuts by county and by legislative district.

The county numbers are interesting, but you need to know the context of how big/small the counties are to begin with. (Alpine County has only 160 Medi-Cal recipients, and 2 children on Healthy Families; Los Angeles has 2.2 million on Medi-Cal, 250,000 kids on Healthy Families).

The legislative districts numbers are interesting because they are more comparable, having similar (although not the same) numbers in each district.

TOP FIVE DISTRICTS IMPACTED BY MEDI-CAL RATE CUTS: Five Senators have more than a quarter of a million constituents on Medi-Cal coverage--largely children, parents, seniors, and people with disabilities--who would lose access to key doctors and hospitals as a result of the proposed Medi-Cal provider rate cuts already adopted. These Senators would have hospitals and doctors in their districts lose over $50 million dollars in Medi-Cal funds.

These five (of 40 total) Senators are:
1) Florez (D-Fresno/Bakersfield): 306,820 on Medi-Cal; $62 million lost funding
2) Vincent (D-Los Angeles): 290, 260 on Medi-Cal; $59 million lost funding
3) Cedillo (D-Los Angeles): 278,180 on Medi-Cal; $56 million lost funding
4) Cogdill (R-Fresno/Ripon): 270,320 on Medi-Cal; $55 million lost funding
5) Ashburn (R-Bakersfield): 253,190 on Medi-Cal; $51 million lost funding

What's interesting about the list is the diversity. We have some districts from inner-city Los Angeles, but also the rural areas of the Central Valley. These districts are represented by Latino, African-American, and white legislators. And they are three Democrats and two Republicans: these budget cuts impact Republican and Democratic areas alike.

While California Republican legislators insist on a cuts-only budget, there are certainly many whose communities will be severely hurt by such a resolution to this budget crisis.

Republican Senators Denham and Runner also have lots of impacted constituents, with over 200,000 people on Medi-Cal in their districts. Of the eighteen (out of 80) Assemblymembers with more than 110,000 constituents with Medi-Cal coverage, eight are Republicans, including La Malfa, Aghazarian, Villines, Fuller, Maze, Runner, Adams, and Garcia.

TOP TEN DISTRICTS ON CHILDREN LOSING COVERAGE: So, as a result of the proposal to increase paperwork and administration burdens on Medi-Cal, here would be the top ten legislative districts that have the biggest number of children fall off coverage by 2010 and become uninsured: Florez (14,420); Vincent (14, 300); Cedillo (14,150); Calderon (11,760); Romero (11, 640); Cogdill (11,570); Ridley-Thomas (10,820); Ashburn (10,510); Padilla (10,490); Correa: (10,280). Again, a diverse crew in region, ethnicity, party, and ideology.

Unlike the other 3/4 of the Senate, these legislators each have over 10,000 children losing coverage as a result of the so-called "quarterly status reports." Sens. Denham and Battin also have high number of impacted children as well; in the Assembly, the list includes Berryhill, Aghazarian, Villines, Maze, Runner, and Garcia, who would have over 2,500 children lose coverage.

MAY REVISE AND BUDGET NEGOTIATIONS APPROACH. The California Budget Project has similar numbers for education, child care, and other programs. I haven't looked closely at those reports, but I imagine that my takeaway would still hold:

The budget crisis knows no bounds. Californians in both "red" and "blue" areas will get hit in a big way, whether cuts to schools, to child care, or to health care--where thousands and thousands of children and adults will have reduced access to doctors and hospitals, if not lose coverage altogether.

We need to come together to find an alternative to a cuts-only budget that would force such cuts.

Labels: Budget, MediCal, Research

posted by Anthony Wright | Permalink | 3:50 PM


 

Who are these made for anyway?

Friday, May 02, 2008

Health Affairs has just released an excellent new study, which challenges the notion that high-deductible health plans with their low premiums are offering the otherwise a good alternative to going uninsured. Based on this research, and an updated report from the Government Accountability Office tells us who does benefit from these plans.



The Health Affairs study just confirms what advocates have been saying -- and debunks what insurance companies argue: high deductible plans are not a sound choice for families who are uninsured. One medical emergency would leave these families vulnerable to tens of thousands in medical debt, if not bankruptcy.

UPDATE: Check out Health Access' earlier report on "Thin Protections," also showing how high deductible plans provide little comfort for middle-income families that are often asset-poor.

Among the Health Affairs report's findings:

• Only 21% of households with one uninsured person could cover a $1,000, along with their other obligations.
• No more than 9 percent of households with one uninsured person could meet the out-of-pocket maximum of $5,000.

Also interesting:

$300: Uninsured families earning less than 300% of poverty ($63,600 for a family of four) had an average of $300 (!) in liquid financial assets. Incidentally, this is pretty much all they have too.

Higher income assets thin: Even for those families, who were uninsured, earning more than $63,600 -- assets were pretty scant. Gross financial assets -- which include stocks and mutual funds -- totalled $3,600 for these families. Families WITH insurance had more than four times that amount: $16,420.

So who are these high deductible plans for anyway? Well, a new GAO report tells us that:

The Government Accountability Office just updated their 2006 report on Health Savings Accounts, which can only be opened with a qualifying high-deductible health plan.

First -- only about half of the 4.5 million HSA-eligible plan enrollees opened an HSA.

And -- those who opened them have more money. The average income for the enrollees of these plans was $57,000. For those who opened an account, though, the average income was $139,000 -- more than twice as much.

I'm hoping some insurer folks or defenders of high-deductible plans can explain, again, why they still believe in light of this research that these plans are a good idea for the uninsured.

email me: hquach@health-access.org

Labels: Insurers, Research, Underinsurance

posted by Hanh Kim Quach | Permalink | 2:31 PM


 

Continued urgency... and a new window...

Monday, April 28, 2008

The new Field Poll out today shows continued urgency for health reform, including increased worries about the current health system, and increased support for the expansion of group coverage, including both the proposal negotiated by Gov. Schwarzenegger and Speaker Nunez, and even a single-payer model.

There's coverage by Bill Ainsworth in the San Diego Union-Tribune where I give my take, as well as by Matthew Yi in the San Francisco Chronicle and Joe Rodriguez in the San Jose Mercury News.

The actual text of the Field Poll is here. There's a lot to chew on.

What's clear: Even though health reform stalled earlier this year, the need and urgency and momentum for reform has not. Californians continue to strongly support broad health reform, especially to expand group coverage, whether through public programs, purchasing pools, or employer-based benefits.

* 72% supported the package negotiated by Governor Schwarzenegger and Speaker Nunez (AB x1 1)--and there is even greater support for specific elements of the proposal, including a minimum employer contribution (73%, 77%), public program expansions (77%), and guaranteed issue requirements on insurers (84%).
* On a broader sense, Californians believe they are better off in group coverage, either through an employer (38%), or government (31%), than a model where they have "personal responsibility for getting your own coverage" (20%)--the focus of moving people to the individual market, which is what President Bush has proposed.

This isn't 1994, when the failure of the Clinton reform effort was caused after the public was scared away from changes in the health system, and soured on reform in general. In fact, the poll suggests that people are understandably concerned and angry about the status quo in health care.

This strong public support creates a new window of opportunity in the 2009-10 legislative session at both the state and federal levels. We have the opportunity this year to pass some key reforms and shore up our budget, so that we are ready to roll starting next year, with a new President on down.

Labels: Research, Schwarzenegger, YearOfReform

posted by Anthony Wright | Permalink | 10:19 AM


 

Find the solutions, not blaming the victim...

Tuesday, April 15, 2008

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Labels: ExpandingCoverage, Hospitals, Research, TimelyAccess, Uninsured

posted by Anthony Wright | Permalink | 10:45 PM


 

Dying for Coverage

Thursday, April 03, 2008

California likes to be first at everything. Unfortunately, according to a new series of state-by-state reports by Families USA, we're also first when it comes to deaths due to uninsurance. You can find this sinister stat at Dying for Coverage in California.

They show that:

• Every day, more than eight Californias die due to lack of coverage;
• In 2006, 3,100 uninsured Californians died;
• Between 2000 and 2006, 19,900 uninsured Californians died.

Other macabre findings include the fact that twice as many people died because they were uninsured than died from homicide. The study augments an early report by the Institute of Medicine, which found 18,000 Americans die annually because of uninsurance.

Why do people die for lack of insurance? Let's see -- in a generic nutshell: They're afraid to go to the doctor because it will cost money. They don't get the proper tests done to make sure they don't have cancer or chronic disease. They don't get the proper prescriptions filled for asthma or diabetes. They get sicker. They feel awful, but are too afraid to seek help because of the cost...then it's too late.

So what to do about this?

Well -- first, we wait about 10 months, according to U.S. Representative Pete Stark of California on a conference call releasing the report this morning. Specifically, we wait 291 days give or take a few hours and minutes to be exact for the departure of our sitting president, who Stark says is the “one individual in the U.S. who has done more to disadvantage people …particularly those with low incomes.’’ Specifically, with respect to regulations on who can qualify for Medicaid (Medi-Cal), expansions of children’s insurance, government negotiation for prescription drugs – you name it.

Next, we laud the seating of either (in no particular order) him or her. And then we see if the federal goverment stops being a hindrance to state efforts to provide universal coverage to children and expanded access to low-income families and adults. We'll have issues with him and particularly his health plan, which would atomize the health insurance market and to essentially raise taxes -- against his promise to do such -- for every American who receives coverage through work.

Then, we get back to work.

Labels: PresidentialCandidates, Research, Uninsured

posted by Hanh Kim Quach | Permalink | 11:05 AM


 

Coverage matters...

Wednesday, April 02, 2008

There are real health consequences to being uninsured.

Because it's in the Metro Section, this article by Steven Magagnini of the Sacramento Bee might be overlooked, but it shouldn't be.

It makes the point by focusing on the death of Melelea Tausinga, a leader in Sacramento's Tongan community, who was uninsured and didn't get the care she needed.

"People who do not have health insurance delay much needed medical care, are more likely to forgo care because of costs, and when they do finally show up for care the conditions they have are often far more severe," James said. "They are more likely to show up with late stage cancer."

That's what happened to Tausinga, said her husband, Tevita Tausinga...

Melelea Tausinga, mother of four and grandmother of seven, not only gave herself to her community, she worked for more than 10 years as motel maid, then as teaching assistant at Susan B. Anthony Elementary, where her granddaughters attend. Neither job provided health insurance.

She kept working even after she started complaining five years ago about severe pain. "She told me to touch her stomach," her husband said.

"It was something like a stone but it was little. The main thing is, we didn't have money. She finally went to a doctor last May after we got Medi-Cal."

The doctor told her she had a cancerous tumor, but it took three months before her daughter-in-law Brianna Tausinga lined up a surgeon who would take Medi-Cal.
"They pretty much said we caught it too late," said Brianna Tausinga

The article further talks of the lack of health coverage in California's growing Asian-American community, referring to a new report by the Kaiser Family Foundation and the Asian Pacific Islander American Health Forum, an important ally and Health Access California board member.

The issue of uninsurance is acute for Latinos and Asian-Americans--but it's a big issue for all of us.

Labels: InTheNews, Research, Uninsured

posted by Anthony Wright | Permalink | 10:57 PM


 

Drug pushing...

Tuesday, April 01, 2008

CALPIRG Health Care Advocate Mike Russo (also a Health Access California board member) makes the case for AB2821 (Feuer) in the California Progress Report, and will later today as well at the Assembly Health Committee.

The bill would place a hard cap of $250 of "gifts" to doctors from drug companies, and require better public disclosure of the pharmaceutical companies' marketing practices. These are real cost drivers in our health care system--not only the cost of marketing, but the encouragement to move patients to the most profitable and most expensive drugs, even when more tried-and-true remedies are as effective, if not more so. For everyone who raises the issue of cost containment, this is a simple but important step.

This is part of an ongoing effort by many groups, an "OuRx Coalition," to get a handle on prescription drug costs--such as getting California to use its purchasing power to bargain down the costs of medicines for the uninsured and underinsured, with AB2911(Nunez/Perata) a couple of years ago.

Another consumer-backed bill of a few years ago, SB1765(Sher), had the drug companies create and publish their own guidelines for their marketing practices. A new CALPIRG analysis, "Playing By Their Own Rules," suggests that:
* Drug companies fail to count some meals and other payments as “gifts,” and therefore not subject to the limit;
* Some companies reserve the right to exceed their limits if they so choose;
* Others assert that they are following a limit, but do not disclose what that limit actually is, while a few fail even to post their policies at all.

Clearly, there's a prescription for some stronger oversight.

Labels: Drugs, Legislation, Research

posted by Anthony Wright | Permalink | 10:08 AM


 

New Paper. Old Problem.

Wednesday, February 06, 2008

Health Affairs has a new report this week about how hospitals recover a higher percentage of their charges from uninsured patients than those on Medicare.
On average, the prices uninsured patients paid in California, from 2004-05, were 20% more than Medicare.

Of course, advocates have tried to deal with this issue in past years -- in 2005 securing a signature on AB774 (Chan), which, among other goals, essentially bans overcharging of the uninsured and ties their rates to Medicare.

It will be interesting to see an update on this study looking at rates after the law's implementation in 2006. We're getting mixed reports from the field about whether hospitals are properly advising uninsured (and underinsured) patients of their rights to apply for discounted rates, and whether information about the policies are properly posted. We also have no idea if patients are getting the reduced rates.

In the meantime, also because of AB774, the Office of Statewide Health Planning and Development (yes, it's a mouthful) has launched its own website on hospital fair pricing. (and yes, we know the URL is really awful and makes no sense) that allows consumers to search hospital discount policies in their area.

Labels: InTheNews, Research, Underinsurance, Uninsured

posted by Hanh Kim Quach | Permalink | 3:30 PM


 

Hot off the Presses -- For the Nerdiest in Nerdland

Tuesday, January 22, 2008

Exciting news. The Federal Register today released its 2008 Poverty Level Guidelines. For most people, this means nothing. But for those who work with/around public programs, these numbers dictate who's in and who's out for Medicaid, SCHIP, food stamps, and other public programs.

Find them here: http://aspe.hhs.gov/poverty/08poverty.shtml

Also, Health Access likes to do a spreadsheet that shows annual and monthly income at different levels, which you can find here.

Our lobbyist Beth Capell likes to carry a miniature version in her wallet for quick reference, and has trained me to do the same.

Labels: Research, Sacramento

posted by Hanh Kim Quach | Permalink | 3:21 PM


 

Payroll Impact Report finalized

Thursday, January 17, 2008

The UC Berkeley Labor Center has finalized its report on the impact of ABx1 1 on payroll costs, which I wrote about earlier this week. Their report can be found here.

Another report, analyzing the impact of ABx1 1 on total operational costs will be forthcoming.

Labels: Legislation, Research

posted by Hanh Kim Quach | Permalink | 5:40 PM


 

Business impact of ABx1 1

Wednesday, January 16, 2008

Republicans have been caterwauling for more than a year about the inclusion of an employer mandate in health reform plans.

They call attempts to level the playing field between employers who provide coverage and those who don't a "tax'' that will crush businesses and cause an exodus of industry from the state.

UC Berkeley Labor Center is working on an analysis on the impact of ABx1 1 on business -- an update of an earlier analysis on various health proposals on business. They have shared a preliminary analysis, however, that shows the impact of ABx1 1 on payroll costs. You can find their preliminary analysis here.

Interesting findings:

• Nearly half of all businesses (47.3%) will not have to pay anything more, having already met or exceeded ABx1 1 health care spending requirements.
• Only 1.7% of businesses in all of California will bear an increase in costs (between 4% and 6.5%)

To the idea that small businesses, in particular will suffer:

• 90% of very small firms (between 3-9 employees) will have their health care costs increased by less than 1%.
• Nearly 70% of small firms (between 10-99 workers) will have their health care costs increased less than 1%.

Labels: Employers, Research, YearOfReform

posted by Hanh Kim Quach | Permalink | 10:52 AM


 

More than you think...

Thursday, September 20, 2007

How many people are uninsured? The answer depends on the question. Typically, the established Census number for California is around 6.5 million. That's what came a few weeks ago

There's also the California Health Interview Survey from UCLA: they have a similar number for those who are uninsured at some point in a given year. The modelers, however, use a different number from that data: 5 million, or the number who are uninsured at any given time.

But how many people experience uninsurance over the course of two years? In fact, it's a much bigger number. As my colleague Hanh indicates, Families USA and the Lewin Group put out a report today, using Census data, that shows that nearly 13 million Californians had a gap in coverage over the past two years.

The highlights:
* 40.5% of Non-Elderly Californians Were Uninsured During 2006-2007
* 12,987,000 Californians Were Uninsured At Some Point Over the Past Two Years
* Two-Thirds (65%)-8,557,000--Were Uninsured for Six Months or More

This study is unique in that it quantifies the people who experience uninsurance over two years, rather than one year, or at a single point in time. In this way, it shows how our current health system leaves many more people at risk than is commonly assumed--and that there is potentially a bigger base for reform.

This study shows why even people with coverage are concerned it is not going to be there for them when they need it. That's why expanding health coverage is so important: Many of the reforms on the table here in California would reduce these gaps, and provide more security, by expanding group coverage, and reforming the individual market.

Labels: Research, Uninsured, YearOfReform

posted by Anthony Wright | Permalink | 11:25 AM


 

Drawing the right conclusions...

Thursday, July 19, 2007

I've been looking at the new Health Research and Educational Trust paper released this week, authored by Susan Marquis and others at RAND. The big headline, which got USA Today's attention, is that even reducing premiums for health care by 50% would reduce the uninsured by merely 3%.

Some tried to make this study about the need for an individual mandate, but I don't see anything here that suggests that. I didn't see anything in the paper that suggested that the reason people are uninsured is that they don't want coverage, and other research disputes that notion. As I read the result, a tax credit simply doesn't go far enough for the vast majority of the uninsured: it's a 50-foot rope for someone in a 100-foot hole.

Instead, the vast majority of the dollars from a tax cut or credit to those who are more affluent, including those with insurance.

What can we learn from the study? Funded by the California HealthCare Foundation, this survey of uninsured California families, is a complete and utter smackdown of President Bush and other Republican proposals that suggest that all the uninsured need is a good tax cut. Other studies, even those by business and industry groups, show that such tax credits are far less efficient than expanding public programs and other strategies for health reform.

What the study also does is indicate how people reject plans with high deductibles and other cost sharing. Even when the high deductible plans offers significantly lower premiums, they'd rather go for the higher premium, lower-deductible policies. They don't see the value in the high-deductible plans: What's the point of having health coverage that doesn't provide much coverage?

If anything, the study suggests serious issues with the Governor's proposal, which depends on these high deductible plans, since it requires individuals who aren't eligible for employer-based coverage or public programs to buy coverage in the individual market. For many of these middle-income folks who would be impacted, the only thing they would be able to afford to buy is the minimum coverage of a $5,000 deductible plan. As a result, the plan would force people to get a health care product that many don't find meaningful. For this reason, any affordability standard needs to include both premium and out-of-pocket costs.

Labels: Bush, IndividualMandate, InTheNews, Research, Underinsurance

posted by Anthony Wright | Permalink | 11:19 PM


 

Taking the challenge on high deductibles...

Friday, June 29, 2007

We've gotten good response from our discussion paper about high deductibles... The omnipresent Don McCanne cites it as his Quote of the Day, for example.

The paper was an honest response to a question by Governor Schwarzenegger and others, which is "Isn't a high deductible policy better than nothing?"

For some people, yes, especially if they have significant asset