Thinking about ten years ago…

Yesterday, we put out a quick “year in review” for 2009. Many are taking the opportunity to look back at the decade of 2000-2009 (even if technically the decade goes into 2010.)

It is striking to see how the conversation has evolved from ten years ago. In California, the health policy debates were focused on (and that Health Access was active in) was the establishment of the HMO Patients Bill of Rights (and the creation of the Department of Managed Health Care to enforce them), and the implementation of the new Healthy Families program for low-income children. Although in the case of Healthy Families, the issue back then was that the program was undersubscribed, and the state was not taking advantage of 2:1 federal matching funds, and so efforts were focused on boosting enrollment like simplifying the overlong application and training application assisters. (Governor Davis didn’t run on health issues, but he highlighted both children’s coverage and patients’ rights as part of his re-election bid in 2002.)

These issues are still with us:
* The Department of Managed Health Care recently implemented language access regulations and will officially put in place standards for timely access to care in a few weeks. They’ve begun a regulatory process on regualting so-called discount health plans.
* Healthy Families has grown steadily and been a success story in reducing the number of uninsured children–although there are still hundreds of thousands of children without coverage that are even eligible but unenrolled. Yet as opposed to a time of budget surplus, the budget crisis has meant that simply keeping the program’s doors open is a victory. State funding for those application assisters has been zeroed out, and the entire program was proposed to be eliminated last year.

The boom times allowed for incremental improvements in access to health care. What was not in the conversation was the major health reforms and expansions in the debate now–perhaps there was still a caution and a recovery from the failure to pass major health reform in the early Clinton years. The 2000 presidential election between Vice President Gore and Governor Bush did not focus on health care issues–and when it did, it was about issues like incremental expansions of children’s health coverage and passing a national version of an HMO Patients’ Bill of Rights. Both elements are parts of the much bigger reform package that is being discussed now.

At the beginning of the decade, California started an effort to invest and get federal money to expand our Healthy Families program to cover the parents of those children–but when we finally got federal permission, an economic downturn–along with 9/11 and the energy crisis–caused a budget crisis we have never really recovered from. Our budget crisis was not helped by the various reductions in revenues that were approved–from the vehicle license fee that Governor Schwarzenegger campaigned on to win the recall to the corporate tax giveaway in the last budget. So much of this decade has been about preserving existing health care public programs through tough budget times. And the last budget–that eliminates various Medi-Cal benefits and much more–is more of a blow because it is a defeat after a decade of defense.

But at the same time, California provided the template for the broader reforms we had now. In 2002, a health care options process generated some ideas on health reform. In 2003 saw the first reintroduction of a single-payer bill, SB921 by Senator Sheila Kuehl–and the passage of an employer mandate, SB2 by Senate President Pro Tem John Burton. That bill was signed by Governor Davis days before his recall in 2003, which set the stage for a referendum campaign in 2004. While unsuccessful, the close vote (49.2%) showed that health reform was achievable, which led to other efforts, like the successful passage and implementation of Healthy San Francisco. Governor Schwarzenegger opposed Prop 72, and vetoed both universal children’s coverage (AB442 in 2005) and single-payer bills (SB840 in 2006), before putting forth his own reform proposal in 2007.

Whatever people thought of the details, the final proposal negotiated with Assembly Speaker Nunez was ambitious, and has similarities to what it now being discussed in Washington, from much bigger Medicaid expansions to insurance reforms including guaranteed issue. We have also seen, however, that a failure means that politicians can quickly move on to many other issues.

So ten years later, some things haven’t changed, but a lot has. We have made some progress, in policy (like HMO consumer protections), and also in what is politically possible. The question is whether, despite the budget and other barriers, we can build on that base for the next ten years.

Health Access California promotes quality, affordable health care for all Californians.
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