LA panel: looking forward to 2009...

Wednesday, June 18, 2008

For those health reformers not in the Bay Area, there's also a star-studded panel tomorrow (Thursday) night in Los Angeles. Sponsored by The California Endowment, it reflects on a special issue of The American Prospect that includes my recent summary of lessons learned from the California "year of health reform," as we attempt to seize a new opportunity in the next year. I'm away and not on the panel, but some of my fellow contributors to that issue are there. Here's the info...:

The American Prospect: What Path to Universal Health Care?
Thursday, June 19 — 7 p.m.

The California Endowment's Center for Healthy Communities
1000 N. Alameda St., Los Angeles, CA 90012
[CLICK HERE FOR MAP AND DRIVING DIRECTIONS]

Will any of the candidates' solutions actually fix our system? This is the central question of a new special issue of The American Prospect and of this Center Scene Public Program. Experts and contributors to the magazine discuss the politics of health reform and what it will take to achieve a system that is truly universal, efficient, affordable and has prevention at its core.

Panelists include:
* Fabian Núñez, member and speaker emeritus, California State Assembly
* Neal Halfon, M.D., director, UCLA Center for Healthier Children, Families and Communities
* Ezra Klein, associate editor, The American Prospect

Moderator:
Matt Miller, senior fellow, Center for American Progress and
host, Left, Right & Center on 89.9 KCRW
Miles Rapoport, president of D?mos, will make opening remarks.

Click here to R.S.V.P. Light refreshments will be served. Admission and parking are free. For more information, please e-mail rsvpchc@calendow.org

Labels: HealthAccessCommunity, YearOfReform

posted by Anthony Wright | Permalink | 8:21 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


 

Digging a bigger hole for reform...

Wednesday, June 11, 2008

As the Budget Conference Committee in the California Legislature is about to begin its deliberations, a couple of reminders.

1) The cuts being discussed are ugly. The proposed cuts by the Governor would deny coverage to over a million Californians, and reduce access to care and coverage to millions more, and defund and undermine the health system on which we all rely.

For six and a half million children, parents, seniors, and people with disabilities, their Medi-Cal coverage will be harder to get, harder to stay on, and for those who keep it, they will have reduced ability to get the benefits and access to the providers they need.

2) The decisions around the budget will have a decisive impact on health reform, at the state level, and even at the national level. These proposed health cuts would go in the exact opposite direction of the policy reforms our broken health care system needs. If adopted, the Governor's proposed cuts take us further from the goal of health reform: it digs a bigger hole, that will need to be filled before embarking on additional expansions.

Medicaid and SCHIP (Medi-Cal and Healthy Families in California) are the groundwork for health reform, on which additional expansions are built--but that only works their funding is strong and sustainable.

Regarding of the plan, from single-payer to a Massachusetts-style proposal to any public program expansion to anything else, any health reform and coverage expansion presupposes that we will need significant subsidies for lower-income families, who simply won't be able to afford coverage by themselves. Yet by significantly cutting public programs that exist now--which are incomplete in policy and practice already--we have less to work with.

If these cuts are made, reformers will have to raise all those additional resources elsewhere--a major task indeed. In the effort for universal health care:
* For every dollar cut from the health care budget by California and other states, that's a dollar that we will have to raise later.
* For every child or parent that loses coverage, that's a child or parent that we are going to have to re-find and enroll later.
* For every policy change to place more administrative barriers to getting care and coverage, that's just more we have to do later.

In other words, the greatest threat to health reform in 2009 may not be the insurance industry or even voter distrust (although they are significant obstacles as well), but the budget crisis and the state Governors and legislators who are making these health care budget cuts around the nation, and are undermining the foundation on which we need to build.

Labels: Budget, MediCal, YearOfReform

posted by Anthony Wright | Permalink | 1:48 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


 

A great debate on the great divide...

Friday, June 06, 2008

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Labels: Insurers, InTheNews, PresidentialCandidates, YearOfReform

posted by Anthony Wright | Permalink | 10:49 AM


 

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


 

Health reform lives on in Sacramento...

Tuesday, May 27, 2008

HEALTH ACCESS UPDATE
Tuesday, May 27th, 2008


KEY HEALTH BILLS PASS FLOOR VOTES IN CALIFORNIA LEGISLATURE
* Senate Passes SB1522 (Steinberg), Standardizing Insurance & Prohibiting "Junk" Coverage
* Assembly Passes AB2967 (Lieber), Providing Transparency on Cost and Quality of Care
* Also: Bills Pass to Regulate Insurers on Rescission, Maternity Coverage, Mental Health Parity, and Requiring 85% of Premium for Patient Care

* More on the Legislative Debate and much more at the Health Access WeBlog (www.health-access.org/blogger.html):


Health reform continues to be a hot topic at the State Capitol. Passing their first floor vote and the half-way point in the California Legislature, key health bills would provide patients with new information and needed consumer protections regarding their care and coverage.

The Assembly and Senate passed several key health care bills, including ones to protect consumers from "junk" insurance; to increase transparency about the cost and quality of care; to regulate the practice of retroactively denying coverage to patients; and to mandate coverage of maternity and mental health services. The health reform conversation is alive and well.


The following bills passed:


INSURER OVERSIGHT

* STANDARDIZING INSURANCE: SB1522(Steinberg), eliminating "junk" insurance and standardizing the insurance market to allow for "apples-to-apples" comparison for consumers. The bill would set a minimum benefit standard for coverage by requiring 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." Here's a fact sheet, and a patient story that illustrates the issue.

Organization of plans into these categories would enable consumers to better track premium, benefits and cost-sharing. The bill would also prevent consumers from not understanding their coverage, or having "junk" coverage where they are paying a premium by are still facing unlimited financial exposure. Sponsored by Health Access California. (Passed by the Senate 22-16 with most Democrats in support; Ducheny and Ridley-Thomas not voting; Correa voting no.)


* MEDICAL LOSS RATIO: SB1440(Kuehl), to require that at least 85% of premium dollars go to patient care, rather than administration, marketing and profit. The proposal seeks to ensure that consumers are getting value for their dollar. (Passed by the Senate 22-16, with most Democrats in support, with Machado and Simitian not voting, and Yee voting no.)

* RESCISSIONS: AB1945(De La Torre), to require insurers to get an independent review before retroactively denying coverage from patients. (Passed the Assembly 57-16, with significant bipartisan support.) Also passing was AB2549(Hayashi) which sets a six-month time limit for insurers to rescind once consumers' applications are approved. (Passed the Assembly 44-26.)

BENEFITS


* MENTAL HEALTH: AB1887(Beall) to expand the requirement on insurers to cover mental health services. (Passed by the Assembly 44-26, with most Democrats in support, and with Arambula, Mullin, Calderon, Galgiani not voting; Soto absent.)

* MATERNITY: AB1962(De La Torre), to require insurers to cover maternity benefits. (Passed the Assembly 44-31, with most Democrats in support; Soto absent; Galgiani not voting; and Calderon and Parra voting no.)


PROVIDER OVERSIGHT

* TRANSPARENCY: AB2967(Lieber), to require better data from health providers and plans to increase the transparency of the cost and quality of care. This effort has yielded one of the most interesting coalitions, with strong support by prominent consumer, labor, and business groups--all purchasers of health care trying to get a better sense of what they are getting for their money. (Passed by the Assembly 41-32, with most Democrats in support but Soto absent; Fuentes, Krekorian, Ruskin, Portantino, Solorio not voting; and Arambula voting no.)

* DISTRICT HOSPITAL TRANSACTIONS: SB1351(Corbett), to require Attorney General oversight over district hospital sales and closures. (Passed the Senate 24-14, with most Democrats in support, and Scott not voting.)

Health Access will continue to track these and other bills on our website, at
http://www.health-access.org/advocating/2008_bills.html

Labels: Hospitals, Insurers, Legislation, Updates, YearOfReform

posted by Anthony Wright | Permalink | 7:46 PM


 

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


 

The new/renewed conversation on health reform...

Friday, May 23, 2008

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

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

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

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

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

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

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

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

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

Labels: InTheNews, OtherBlogs, Uninsured, YearOfReform

posted by Anthony Wright | Permalink | 12:11 PM


 

Senate Bill update

Thursday, May 22, 2008

Senate Appropriations ran through their suspense file. Here is the outcome for bills tracked by health consumer advocates:

• SB 1522 (Steinberg): Standardization of the Individual market -- PASS
• SB 1440 (Kuehl): Requires insurers to spend at least 80% of premium dollars on health care -- PASS
• SB 1351 (Corbett): Requires attorney general oversight into transactions involving district hospitals -- PASS
• SB 1332 (Negrete-McLeod): Pilot Medi-Cal managed care program -- FAILED
• SB 1622 (Simitian): Would knit together local county initiatives to create a public insurer that would compete with private health plans -- FAILED

SB 1522, SB 1440 and SB 1622 are all bills that came out of AB x1 1 from the Year of Health Reform and would begin to lay a foundation for comprehensive health reform.

Those bills that pass today will need to pass floor votes by next Friday.

Labels: Legislation, YearOfReform

posted by Hanh Kim Quach | Permalink | 2:58 PM


 

...and don't forget health reform

Friday, May 16, 2008

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


 

Bass fishing...

Tuesday, May 13, 2008

It was a moving ceremony today to install the new Speaker of the Assembly, Karen Bass.


Some common points were made in the various speeches and comments: her position is historic, as the first African-American female to lead a legislative body in the U.S.; her background in community organizing; her courage in the face of a recent tragedy of losing her daughter; and her personal interest in and advocacy for foster care children. She gave a beautiful speech as well.


Through the day, the topic that loomed was, predictably, the state budget. It's the task at hand, and one that will impact everyone in California, and every issue. And especially health care, given that health care is second only to education in its claim on the state budget.


Jon Myers at KQED Capitol Notes has an interview and asked about the future of health reform. While the new Speaker made clear that the budget was (appropriately) the first, second and third priority, she said, in reponse to Myers' questions, "I don't think it is dead at all... I absolutely want to get back to health care reform, but we have to deal with the budget first.... There will be time left in the legislative year to address health care reform.... No, I don't think it was too much bitten off.... I would very much like to tackle the whole issue."


Important signal. Shoring up the budget is an important foundation for health reform, but we have a Speaker that is willing to move forward this year and next, in order to win elements of a comprehensive reform package.


And so congratulations to Speaker Bass: she also now gets her own label on this blog, so that people can click on her below, and get most of this blog's posts related to her and health care.

Labels: Bass, Budget, YearOfReform

posted by Anthony Wright | Permalink | 10:45 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


 

Tobacco's doubly dirty deeds...

Tuesday, April 29, 2008

Niko Karvounis at the Health Beat Blog has a full article on Big Tobacco being the leading cause of death for... state health reform.

The excellent piece appropriately spotlights Big Tobacco's $65 million opposition to Proposition 86--which would have funded emergency rooms and children's coveage, and their instrumental role in opposing health reform in 2007-8. It's worth quoting the California section:

Consider California. The Times notes that the state’s recent bipartisan plan for instituting universal health care, endorsed by Republican Gov. Arnold Schwarzenegger and Democratic Assembly Speaker Fabian Núñez, “died in the State Senate in January partly because of opposition to the $1.50-a-pack increase it included.”

This wasn’t the first time cigarette taxes have been an issue in California. In 2006, California voters turned back a ballot initiative, Proposition 86, that proposed to increase the cost of a cigarette pack by $2.60. Supporters of the proposition estimated proceeds from the tax at $2 billion—which would have been used to help fund health care reforms—and forecasted a $16.5 billion long-term decline in health care costs thanks to reductions in smoking. Good stuff.

But the proposition failed by a narrow margin: 48 percent of voters approved the measure while 52 percent said no. Observers are quick to note that this close call came about despite the fact that Big Tobacco spent a whopping $65 million to fight Proposition 86, pouring that money into lobbying and advertising.

These efforts often get ugly. The industry's anti-tax campaign listed non-existent groups like the “Chamber of Commerce of Los Angeles County” as being opposed to the proposition. It also sent out mailers that attributed anti-86 stances to politicians—wrongly—without their approval, and issued statements suggesting that terrorists would somehow benefit from a higher tobacco tax.

In retrospect, it’s unsurprising that tobacco companies got down and dirty—after all, the tobacco industry has a lot invested in California. A 2006 Business Week article breaks down the numbers: “California is home to 9 percent of all U.S. smokers, and a successful Prop 86 would certainly dent tobacco companies' bottom lines. An analysis by the Tobacco Control Section of the California Health Services Dept. expects that it could cut cigarette sales by 312 million packs a year. Let's estimate, conservatively, that Philip Morris makes a profit of 20 cents per pack. Given its 51 percent market share, that's a $32 million hit. Plus, the Tobacco Control Section predicts the smoking rate among high school students will drop from 13.2 percent in 2004 to 7.6 percent [after the passage of Proposition 86].”

Clearly, tobacco companies had a lot to lose. $65 million and lots of lies later, however, it seemed they were safe. That is, until Governor Schwarzenegger’s 2007-2008 health care plan began to garner public support. In a February analysis, Daniel Weintraub of The Sacramento Bee noted that “the basic outline of the governor's plan – a requirement that every Californian have insurance, with the costs shared by employers, health care providers and individuals themselves – attracted the support of 60 percent to 70 percent of those surveyed by the Public Policy Institute of California in several polls taken during 2007.” Here, it seemed, was a plan that could pass.

Of course, health care reform is never cheap because if you are going to mandate that everyone have insurance, you must provide subsidies for the many families who cannot afford to pay for it on their own. California’s plan was estimated to cost $14 billion, to be funded partly by an increase in cigarette taxes.

Enter Big Tobacco. The industry had been digging its heels into the Golden State’s political scene for years. According to an October report from the Center for Tobacco Control Research and Education at the University of California San Francisco School of Medicine, the tobacco industry had already made major inroads into the CA State legislature by the time Schwarzenegger’s proposal surfaced.

The report notes that “the [tobacco] industry steadily increased monies spent on state level political activities in the period 2003-2007, from $4,086,553 in 2003-2004 ($1,083,448 to candidates) to $4,359,205 in 2005-2006 ($1,895,584 to candidates).” In the 2005-2006 election cycle, almost one quarter of the state legislators on committees relevant to health care—the Health, Budget, and Appropriation committees in the State Assembly and the Health, Human Services and Budget and Fiscal committees in the State Senate—received contributions from the tobacco industry.

It’s thus unsurprising that the tobacco tax became a sticking point for California’s health care plan, and that the proposal sunk. But it’s not just California that’s in Big Tobacco’s crosshairs—the shoot-out between health care reformers and Big Tobacco extends across the nation.

Tobacco has a major negative impact, and not just on the health of our youth...

Labels: YearOfReform

posted by Anthony Wright | Permalink | 11:26 PM


 

Gov: Another round?

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


 

Working on both fronts...

Friday, April 25, 2008

Lots of hub-bub in health circles about an article in the Capitol weekly publication The Hill, suggesting health reform isn't a certainty in 2009 at the federal level. There's lots of pushback and clarification as a result.

Either way, it suggests that reformers and advocates, while continuing to push for national health reform, should *not* sit on their hands at the state level. We have a window of opportunity in 2009-10 at *both* the federal and state levels, with a new President and Congress, and here in California with new legislative leaders and a Governor interested in prioritizing health care. We need to work on both, in simultaneous and complementary ways.

Labels: Federal, OtherBlogs, YearOfReform

posted by Anthony Wright | Permalink | 5:50 PM


 

Chaps my hide

Wednesday, April 09, 2008

It's really really annoying to me when people who talk about the "affordabilty'' of insurance only fixate on the premium prices.

And it's especially offensive when we have a person travel from Los Angeles to Sacramento to testify about junk insurance plans -- after having incurred $40,000 costs -- be told that "at least you had insurance.''

As part of an illustration for why we need SB1522 (Steinberg) to organize the individual health insurance market and weed out junk insurance plans, we brought up someone who actually had one of these hospital-only junk insurance plans -- Susan Braig, a former art teacher.

Susan was a conscientious consumer with a modest income. Approaching age 50, she decided she needed to get health insurance after having dropped it briefly in the late-90s during the huge run-up in premium prices. After carefully researching the balance of premium and benefits, she selected the coverage she could afford -- hospital-only, catastrophic coverage through Blue Cross -- the Basic PPO 1000. This has a $1,000 deductible with a $3,500 maximum out-of-pocket, and did not cover doctors visits. After the deductible, 80% of big-ticket services (like surgeries, hospitalizations, etc.) would be covered.

But, Susan rationalized, as many in her predicament might, that she's healthy, never used her insurance before, and could afford the doctor's visits here and there, but that $3,500 was a modest amount to pay if a catastrophic illness befell her.

Well -- shortly after purchasing the policy, she was diagnosed with breast cancer -- and over two years, her credit card debt increased from $5,000 to $45,000.

None of the series of doctors visits, prescription drugs, ultrasounds and lab tests were -- or will be -- covered by Basic PPO 1000. What's worse, it also did NOT count toward her deductible $1,000 deductible.

"Even my chemotherapy treatments were considered "doctor visits'' unless I had the identical treatments an hour from home in a hospital.''

Functionally, Susan is uninsured. This experience has left Susan wondering -- "I'm paying insurance premiums for WHAT?''

So it continues to gall me that the industry makes arguments that the "cost'' of insurance will go up if we weed out plans like Susan's. Up from what? Isn't $40,000 over two years enough already?

Labels: BlueCross, Insurers, Legislation, Underinsurance, YearOfReform

posted by Hanh Kim Quach | Permalink | 4:33 PM


 

Looking back, looking forward...

Thursday, March 20, 2008

Steve Wiegand of the Sacramento Bee brings us a fascinating blast from the past, explaining some of the details with Gov. Earl Warren's attempt at health care reform many decades ago. The question is whether the current Republican Governor's second attempt at health reform (he says he's committed) will be more successful...

Lots of posts about state and national health reform in this week's Health Wonk Review, hosted by Joe Paduda at Managed Care Matters. It nicely spotlights our recent post asking what's wrong with the restaurants...

Ground zero in health care reform (at least one of the 'zeros') is San Francisco, perhaps the largest political entity in this country to legislate universal coverage. Anthony Wright finds the most vocal opposition to Healthy San Francisco came not from insurers, or pharma, or physicians or neocons, but restaurants. From his desk, it looks like the restaurant's opposition may be backfiring, as some patrons are happy to pay a surcharge to cover their server's health benefits.

I've always said that given the raw numbers, Los Angeles was the ground zero in the uninsured crisis in the nation--so maybe it's appropriate California offer a ground zero in the solution--hopefully Sacramento will re-establish it's claim to that mantle as well.

Other interesting posts noted include:
* a series on the state of America's health system by Tom Lynch (a four-part post: One,