"The choice is clear..."

Tuesday, July 01, 2008

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


 

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


 

This year's health reforms...

Tuesday, June 03, 2008

Health reform is alive and well, reports Jordan Rau at the Los Angeles Times.

More than a dozen health bills are advancing through the Legislature, many over the objection of insurers. Some of the proposals were transplanted from the plan that passed the Assembly last year, only to be rejected in the state Senate in January. Other measures are newly devised by the Democrats who control the Legislature.

The bills would require insurers to spend at least 85% of their earnings on patient care; block insurers from canceling policies of patients who need extensive care; and force them to cover more procedures, such as maternity services. Over the
objections of the major doctor and hospital lobbies, the Assembly approved a measure backed by Schwarzenegger that would require medical providers to publicly reveal their costs and medical performance.

In a sign that a desire for piecemeal healthcare changes is strong this election year, some of the Democrats' bills even have picked up votes among Republicans who did not support Schwarzenegger's package.

Many of these are good bills, and would be considered big deals in any other year, if it wasn't in comparison to the huge, comprehensive effort of AB x1 1. But it is important to recognize that they aren't just small pieces: some of the legislative proposals form a foundation for future reforms:

Daniel Zingale, a senior advisor to Schwarzenegger, said the governor favors many of the ideas, if not the exact language, in the bills and plans to add others into the mix in a few weeks. "This year, the first floor of healthcare reform will be built, and it will make current coverage more secure, control costs, promote prevention and end the worst anti-consumer practices by HMOs," Zingale said.

Many of the bills would affect the insurance market for individuals who buy coverage themselves rather than through employers -- now more than 2 million Californians. It is a more lucrative niche for insurers than selling policies through employers because insurers have more leeway to set the terms of individual policies and face fewer regulations about what medical procedures must be covered and which customers must be accepted.

The Senate passed a proposal by the incoming president pro tem, Darrell Steinberg(D-Sacramento), that would make it easier for individual customers to compare competing plans. The bill also would limit maximum out-of-pocket costs for those individuals and force insurers to offer a whole range of policies if they want to do business in the state.

That bill, SB1522(Steinberg), sponsored by Health Access California, is an example of a bill that if implemented, creates a much sounder floor from which to build reform.

Most of note, the article indicates that this agenda to placing greater oversight over the insurance industry is getting bi-partisan support.

Opposition from insurers, however, is not dissuading Republicans -- a traditional ally of the industry -- from supporting some new restrictions. On Thursday, 12 of 32 Assembly Republicans joined Democrats to require insurers to obtain approval from state regulators before canceling coverage for people who have become ill and submitted medical bills. That bill, by Assemblyman Hector De La Torre (D-South Gate) is one of three measures the Assembly has passed to address that practice, which has prompted state investigations of -- and in some cases led to fines for -- many of the state's biggest insurers.

Some GOP lawmakers also are agreeing to expand the type of procedures insurers must cover. Twelve of 15 Republicans joined their Democratic colleagues in the Senate and voted to require insurers to pay for surgery to fix cleft palates, a common birth defect that occurs in one of every 790 babies. A panel of experts said this would add only $146,000 in annual costs to California's $79-billion insurance industry, but insurers are opposing it because they don't want lawmakers limiting the policies they offer.

On the Senate floor in mid-May, five of 15 Republicans ignored industry opposition by voting to compel insurers to reveal how often they rule that procedures are not medically necessary.The bill, by Kuehl, also would force insurers to disclose the medical qualifications of the employees who make those decisions.

That same day, four Republican senators voted to pass another Kuehl bill that would require insurers to offer customers the option of adding, for an additional charge, coverage to include the purchase of wheelchairs, oxygen tanks and other durable medical equipment.

Sen. Sam Aanestad (R-Grass Valley), who voted for the measure, said insurance policies have become too complicated to understand."I've got grown kids who have advanced college degrees, and they're not sure if something's covered or not," he said.

Amen to Dr. Aanestad's comment. If there's a theme to the reforms this year, it's that people are concerned that there coverage will not be there for them when they need it. In some cases, it's because the insurance company rescinds coverage; but in many others, it's because you don't realize what is covered, and not covered, until it is too late.

We can begin to fix that with these bills, as well as with fighting the budget cuts that undermine that security for the millions with public coverage programs.

Labels: Insurers, Kuehl, Legislation, Schwarzenegger, YearOfReform

posted by Anthony Wright | Permalink | 11:26 AM


 

The budget stage is set.

Sunday, June 01, 2008

HEALTH ACCESS UPDATE
Friday, May 30th, 2008


ASSEMBLY, SENATE BUDGET COMMITTEES VOTE OF PROPOSED CUTS (FOR NOW)

* Assembly and Senate budget committees vote to reject severe cuts to Medi-Cal, including major denials of coverage to working parents & others, elimination of dental & other benefits. Votes would also restore some of the provider rate reductions.
* Significant cuts agreed to by at least one committee include: Cuts to public and private hospitals, counties, health plans; increases in Healthy Families premiums; additional reporting for children; increased premiums for seniors
* Clear choice in budget debate moving forward: Hundreds of thousands of Californians denied coverage & care, or an alternative to a cuts-only budget that includes revenues.

Click Here for What's New on the Health Access WeBlog: Floor Reports on Health Bills Passing This Week; Ongoing Updates from Budget Committees; What Makes Coverage Coverage?; Health Reform in Obama's First 100 Days?; and more...


After a busy week on the floor, Senate and Assembly budget committees topped off the week with simultaneous hearings and votes on outstanding health budget items. A number of items that were left open in previous months while committees vetted the issues were either modified, approved or rejected Friday morning (listing below).

Health Access has posted a Health Care Budget Cuts Scorecard, which details the Governor's proposed cuts, and for each cut, the budget savings, the number of people impacted, and the actions by the Assembly and Senate today. The scorecard is here, at:
http://www.health-access.org/preserving/Docs/Health%20Access%20-%20BudgetScorecard%20053008.pdf

BUDGET BLUES

The Senate Budget Committee, chaired by Senator Denise Ducheny, and the Assembly Budget Subcommittee on Health and Human Services, chaired by Assemblywoman Patty Berg, both voted to approve or reject the many health care cuts proposed by Governor Schwarzenegger in the May Revision of the budget. That budget sought to bridge a $17.2 billion shortfall in a $100 billion general fund budget without raising taxes.

While no action is final until a final budget is approved and signed into law, both the Assembly and Senate committees rejected many of the Medi-Cal cuts to eligibility and benefits as too severe, and both proposed restoring some of the provider rate cuts made earlier in the year.

At the same time, both committees did vote to approve other cuts proposed by the Governor, and other cuts. Cuts approved by at least one committee included cuts to hospitals, cuts to counties, cuts to Healthy Families health plans; caps in benefits; increases in Healthy Families premiums; additional reporting requirements for children; and increased premiums for seniors.

Health Access is posting summaries on its blog, at www.health-access.org/blogger.html.

WHAT’S NEXT

In the Senate, the budget committee’s proposal will head to the floor for a vote. In the Assembly, the full Assembly budget committee will still need to approve each sub-committee’s proposal before being perfunctorily approved by both houses with the intent that the conference committee -- made up three budget committee members from each house – will reconcile differences between each house’s working proposals. The Legislature is supposed to finish working on its budget June 15th, but that has only happened five times in the past 40 years.
The fiscal year begins July 1 – a mere 30 days from now -- and there is no expectation that California will have a budget on time.

ACTIONS TAKEN FRIDAY

Below is a listing of major decisions made by the Assembly Budget Subcommittee on Health and the full Senate Budget Committee. For a full list of actions taken this year, click here.

* Direct denial of coverage to very low income working parents: Would have denied coverage to parents earning wages between $11,000 and $18,000 a year (for a family of three). A parent would need to work fewer than 100 hours a month in order to qualify. REJECTED by both houses.
* Quarterly Status Reports for children and adults: Would have required Medi-Cal recipients to report any changes in their life every three months. Currently, children only have to report annually, and adults every six months. MODIFIED by Senate to require reports every six months for both children and adults. REJECTED by the Assembly.
* Medi-Cal rate reimbursement: Approved earlier this year, will reduce reimbursements to Medi-Cal doctors by 10%. California already ranks near the bottom (43rd) on reimbursements for providers in this program. Both houses sought to restore this already-made cut: REDUCED to 5% reduction by Senate. REVERSED by Assembly.
* Reduced benefits for legal immigrants: Legal immigrants who currently receive comprehensive Medi-Cal benefits would lose all but four services: emergency, pregnancy, some long-term and cancer care. REJECTED by both houses.
* Monthly reporting for immigrants: Would require undocumented immigrants to establish their eligibility for limited emergency Medi-Cal services every month. REJECTED by both houses.
* Elimination of dental benefits for adults on Medi-Cal: Would have eliminated the ability for adults on Medi-Cal to receive cleanings, crowns, filling or other oral surgery unless a physician treated them. REJECTED by both houses.
* Eliminate vital services for Medi-Cal recipients: Adults would no longer be able to see an optometrist, fill eyeglass prescriptions, obtain hearing aids, get speech therapy, treat sores caused by incontinence, see a podiatrist, chiropractor, acupuncturist or psychologist. REJECTED by both houses.
* Require very low-income seniors to pay more for their health care: Would have required seniors who earn $1,100 a month to either pay $100 premium for coverage to see their doctor, or spend half their monthly income on healthcare. MODIFIED by both houses to continue to pay premium for enrollees who do not pay $500 a month for health services.
* Premium increase for some Healthy Families subscribers: Would have increased Healthy Families premiums between 27% and 77% for subscribers between 151 to 250 percent of the poverty level. MODIFIED by both houses to increase premiums by half the amount proposed.
* Co-payment increase for Healthy Families subscribers: Families between 151 to 250% of the poverty level would pay $7.50 (rather than $4) for “non-preventive’’ services, such as prescriptions, some emergency room visits, some doctors visits, eye exams and glasses, therapy and dental work. REJECTED by both houses.
* Capping Healthy Families dental benefit: Would limit dental coverage to $1,000 per enrollee. MODIFIED. Both houses increased the cap to $1,500.
* Shifting money away from public hospitals: Takes federal money used for public hospitals to pay for unrelated programs. REJECTED by the Senate. REJECTED by the Assembly.

No action, including the rejection of cuts in both houses, is final unless the final budget is approved and signed into law by the Governor. However, the actions to reject many of these cuts sets the stage for the budget debate this summer: whether to deny care and coverage to millions of Californians, or whether the state raises the revenue to prevent these cuts. That's the clear choice.

Health Access will continue to track budget actions on the floors and in conference committee during the budget season. For more information, contact the author of this report, Hanh Kim Quach at hquach@health-access.org

Labels: Budget, MediCal, SCHIPHealthyFamilies, Schwarzenegger, Updates

posted by Anthony Wright | Permalink | 1:01 AM


 

Phase one: stop the cuts...

Monday, May 26, 2008

Last week, Governor Schwarzenegger's staff met with a variety of health stakeholder groups, on the subject of continuing the effort on health reform.

What was newsworthy was that the Governor signalled his strong commitment of coming back to health reform; and that as part of that, he showed his interest to pass, sign, and implement elements of health reform this year.

Of course, the budget crisis hung over the entire conversation.

Many of the concepts and issues that the Governor's staff expressed interest in--in the broad areas of cost containment, prevention, and consumer protection--are worthy goals, both as a foundation for future health reform, and in their own right, to provide immediate help to many health care consumers.

The connection between the goals for this year is that they all have one thing in common, explicitly--none would have an impact on the general fund.

It's not just that the budget crisis prevents movement on the heart of health reform--coverage expansions, provider rate increases, guaranteed issue, etc. It's that the Governor's budget proposals go in the exact opposite direction of the reforms and coverage expansions proposed earlier this year. The very logic of health reform, of reducing the "hidden tax" and fixing the "broken health system," argues against the cuts to eligibility, enrollment, benefits, and provider rates that the Governor proposes.

It's good that the Governor is still interested in health reform. We should take him up on passing consumer protections and other reforms this year, but push him to abide by the urgency and logic of his statements about health reform from last year. He made a decision last year, to agree that we needed to raise revenues to pay to expand health coverage... We need revenues this year, just to maintain the health coverage California currently provide to children, working parents, seniors, and people with disabilities.

It seems that phase 1 of health reform includes defeating the Governor's health care budget cuts and work for an alternative to a cuts-only budget. It also includes defeating the Governor's power grab proposals to change the budget process so that it would be nearly impossible to pass and maintain health reform into the future.

We should be consistent with our goals, even if the Governor isn't.

Labels: Budget, Schwarzenegger, YearOfReform

posted by Anthony Wright | Permalink | 2:23 PM


 

We live to fight another day for drug discounts...

Friday, May 23, 2008

Wednesday morning, without taking testimony, the Senate Budget Subcommittee chaired by Senator Elaine Alquist, with Senator Alex Padilla concurring, voted to eliminate funding for the drug discount program.

At noon time, I came back to the office and looked at the blog post by my colleague, Hanh Quach, with that wonderful picture of Governor Schwarzenegger signing the bill, framed on either side by supporters including Anthony Wright, Health Access executive director, and Assembly Speaker Fabian Nunez, who stepped down from that position a week ago yesterday.

I found it hard to believe that only a week after Nunez had stepped down as Speaker, the Assembly would just agree with the Senate and eliminate funding for the drug discount program that every article on his tenure as Speaker cited as one of his major accomplishments.

At 1:30pm, I found out I was wrong. The Assembly Budget Subcommittee convened and we discovered that they too planned to eliminate funding, in the technical language of the legislature, “conforming” to the Senate action. Things can move quickly around the Capitol.

I noticed that somehow the drug companies had found out that they were about to win a delay in this program that they had fought so hard to stop—I saw several of their lobbyists in the back of the hearing room.

Fortunately, the Assembly Budget Subcommittee allowed public testimony. Bill Powers, advocate for California Alliance of Retired Americans (CARA), and I spoke. I pointed out that Health Access had sponsored a ballot measure that Pharma spent $80 million to defeat and that the law was a compromise based on the Legislative Analyst Office (LAO). Consumers and labor supported the law, Pharma bitterly opposed. I said we strongly opposed not funding the program.

Bill Powers spoke about the travesty of the Medicare drug program where Medicare cannot negotiate prices with the drug companies. He pointed out that the State of California negotiates with drug companies for both Medi-Cal and for this new program for the uninsured. Medi-Cal gets very good prices from the drug companies—that is why they opposed this new discount program. If we don’t get the new program, Bill said, we will never know for sure how much we can benefit the uninsured.

And rare in what all too often feels pre-scripted, Assemblymember Patty Berg, the Budget Sub chair, moved to hold the item open, postponing action to another day. The Democrats present, Assemblymembers Jim Beall and Ed Hernandez, concurred. I was so relieved I forgot to notice what the Republicans did.

So we still have a chance to win. But it is a slim one. At any time, the Assembly could agree with the Senate and consumers will be out of luck on drug discounts and the drug companies will have won through the backdoor because of the bad budget year. It seems a poor tribute to the work Speaker Emeritus Nunez has done on health care.

Labels: Budget, Drugs, Nunez, Perata, Schwarzenegger

posted by Beth Capell | Permalink | 10:13 AM


 

Senate Committee says No to Prescription Drugs

Wednesday, May 21, 2008

The Senate budget subcommittee that oversees the state's health budget voted to eliminate funding that would have implemented the California Discount Prescription Drug Program.

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

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

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

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

Labels: Budget, Drugs, Schwarzenegger, Uninsured

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


 

Guest blog on balanced billing from a veteran health advocate...

Friday, May 16, 2008

Beth Capell, Health Access' contract lobbyist extraordinaire, has been advocating for consumers for more than two decades. She offers these thoughts on balance billing, an insidious practice of some doctors and hospitals who decide to threaten insured consumers with aggressive collection agency if the consumer does not pay the “balance” between the insurer or HMO paid for their care and what the doctor or hospital wanted to be paid. (Relatedly, we blogged on a recent and egregious example of the Prime/Kaiser situation. 5/17 UPDATE: There's a new development, where a legal injunction has been ordered, as reported in the Orange County Register on balance billing. The LA Times also has a story.)

“Balance” billing has been illegal for Medicare and Medicaid enrollees for decades. It is illegal for HMO enrollees if they go to a contract facility. And until a few years ago, we probably would have said balance billing was illegal when an insured consumer got emergency care, even at a non-contract hospital.

As consumers, we are sympathetic to doctors and hospitals who feel badly treated by HMOs and insurers. We know what that’s like.

But as consumer representatives, we are pretty impatient with doctors and hospitals that treat consumers badly. We don’t like that either. And when it is all about a billing dispute between providers and plans, we say a pox on both their houses: get consumers out of the middle.

Well, this week DMHC had a hearing on a regulation to do just that: to say that if a consumer with coverage regulated by DMHC gets emergency care, then the consumer is only responsible for applicable copays or deductible, not for the difference between what the emergency doctor or the hospital wanted to be paid and what the HMO paid. Health Access is fortunate that our representative at this hearing is Elizabeth Abbott, who formerly headed the federal Centers for Medicare and Medicaid Services (CMS) in the western region of the United States: she has heard plenty of plan-provider disputes in her day and has no surfeit of patience with whining. She reports that doctors are furious at the proposed regulation.

As we said, we are sympathetic to doctors and hospitals fighting with HMOs. And indeed we as well as the Department have spent endless hours listening to the complaining of doctors and hospitals.

After all that, we know several things: first, consumers deserve to be protected from bad behavior by doctors and hospitals as well as HMOs and insurers. Second, under California law, doctors and hospitals that do not have a contract with the consumer’s HMO do in fact get paid and usually get paid in a reasonable period of time (less than 60 days). So what are the doctors and hospitals fighting with the HMOs about? It turns out it is not just about the amount of the payment but also what counts how.

You would think that it would be easy to decide that when an ER doc takes care of you because you have a broken bone, he should be paid for reading the x-ray or MRI, but it turns out whether that is part of the bundle of services or not is part of what providers and plans fight over. And they fight over it partly because there is no standardization of bundling. The docs, not surprisingly, want the bundling system the docs have developed (called the AMA/CPT code, if you care). But Medicare decided a long time ago that letting the docs set the rules by which they are paid does not make much sense and ditto with Medi-Cal.

And we made it lots more complicated in California when we allowed the development of the “delegated medical model”. (If your eyes are crossing, welcome to my world.) That means that Blue Shield does not just contract with individual docs, but instead contracts with Sutter Medical Group or Hill Physicians or Beaver or Scripps or some other outfit with thousands of docs and hundreds of thousands of patients. So if you are a Sutter Medical Group patient but you end up at UC Davis emergency room because that is where the ambulance took you, what are the rules for bundling the claim? Is that thing-y they put on your finger to check your blood oxygen in or out of the bundle? Is it the Medicare rules? The Sutter group rules? The Blue Shield rules? Or are you actually HealthNet? And why do you care? Well, probably you will when the ER doc or the hospital loses their
patience with the HMO and just decides to send you to collections and let you
fight it out with the HMO.

And yes, this is yet another way in which our current system piles on administrative overhead for no good reason. So in addition to fighting to prohibit balance billing of consumers, we are trying to help figure out how to minimize the provider-plan disputes by supporting a single set of rules for bundling as well as other changes.

The need to end balance billing got a lot more obvious this week when we found out that one hospital system in Southern California, Prime Healthcare, had sent over 6,000 Kaiser members to collections because Kaiser would not pay whatever Prime Healthcare wanted to charge for their emergency care. Prime Healthcare is a system that refuses to contract with most insurers---so it is not just Kaiser members who are at risk: it is anyone with insurance who walks into their emergency room. It looks as if Prime Healthcare took on Kaiser first but nothing prevents the hospitals from doing the same thing to consumers covered by other insurers that Prime fails to contract with. And Prime also seems to be engaged in the same old game that for-profit Tenet used to play of turbo-charging the charges for care so that the sticker price goes up and up.

As well as the proposed regulations, we are working on AB1203 (Salas) and SB981 (Perata) to prevent balance billing of patients who get emergency care. While both these bills are still in progress, we hope this year we can get consumers out of the middle of these provider-plan disputes.

Labels: BalanceBilling, Hospitals, Insurers, Schwarzenegger

posted by Hanh Kim Quach | Permalink | 4:53 PM


 

...and don't forget health reform

In Schwarzenegger's presentation on the budget Wednesday, when being grilled by the media on the specifics of his lottery proposal and other elements of his budget, he made a point to invoke his "don't forget health reform" pitch: he indicated it was a shame it didn't pass earlier in the year, and how he is still committed to doing health reform in his term.

"As you know, we have made severe cuts in health care. And when it comes to health care, what is even more painful is that we didn't get health care reform done, because that would have given Medi-Cal an additional $4 billion dollars. So we are going to go and continue staying on that subject of health care reform, and continue working with the stakeholders together to get this done."

Some, especially those in the Senate, used the budget crisis as an excuse to stall AB x1 1, the negotiated plan between the Governor and the Speaker, saying it wasn't the right time for such an ambitious effort in the middle of a budget crisis. Others, especially in the Administration, stated that the budget deficit only reinforced the urgency of health reform.

My take: Passing health reform would not have prevented the tough choices presented by the budget crisis, but it would have provided additional--and better--options for a solution.

What would have happened if the plan passed? AB x1 1 and its companion ballot measure would have raised $15 billion in new revenues for health care coverage expansions and provider rate increases.

There's no doubt that the cuts announced today and back in January take us in the absolute opposite direction--a cut of $2 billion plus in both state and federal funds. Instead of raising $15 billion with AB x1 1, we are facing gruesome cuts:

* Instead of expanding Medi-Cal coverage and broadening the eligibility rules, the Governor has proposed restricting eligibility.

* Instead of raising provider rates, the Legislature and the Governor has already cut those rates, so millions now have less access to doctors and hospitals.

* Instead of streamlining and simplifying these programs, the Governor proposes making them more bureaucratic and cumbersome.

* Instead of bringing in more federal matching funds, the Governor proposes making cuts and thus losing those matching funds, leaving even more federal money in DC.

* Instead of dramatically reducing the number of uninsured Californians and the resulting "hidden tax" on the health system as a whole, the Governor's proposal would markedly increase the rate of uninsurance, for children and families.

If we had passed health care reform and still had to deal with $2 billion in cuts, then that would have meant that we only had $13 billion for health care expansions and improvements--and so then we would have the choice of raising additional revenues to make the new expansions and commitments whole again, or restructure the proposal to work with the $13 billion (rather than $15 billion) raised. Any of those choices, while tough, would have been preferable to what we have now.

If adopted, the Governor's proposed cuts take us further from the goal: it digs a bigger hole, that will need to be filled before embarking on additional expansions.

Medi-Cal and Healthy Families are the foundation for health reform, on which additional expansions are built atop--but that only works if the budget that funds them are strong and sustainably funded.

We will also be pursuing legislative and policy reform that we believe lays a foundation for reform in 2009-10, and we are pleased that the Governor have indicated an interest in such efforts. But the budget is also a key foundation that needs a resolution this summer.

Even with these ugly budget cuts hanging in the air, I have to hope that the Legislature will once again decide to reject these health cuts as too severe, as they have in the past. I have to hope that constituents in rural and "red" areas care about their schools, emergency rooms, seniors and children as much as anyone else.

And I have to hope that the logic of health reform will prevail upon this Governor: that the best arguments against these cuts, and for revenues to prevent these cuts, were all made by this Governor last year as he stumped for health reform:

* that California is visionary enough to get everybody covered, and not leave people to be uninsured;
* that Californians are willing to contribute to support and expand health coverage;
* that we need to invest in our health care system, for its own sake and to bring in new federal matching dollars that are left in DC; and
* that investments in health care have broader benefits, including positive health, societal, and economic implications.

Finally, it's worth remembering that part of the Massachusetts health reform was a deal to restore of several key cuts to that's state's Medicaid program (for example, to benefits) made in previous years. Our work this year will be to prevent such cuts, so they won't have to be restored in the first place when we pursue comprehensive health reform in the near future.

Labels: Budget, Schwarzenegger, YearOfReform

posted by Anthony Wright | Permalink | 12:20 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


 

A deeper wound for our health care system...

Wednesday, May 14, 2008

HEALTH ACCESS UPDATE
Wednesday, May 14th, 2008


GOVERNOR'S MAY BUDGET REVISION MAKES DEEPER HEALTH CUTS

* Budget shortfall projected at $17.2 billion; Governor continues "cuts & borrow" approach
* Health cuts keep in place January proposals, goes further in directly denying coverage
* Hundreds of thousands of the poorest working families would lose coverage

Click Here for What's New on the Health Access WeBlog: Much more on the budget cuts; Welcome, Speaker Bass; Bass and health reform; Balance billing; Canadian health care; Underinsurance; Who gets hurt by a cuts-only budget?; High deductible health plans for who?; MRMIP's waiting list; McCain's risky high-risk pool proposal; The new opportunity for health reform; Big Tobacco's track record on reform; More on the McCain health plan.


SACRAMENTO--Gov. Arnold Schwarzenegger released the revised version of his budget proposal today, which makes deeper cuts in health and human services programs in order to address the state’s shortfall, which has grown by nearly $3 billion since he first released the budget in January. Altogether, the $100 billion general fund budget is $17.2 billion short.

“The crisis is very real and it is very serious,’’ the governor said. His proposal would attempt to bring in $11.7 billion in new money ($3.5 billion from deficit bonds of years past), and another $5 billion by selling the lottery’s income to Wall Street. Schwarzenegger would cut an additional $12.5 billion from state programs, on top of the $1 billion that was cut earlier this year to help minimize the deficit.

“We had to make very difficult cuts. No one wanted to do this. But because health and human services was the second largest part of the budget, this is where we had to cut,’’ Schwarzenegger said. Twenty percent of the cuts imposed come from Health and Human services, reported Director of Finance Mike Genest. Deficit aside, Schwarzenegger restored funding to some of his original cut proposals in January and will now keep parks open and will not release inmates nearing their release date early.

View the full May Revision at the website of the Department of Finance here: www.ebudget.ca.gov.

The Health and Human Services Agency has their summary of the health and human services cuts here, at:
http://www.chhs.ca.gov/Documents/HHS%20Budget%20Facts%20Final%205%2008.pdf

THE CUTS

CUTS ALREADY MADE (PROVIDER RATES): Health programs were already dealt a blow earlier this year. Medical providers that treat Medi-Cal recipients will see their reimbursement rates cut by 10% as a result of a budget cut package already approved earlier in the year. Already California ranks near the bottom for reimbursement rates for doctors caring for Medi-Cal patients. That cut -- saving the state $544 million (and losing an equivalent amount in federal matching dollars) -- will begin July 1st.

CUTS ALREADY PROPOSED AND STILL PENDING (MEDI-CAL BENEFITS, QSRs): Still pending from the Governor's January proposal are a range of cuts, such as eliminating benefits for adults on Medi-Cal, including dental coverage, optometry, podiatry, and other services. The pending proposals also included imposing additional paperwork burdens on children and families so hundreds of thousnads enrollees fall off the program (known as quarterly status reports).

NEW MAY REVISE CUTS: The Governor's May revision retain all cuts to health care proposed in January, that would make it harder for the 6.6 million children, parents, seniors and people with disabilities on Medi-Cal to get the care they need--by reducing access to providers, by eliminating benefits, by increasing paperwork so that it is easier to fall off coverage. The May Revision also does the one major type of cut that the January budget did not do--directly deny people coverage by changing eligibility rules. The May revision cuts of interest to health advocates are as follows:

* DENIAL OF COVERAGE TO LOW-INCOME WORKING PARENTS: Parents earning very low wages (roughly between $11,000 and $18,000/year for a family of three) would no longer be eligible for Medi-Cal coverage.

Under the new proposal, a family of three would need to earn even less: $891 a month, and work fewer than 100 hours a month. The cut is expected to reduce spending by $31.2 million this year, but increase to $342.5 annually in three years. In the first year of implementation, 39,000 parents would be denied coverage. After a couple of years of full implementation, over 429,000 Californians would be denied Medi-Cal coverage.

This proposal was also proposed for the 2003-04 budget by then-Gov. Gray Davis, but rejected. Earlier reform expanded coverage to these parents as part of welfare reform, so that families working their way off of welfare would not lose health coverage as they found jobs (that likely did not provide health benefits). If this cut stands, then the potential incentive is to work less, in order to keep coverage.

* CONTINUED BUREAUCRATIC ENROLLMENT PROCEDURES: The Administration, which had championed efforts to make it easier for families to enroll in public programs, is now further seeking to delay the implementation of SB437 (Escutia) of 2006, which would have streamlined and fast-tracked enrollment for children into Healthy Families or Medi-Cal. This delay saves the state $13 million.

* ADDITIONAL BENEFIT CUTS: Qualifying low-income legal immigrants who permanently live in the US will lose various benefits, including prescription drugs and dental coverage, and only get four services: emergency care, pregnancy-related coverage, certain long-term care services, and some cancer treatments. This would be a $86.7 million cut.

* MORE PAPERWORK FOR EMERGENCY SERVICES: The limited emergency services coverage that Medi-Cal provides to undocumented immigrants would be more limited, through the implementation of a monthly eligibility process. The savings would reduce state payments to California health providers by $42 million.

* CUT TO NON-CONTRACTING HOSPITALS: Hospitals that don't contract with Medi-Cal would face a rate cut of either 5% of regional contracted rates, or 90% of cost, whichever is lowest. This would provide $11.2 million in savings.

* COST AND QUALITY DATA: The budget proposes to take money from the state’s Health Data and Planning Fund, which would be used to give consumer a glimpse of providers’ prices, error rates and other key information that would help health care purchasers make informed choices. This cut saves $12 million.

Again, these cuts come on top of more than $1 billion cuts proposed in January. The governor had previously proposed higher premiums and co-pays for Healthy Families enrollees, requiring families to report changes to their income every three months in order to remain on Medi-Cal, and the elimination of essential benefits, such as adult dental care and incontinence creams and washes for aged, blind and disabled Californians.

View the fact sheet and previous reports here and here.

WHAT'S NEXT

With the latest budget figures, the Legislature can now begin making decisions and negotiating on the budget in earnest. Many decisions had been postponed -- in part because it was unclear how much money the state had to work with, and in part, because the cuts were so untenable. Next week, budget subcommittees will continue to hammer out details. Health Access will monitor the status of the health budget proposals and keep advocates informed.

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

Labels: Budget, Schwarzenegger, Updates

posted by Anthony Wright | Permalink | 7:03 PM


 

By The Numbers

Gov. Arnold Schwarzenegger's budget will impact tens of thousands of Californians. Here's a compilation of the cuts and lives affected:

• Quarterly-status reports: 160,000 children; 15,000 adults impacted in 2008-09. Two-year total is 300,000 children impacted. Five-year total is 471,000 impacted. Requires families to justify every three months that their income has not changed. If they fail to do so, they would be dropped from Medi-Cal.
• Elimination of essential benefits, such as dental, speech therapy, eyeglasses and optometrist services and incontinence creams and washes.

1. Dental: 900,000
2. Optometrists: 214,000
3. Eyeglasses and Contact lenses: 457,000
4. Podiatrists: 85,000
5. Incontinence creams and washes: 66,000
6. Acupuncture: 33,000
7. Hearing aids: 28,000

• Seniors and Medicare premiums: Requiring some low-income seniors (earning, at most, $1,100 a month) to pay $97-a-month co-pay on for their Medicare coverage for doctors visits. 57,000 seniors affected.
• Low-income working families: Would deem families earning very meager wages ($1,500 a month for three people) too wealthy to qualify for Medi-Cal. Such a family would need to drop its income to $895 a month -- and work no more than 100 hours a month -- in order to qualify. Numbers of people affected by this are unclear. We do know that 429,000 adults with children are on Medi-Cal now. About one-third of those are single moms.

Labels: Budget, MediCal, Schwarzenegger

posted by Hanh Kim Quach | Permalink | 5:16 PM


 

Ugly.

The Governor’s budget cuts will result in closing the doors to coverage and care for hundreds of thousands of Californians, and further unravel the broken health care system that we all rely on.

We need to remember: The new cuts that block people from getting coverage is on top of severe cuts already made this, and others still pending, that would reduce access to doctor and hospitals, eliminate basic benefits like dental care, and have people dropped from coverage. As a result, millions of Californians, including children, parents, seniors, and people with disabilities will live sicker and die younger as a direct result of these budget decisions.

THE BIGGEST CUT: The biggest of the new cuts is the "1931b" eligibility cut that would mean that a parent in a three-person family with a $11,000/year income would no longer be able to get Medi-Cal coverage. Such a cut is calculated to save $342.5 million a year in state funds, although it would also mean an equivalent loss of federal matching funds to our health system.

Developing...

Labels: Budget, Schwarzenegger

posted by Anthony Wright | Permalink | 2:01 PM


 

Closing the doors to coverage and care...

The cuts are here, and they are bad. The Governor is proposing major new cuts to health and human services.

In Medi-Cal, the major new cut is to eligibility: changing the rules so that people will no longer be able to get coverage. Our back-of-the-envelope proposal is that hundreds of thousands of people would no longer be able to get health coverage...

More soon...

Labels: Budget, Schwarzenegger

posted by Anthony Wright | Permalink | 1:13 PM


 

The Quiet before the Storm

Tuesday, May 13, 2008

There's the steady drone of doom and gloom emanating from the Capitol, but Sacramento is collectively holding its breath, waiting for Gov. Arnold Schwarzenegger to release his updated budget proposal tomorrow in what's known in Capitol parlance as the "May Revise.''

This second version of the budget comes out a month after tax day, when the state has a better idea what kind of income it has to work with the following year ....and by all accounts, it has not been pretty. Estimates of the deficit -- which started at $14.5 billion in January -- are more like $16 billion to $20 billion now.

While the entire state budget is $140 billion -- the general fund, where we have the shortfall -- is $100 billion. That means the deficit is nearly one-fifth of our budget.

Accompanying the bad figures are equally as bad rumors: Cuts, cuts and more cuts. On the flip side, precious little in new income for the state.

For most of this decade, we have grappled with multibillion dollar deficits larger than the entire budgets of many of the states in the US. And what have we done? We've borrowed and cut.

And now, we're down to the bone. Many of you may recall -- and here's a reminder -- that the governor already proposed more than $1.1 billion in health program cuts, which will mean:

• 500,000 children losing health coverage over the next five years because the state will require that their families report every three months any changes in their life.
• People with disabilities, who live on (at most) $997 a month, could develop infections and sores on their body and other sensitive areas because they lose coverage for incontinence creams and washes.
• The poorest adults will lose their dental care -- and many with already poor dental health will not treat their cavities, develop gum disease, abscesses and possibly lose their teeth.

We will all know at 1 p.m. tomorrow what the total damage will be. But this we know -- There are only three ways to cut Medi-Cal:

• Reimbursement rates for providers -- Check. That was already proposed in January and approved by the Legislature months later to go into effect July 1.
• Benefits to recipients -- Check. See a couple of the bullet points above.
• Eligibility -- Quasi - check. Requiring families to justify their income every three months is a passive aggressive way to knock people off of the Medi-Cal rolls. The state is secretly hoping that families will be too overwhelmed, their life in too much chaos, they will lose or somehow fail to complete the form and send it in. Of course, that means 500,000 children won't get health care....

By process of elimination, a direct cut to eligibility is the only thing left for the state to do to the Medi-Cal program.

Let's cry ourselves to sleep and see what's in store for us tomorrow.

Labels: Budget, MediCal, SCHIPHealthyFamilies, Schwarzenegger

posted by Hanh Kim Quach | Permalink | 6:38 PM


 

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


 

Gov: Another round?

Tuesday, April 29, 2008

Governor Schwarzenegger is committed to trying health reform again, according to a 30-minute interview with Juliet Williams at the AP:

"Now we'll try again. We will continue on, keeping the stakeholders together, fine-tuning it and seeing if we can improve on it since we have the time now, then be back again. We feel very confident."

We have an interest in making as much progress as possible under Governor Schwarzenegger in 2009. We don't know who the next Governor will be, and what their interest in health reform will be. And if they do prioritize health reform, they will be able to do more if there was some momentum from their predecessor. The poll shows strong support and the opening of a new window of opportunity, but these windows are short-lived, and you never know when the next time will come.

There is time now to look at the proposals, fix things that weren't right, resolve issues that were pushed to the future, and even take another look in areas where there might be better alternatives. The key thing, as well, is to lay a foundation for reform, which includes a budget that doesn't take us backwards in terms of Medi-Cal cuts, and is sustainably funded.

Not small tasks for the rest of the year.

Labels: Schwarzenegger, YearOfReform

posted by Anthony Wright | Permalink | 11:04 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