Covered California Board Meeting – May 21, 2015

The highlight of today’s Covered California Board meeting was a discussion on the proposal to place a monthly cost cap on specialty drugs, a goal for consumer advocates. Today’s proposal came out of a Covered California Specialty Drug Workgroup process, which Health Access, Consumers Union and other consumer advocates participated in. The Board had previously voted in favor of policy changes improving the transparency of drug formularies and requiring the placement of some high-cost drugs on lower benefit tiers, proposals that also came out of the Specialty Drug Workgroup process.

Following public comment, which underscored the need to help consumers’ access very expensive specialty drugs, the Board voted in favor of placing a monthly cost cap of $250 (with a $500 cap on Bronze plans). There will be a monthly cost cap of $150 for “enhanced Silver” 87 and 94 plans, which are designed for low income individuals.

The general sentiment among consumer advocates was that the caps are an improvement from where we are currently, even if they are not low enough. The MS Society, for example, expressed that individuals with MS have been found to stop taking their prescription drugs when the cost is more than $200 for a single prescription. CMA also testified in support of a monthly cost cap, citing reports of issues with medicine regimen adherence due to high cost prescription drugs.

The Board also adopted a policy to allow for one year, with limits and consumer protections, plans with different “hospital tiers.” While consumer advocates called such plans confusing and concerning, and the Board agreed they were “messy,” the policy was agreed to with the understanding it would be reviewed for next year.

Today’s Covered California Board meeting also discussed the Covered California 2015-16 Budget, leading up to a vote next meeting. Executive Director Peter Lee pointed out that the budget allocations take into account operations and technology costs, the need for permanent ongoing work around marketing, outreach and enrollment, the reality that California is the only state that has state workers doing the customer service work, and the value that Covered California places on partnerships with community organizations in their effort to improve enrollment. Board Member Paul Feuer, who dialed in from a remote location characterized the proposal as a “thoughtful and prudent beginning.” Several advocates urged that money for navigators and for consumer assistance–categories that faced reductions from the current year–be restored. Anthony Wright for Health Access urged the Board to allocate additional monies to outreach and customer service to improve enrollment, highlighting the need for more investment on communicating with existing members for higher retention, and on outreach and enrollment to capture individuals who experience life changing events. While urging a smaller budget, Kaiser echoed similar comments in which individuals who are going through a life changing experience can be enrolled.

Covered California is seeking comments on the 75-page budget document, and expects to vote on it next meeting in June.

Budget Subcommittees Act to Restore Services and Expand Access to Medi-Cal

The Senate and Assembly Budget Subcommittees on Health and Human Services met this morning to take final actions on the Governor’s proposed budget and trailer bills and advocates’ proposals for augmentations and restorations. The full budget committees for both houses will be meeting in the coming days to act on subcommittee actions. We expect budget conference committee will convene before the end of the month to resolve the differences between the different budget proposals, and setting the stage for negotiations with the Governor.

Many of Health Access’ budget priorities were adopted at least in part by at least one of the subcommittees.

Restoration of Medi-Cal Cuts: The State eliminated non-federally mandated Medi-Cal benefits and cut provider rates during the fiscal crisis in 2009-2010. The budget subcommittees have voted to restore the cuts as follows:

  • Benefits: Both subcommittees voted to restore “optional” Medi-Cal benefits including acupuncture, audiology, incontinence cream/washes, optician/optical lab, podiatry, and speech therapy ($15 million). Chiropractic services are not proposed for any restoration.
  • Full Adult Dental: In addition, the Senate Budget Subcommittee voted to restore full adult benefits ($67.5 million). The 2009 budget eliminated adult dental benefits, some of which were restored in the 2013-14 budget. The Senate also voted to increase the dental anesthesia rate to provide rate parity between general anesthesia and dental anesthesia providers ($4.3 million). All of these items will go to conference committee.
  • Provider Rate Reductions: Medi-Cal provider rates were cut by 10% during the state fiscal crisis. The Senate voted to restore the rate cut for dental providers only ($30 million), while the Assembly voted to repeal the 10% rate cut for all providers by increasing rates by 5% on April 1, 2016 and by another 5% on April 1, 2017 ($32.75 million in 2015-16). Both of these items will go to conference committee.

Immigrant Health Care: Both Subcommittees adopted the Governor’s estimates and funding for covering immigrants newly eligible for Medi-Cal due to the President’s Executive Action on Immigration. This action continues California’s existing commitment to providing full-scope Medi-Cal to those who have deferred action status. The Senate also set aside $40 million to cover the remaining uninsured regardless of immigration status (as also proposed in SB4, Health4All). This item will go to conference committee. The subcommittee did not specify how eligibility would be determined, and these issues will be worked out through the budget or legislative process.

Public Health & Prevention Programs: Both the Senate and Assembly subcommittees voted to fund various Hepatitis C and HIV prevention programs, with the Senate investing $8 million and the Assembly proposing $6 million. These items will go to conference committee.

Medi-Cal Estate Recovery: Unfortunately, neither subcommittee acted to include limiting Medi-Cal estate recovery to the minimum federal requirements in their budget actions. Health Access and other advocates strongly believe that older low-income Californians should not have to make a trade-off between seeking health care coverage and keeping their family home. California needs to limit Medi-Cal estate recovery to costs associated with long term care services and supports, consistent with minimum federal requirements. Last year, the Governor vetoed a bill to limit Medi-Cal estate recovery, arguing the policy change should be considered in the budget instead. We will continue to push for changes this year, through Senator Hernandez’s SB 33 and in budget discussions.

What’s Next: The Senate Budget Committee will meet tomorrow (Friday) morning to review and act on subcommittee actions. The Assembly Budget Committee will meet Wednesday (May 27) to do the same. We expect a budget conference committee to convene shortly thereafter.

Medi-Cal Stakeholder Advisory Committee: Highlights from May 20, 2015

With the state still awaiting initial feedback from CMS (Centers for Medicare and Medicaid Services) on its pending “Medi-Cal 2020” waiver renewal, most of the meeting was devoted to Medi-Cal programs with significant transformation initiatives.  Today’s blog covers these topics:

  • Governor’s May Budget Revision
  • Update on Medi-Cal and Covered California Enrollment
  • 1115 Waiver Renewal Concept and Application

Governor’s May Budget Revision (Mari Cantwell)

In her brief review of the Governor’s May 14 Budget Revision (see our preliminary analysis), Medi-Cal Director Mari Cantwell pointed out that most of the $6.7 billion in additional revenues since the Governor’s January budget proposal went directly to education due to Proposition 98’s constitutional funding guarantee or to the “rainy day” reserve thanks to Prop 2. This, the administration says, leaves little room for Medi-Cal investments beyond the minimum required managed care rate increases. The Governor has allocated funding for Medi-Cal coverage of those newly eligible because of the President’s executive order on immigration.

When asked about the rationale for no increases in rates beyond the required minimum, Ms. Cantwell explained that any increases in this area would need to be linked to measurably improved access (like taking more patients or engaging more providers) and that the budget revision process does not leave room to make such a determination.

To the group discussion about access and how/when to measure it or the need for related infrastructure investments, DHCS Director Jennifer Kent clarified that the first thing that DHCS wants plans to do is meet the terms of their contract. To the extent they can negotiate favorable rates that leave any wiggle room for local infrastructure or community investments, DHCS is fine with that…as long as this does not diminish access.

The May Budget Revision also includes $150 million for counties’ increased eligibility determination workload. To Gary Passmore’s (Congress of California Seniors and Health Access CA Board member) question about how disruptive the renewal process might be to the care process, particularly for patients with chronic conditions, Kent explained that DHCS has been engaging the counties in pro-actively anticipating the need for renewal so as to minimize disruption to patients. Cathy Senderling (County Welfare Directors Association) confirmed this, adding that as more Californians have moved into managed care, the counties have been more involved in the renewal process.

Churn (where people move on and off programs) has been quite disruptive to care, says Steve Melody of Anthem Blue Cross. To the extent plans can be engaged in eligibility renewal, this can help mitigate churn. Speaking for the California Primary Care Association, Marty Lynch of Lifelong Medical added that community health centers have enrollment assistors specifically trained and funded to help with renewal. The counties ought therefore to engage them more.

Update on Medi-Cal and Covered California Enrollment

Reports from Covered CA’s second open enrollment show 495,073 new enrollments for coverage effective sometime in 2015, a little lower than anticipated. Latino and African American share of total enrollment (37% and 4%, respectively) moved closer to Cal SIM estimates (38% and 5%, respectively)  New and more specific data and more will be posted in time for Covered CA Board Meeting today (May 21). The renewal rate of 92%, with younger mix of new enrollees, and increased use of enrollment assistance (a deliberate goal of Covered CA for year 2 to help people make more informed choices about plans and metal levels).

The new data show slight migration from gold and platinum metal levels to bronze and silver plans, with that migration more pronounced for the 90% of enrollees receiving a subsidy. In response to concerns raised about whether folks are making informed decisions when they choose the bronze plans Covered California’s Katie Ravel said that Covered CA is working on analytics to sort this out.

On the Medi-Cal side open enrollment 2015 shows 1,094,791 enrolled (with 87.1% found eligible) for the MAGI population (under the new ACA eligibility rules) and 90,602 for non-MAGI (they still have have an asset test and are typically using Medi-Cal for long term care services, and supports). Of the 2.4 million cases due for renewal in 2015, 80% have been processed, and so far of these 80%, 82% continued their Medi-Cal coverage.  DHCS is working with Covered CA to smooth out the transition from Covered CA to Medi-Cal for those experiencing a change in circumstances (see “transition flows” documents here).

Find complete Medi-Cal enrollment and renewal data here: http://www.dhcs.ca.gov/Documents/Medi-CalEnrollmentSACMay2015.pdf.

1115 Waiver Renewal Concept and Application

With the state’s application for a Medi-Cal 2020 renewal submitted and comments letters in, DHCS anticipates receiving initial feedback from CMS any day now. In the meantime, DHCS expects most of the initial dialogue with CMS will be about budget neutrality assumptions and the state’s case for shared savings. The state’s case rests on the notion that if a state (and the largest one at that) does something that saves the federal government a lot of money, the state should be able to participate in those savings.

Addressing Cantwell’s concern that CMS may want to base budget neutrality on managed care rates, rather than the current fee-for-service rates, effectively lowering the amount of funding available, Erica Murray of the California Association of Public Hospitals pointed out that the public hospitals would simply not be able to continue what they are doing on delivery system reforms. The public hospitals and other key stakeholders were encouraged to be fully engaged around the waiver negotiations. To this point, echoed by many in the room, Kent said that as soon as they have something to share, DHCS will be as open and transparent as possible. At a minimum stakeholders can expect a webinar or conference call following the first round of feedback from CMS.

For complete meeting minutes on all topics (when ready), click here.

Budget Subcommittee Hearings on May Revision

The Senate and Assembly Budget Subcommittees on Health and Human Services held the first of two hearings on the Governor’s May Revision on Monday, May 18. These hearings follow dozens of hearings that were held the past couple months on the Governor’s January budget proposal and proposals for reinvestment. See the Senate and Assembly subcommittee agendas for details about the items heard.

In her opening remarks, Subcommittee Chair Senator Holly Mitchell said, “We heard you,” referring to the hundreds of advocates and constituents that have appeared before the committee. “The budget decisions we make in health and human services,” she added, “have real life and death impacts on hundreds of thousands of Californians.”

Noting that the Governor’s May Revise includes a proposal for a state Earned Income Tax Credit, Sen. Mitchell said, “But we need to look at a broader, more strategic approach if we’re going to reduce the number of Californians living at or below poverty… I believe the Legislature has a responsibility to reinvest in the human services and safety net programs that offer families, seniors, and Californians living with developmental disabilities a fighting chance to live beyond the desperate demands of the moment and invest in California’s future.”

The budget subcommittees of each house heard the following May Revision issues:

  • Medi-Cal: County Administration Funding: The May Revision proposes to increase Medi-Cal county administration funding by $150 million, the same amount given last year, for supplemental funding for eligibility determination workload related to the ACA. Counties believe the proposed level of funding is insufficient to meet the workload demands and have asked for $300 million, along with expediting the adoption of a new funding methodology. Health Access spoke in support of the counties’ need for sufficient resources to do eligibility determinations and provide eligible people with meaningful access to Medi-Cal. Both the Senate and Assembly subcommittees held this issue open pending further conversations.
  • Medi-Cal: Impact of President’s Executive Order: The May Revision includes funds to provide full-scope Medi-Cal to newly qualified individuals as a result of the President’s Executive Order on immigration. The funding includes $41.5 million in 2015-16 and $206 million on an ongoing basis. Health Access testified that the Administration’s estimates are both too high and too low. The estimates are too high because the enrollment phase-in is likely to take longer than estimated by the Administration; and they are too low because our experience with DAPA and DACA show that more people will likely enroll in Medi-Cal than estimated by the Administration. Both subcommittees held this issue open pending further conversations.
  • Medi-Cal Enrollment Application Assistance Payments: The State has received a series of grants from the California Endowment to help Medi-Cal beneficiaries apply for, and stay on Medi-Cal. One of the grants provides in-person enrollment application assistance payments of $58 per approved Medi-Cal application to certified insurance agents and enrollment counselors. DHCS needs to transfer about $2.5M in unused funds to county outreach and enrollment grants effective June 30 of this year. Health Access and other health advocates testified to the need to ensure that community-based organizations are able to access these funds after the transfer. The Senate adopted placeholder trailer bill language to keep the conversation going, while the Assembly held the issue open.
  • Health Home Program: Two years ago Senator Mitchell authored AB 361 to create, upon federal approval, an ACA Health Home Program to serve Medi-Cal beneficiaries with multiple chronic conditions who are frequent utilizers of services and may benefit from more care management and coordination. The May Revision proposes trailer bill language to allow DHCS to allocate federal dollars and private grants to implement AB 361. Health Access supported AB 361 and spoke in support of the proposed trailer bill. The Senate budget subcommittee adopted placeholder trailer bill language to keep the conversation going while the Assembly budget subcommittee held the issue open.
  • High Cost Drug Proposal – Hepatitis C: The May Revision proposes to allocate about $275 million in funding to various state agencies (health care services, corrections, state hospitals, public health) for Hepatitis C treatment. The May Revision also indicates the California Health and Human Services Agency will convene two workgroups on clinical and procurement issues with the goal of developing a proposal for the 2016-17 budget. In our public comments, Health Access stated that any proposal to address high cost drugs should include efforts to reduce the number of new infections. Both Committees held this item open to allow for additional time to study the issue.

What’s Next?

Both budget subcommittees will meet again on Thursday to take additional actions and report their actions to the full budget committees of their respective houses.
• Friday, May 22: Full Senate Budget Committee hearing
• Wednesday, May 27: Full Assembly Budget Committee hearing
• End of May/early June: Budget Conference Committee
• June 15: Deadline to pass State Budget

Scott Graves of the California Budget and Policy Center wrote a helpful blog about the budget process between now and June 15.

May Budget Revision: Key Investments Still Needed

Earlier today, California Governor Jerry Brown released his May Revision for the proposed 2015-16 state budget, a $115.3 billion spending plan that he said focuses on “the fundamentals of health and education.”

The May revision includes $6.7 billion in additional revenues that the state has collected since the Governor’s January proposal, almost all dedicated to Proposition 98’s constitutional funding guarantee for education and Proposition 2’s “rainy day” reserve. As such, there were few new investments or restorations in health care beyond continued implementation of the Affordable Care Act. The most notable health-related change from January was that the Governor did allocate funding for Medi-Cal coverage for Californians impacted by the President’s recent executive order on immigration. This continues California’s longstanding policy to provide coverage to immigrants with “deferred action” status, but it does not go beyond existing law.

But on health care, the May Revision of the state budget continues the cuts to public health programs and Medi-Cal rates and benefits made during the recession. With the May Revision as the context, health and community advocates are urging the Legislature to craft a budget that includes investments needed to reduce barriers to coverage, increase access for Medi-Cal patients, and cover the remaining uninsured.

A RESPONSE ON REDUCING POVERTY: The biggest policy change in the Governor’s May Revision was a state Earned Income Tax Credit (EITC) on top of the federal credit, which has a proven track record for encouraging work and reducing poverty. Governor Brown said the state EITC had a “minimum of bureaucracy and complexity” and is “just a straight deliverance of funding to people who are working very hard and are earning very little money, so in that sense I think it does a lot of good things.” See the California Budget and Policy Center’s information on understanding the state EITC.

The Governor indicated he heard the critique from many, including legislators, Health and Human Services (HHS) Network advocates, Health Access California, and other allies—about the need to address poverty. “I’ve heard that loudly. I thought this was a reasonable response,” the Governor said of the $360 million proposal. Today and throughout this week, community advocates have held press conferences around the state, urging a comprehensive approach to helping low-income families beginning with a state budget that not only pays down the wall of debt but also breaks down the wall of poverty. Recognizing poverty is both a cause and a consequence of poor health, Health Access welcomes the proposed state EITC, but maintains this  should be part of a multi-pronged effort, including making Medi-Cal more inclusive so families getting the EITC are covered and are not one emergency away from financial ruin.

HEALTH CARE IN THE MAY REVISION OF THE BUDGET

The Governor’s May Revision of his proposal budget includes $31.8 billion in general fund spending under the Health and Human Services Agency, representing a 5.9% increase from last year. The Department of Health Care Services, which operates Medi-Cal, has a $19 billion general fund budget ($98 billion includes over $61.4 billion in federal funds and $17.6 in other special funds and reimbursements).

Continued Implementation of the Affordable Care Act: The Governor’s May Revision includes funding for California’s continued implementation of the ACA. This includes funds for the mandatory (simplifying eligibility, enrollment, and retention rules) and “optional” (extending eligibility to adults without children, and parent and caretaker relatives living under 138% of the FPL) Medi-Cal expansion. In his press conference, the Governor again noted the significant rise in Medi-Cal enrollment, estimated in his May Revision to be 12.4 million in 2015-16.

The May Revision also includes an additional $125 million for managed care rate increases and $150 million recognizing the increased county workload required for eligibility determination.

Immigrant Health Care and the Remaining Uninsured: The Governor’s proposal allocates $200 million to fund Medi-Cal coverage and a few other health and human services programs for Californians newly eligible for relief under President Obama’s November 2014 executive order on immigration. This continues California’s longstanding tradition and policy of including Californians with “deferred action” immigration status in Medi-Cal coverage—people excluded under federal Medicaid and the Affordable Care Act. The budget also includes $5 million for grants to nonprofit organizations to help provide application assistance to Californians seeking deferred action status under the President’s order.

Consumer advocates, including Health Access, will continue pressing for expanding access to all Californians income eligible for Medi-Cal without regard for immigration status, as proposed in SB 4 (Lara). After accounting for those covered under the President’s Executive Action, the cost would be a small fraction of last year’s proposal, amounting to $100-300 million, or around 2 more cents for every dollar spent on Medi-Cal—far less than the “billions” the Governor speculated such an expansion would cost when questioned this morning. When asked if he would sign SB 4 during his press conference, the Governor said he’s not inclined to spend money that’s not available and pointed to the need to account for costs in the future and for future recessions.

OTHER HEALTH INVESTMENTS NEEDED: Perhaps most telling were the priorities that were not included in the Governor’s budget proposal, including many investments that health and community groups continues to support.

Medi-Cal Estate Recovery. Arguing that older low-income Californians should not have to make a trade-off between seeking health care coverage and keeping their family home, advocates are seeking that California limit Medi-Cal estate recovery to costs associated with long term care services and supports, consistent with minimum federal requirements. Last year, the Governor vetoed a bill to limit Medi-Cal estate recovery, arguing the policy change should be considered in the budget instead.

Restore Medi-Cal Benefits Eliminated in the 2009-10 Budget. Also missing from the May Revision are a number of Medi-Cal benefits that were eliminated in 2009 during the state’s fiscal crisis for budgetary, not policy reasons. They include, among other things: acupuncture, audiology, chiropractic, podiatry, speech therapy, and full restoration of adult dental coverage. Adult dental services, which gives Medi-Cal beneficiaries access to preventative care, restorations, and full dentures, were partially restored in the 2013-14 budget,. However, important services such as gum treatment and partial dentures or implants are still not covered in Medi-Cal.

Medi-Cal Provider Rates. To encourage more providers to participate in Medi-Cal and help increase access for Medi-Cal beneficiaries, providers and consumer groups have sought to increase reimbursements to providers in Medi-Cal. In fact, even before a recent 10% rate cut, California’s Medi-Cal provider reimbursement rates were among the lowest in the nation, making access to doctors, specialists, and beneficiaries harder for some of the 12 million Californians with Medi-Cal coverage.

WHAT’S NEXT? The Senate and Assembly Budget Subcommittees will have hearings on the Governor’s May Revision next week. We expect a Budget Conference Committee to convene at the end of the month to hash out differences between actions taken by the two houses. The deadline for a final budget to be passed is June 15th. Health Access will provide updates on our blog.

Quick reaction to the Governor’s May Revise…

Today, California Governor Brown released the May Revision of his proposed 2015-16 state budget. Here’s some quick takes–more to come later today:

THE NEED FOR MEDI-CAL RESTORATIONS AND INVESTMENTS: This budget lacks needed investments to improve Medi-Cal and the health system on which we all rely. After an expansion of Medi-Cal through almost entirely federal funds, we need added state investments to make Medi-Cal more inclusive, more streamlined, and to ensure that Californians get the care and services they need. The Governor’s budget continues to leave in place cuts to key public health programs, Medi-Cal benefits, and provider rates made during the recession. We should remember that any surplus was created in part out of $15 billion in cuts to health and human services–cuts that continue today and into the future without some reinvestment.

IMMIGRANT HEALTH CARE: We appreciate that the Governor’s recognition of California’s existing policy of ensuring Medi-Cal includes those with “deferred action” immigration status, by allocating funds for covering Californians under the President’s executive order. Immigrants are a vital part of our community and economy and should be fully included in our health system. By the same logic, the Governor and Legislature should extend Medi-Cal coverage to all income-eligible Californians regardless of immigration status, which is more cost-effective and efficient than just the emergency services provided today. In his comments, the Governor wildly overestimated what would be the cost of such an expansion; over the next few weeks, we will make the case about how this is actually a modest investment with a big benefit to our whole health system and economy.

ANTI-POVERTY EFFORTS WELCOME: We appreciate the Governor’s support of an earned income tax credit, but it needs to be part of a multi-pronged strategy to address poverty. More resources to low-income families is certainly welcome, but those dollars are at risk if the family is uninsured and one emergency away from crushing medical debt. Making Medi-Cal more inclusive gives low-income families some additional financial security in in their efforts to rise out of poverty. While we address the wall of debt, policymakers also need to break down the wall of poverty in California.

State Budget Preview: Key Investments Still Needed

The annual state budget process, which began in January, comes into focus later this week when the Governor releases the May Revision of his proposed 2015-16 budget. Health and community advocates are urging the Governor and the Legislature to include funding for critical health programs in upcoming budget negotiations. These investments continue the Affordable Care Act’s momentum by removing barriers to coverage, ensuring those covered in Medi-Cal get access to care along with important benefits, and extending coverage to the remaining uninsured.

The deadline for the Legislature to pass and the Governor to sign a budget is June 15. The Governor’s May Revision sets the stage for a short month of negotiations, shaped by information about how much of a surplus is available given the state revenues that came in during April tax time, and constitutional formulas that limit the use of these funds.

Recent Budget Subcommittee Hearings: Since introducing the budget in January, the legislature’s budget subcommittees have reviewed the Governor’s proposed budget along with budget requests from advocates. In recent days, the Senate and Assembly Budget Subcommittees on Health and Human Services completed their reviews of the Governor’s proposed budget, along with a range of urgent and needed health investments that were not included in the Governor’s proposed budget, from expanding coverage without regard to immigration status to limiting estate recovery in Medi-Cal to restoring Medi-Cal benefits. The subcommittees left most of these items open for further discussions pending the May Revision. Many consumer and community organizations including Health Access California were on hand to strongly support these critical investments.

Immigrant Health Care. Although the Affordable Care Act made health coverage possible for millions of Californians, it excludes undocumented immigrants currently living and working in any state. If and when the President’s executive order on immigration is upheld in court, those newly eligible for deferred action will have access to Medi-Cal. Advocates are proposing to expand that access to all Californians income eligible for Medi-Cal, without regard for immigration status, as proposed in SB 4 (Lara). The cost would be a small fraction of last year’s proposal, amounting to only 2 more cents for every dollar spent on Medi-Cal, but would make a world of difference for not just immigrant families, but for our health system and society.

Estate Recovery. Advocates are also seeking that California limit Medi-Cal estate recovery to costs associated with long term care services and supports, consistent with minimum federal requirements. Last year, the Governor vetoed a bill to limit Medi-Cal estate recovery, arguing the policy change should be considered in the budget instead. Health Access will continue to vigorously advocate for this policy change so that older low-income Californians don’t have to make a trade-off between seeking health care coverage and keeping their family home.

Restore Medi-Cal Benefits Eliminated in the 2009-10 Budget. Major cuts were made during the budget crisis that have yet to be restored, including Medi-Cal rates and benefits, and consumer advocates including Health Access request undoing those cuts. In this part week, the budget subcommittees heard a proposal to restore non-federally mandated yet critical Medi-Cal benefits that were eliminated for budgetary, not policy reasons, in response to the state fiscal crisis. They include, among other things: acupuncture, audiology, chiropractic, podiatry, speech therapy, and full restoration of adult dental coverage. Partial restoration of adult dental was done in the 2013-14 budget, which gives Medi-Cal beneficiaries access to preventative care, restorations, and full dentures. However, important services such as gum treatment and partial dentures or implants are still not covered in Medi-Cal. According to a recent study published in Health Affairs, California emergency departments experienced a spike in visits for dental issues after comprehensive dental benefits for adults were cut from Medi-Cal. The study further found that the lack of adult dental benefits shifts dental care needs to costly emergency departments where dental issues are not adequately addressed.

Medi-Cal Provider Rates. Many providers and consumer groups have sought to rescind the 10 percent Medi-Cal provider rate cut, which will encourage more providers to participate in Medi-Cal and help increase access for Medi-Cal beneficiaries. In fact, California’s Medi-Cal provider reimbursement rates are among the lowest in the nation, making access to doctors, specialists, and beneficiaries harder for some of the 12 million Californians with Medi-Cal coverage. 

What’s Next: The Governor is expected to release his May Revision of the budget later this week. The budget subcommittees will then hold hearings to review the May Revision the following week (May 18-22), and the Budget Conference Committee will convene at the end of the month to hash out differences between actions taken by the two houses. A final budget must be passed by June 15th. Stay tuned for updates!

Betty Perry, RIP

This weekend, the Sacramento, Capitol, and social justice community lost a legendary advocate in Betty Perry. For years, she worked diligently and effectively on health care, housing, budget, civil rights, and other issues as the most prominent representative in the California Legislature for the Older Women’s League of California, serving in multiple volunteer roles including public policy director and statewide president. She served in many other capacities, including as board member and president of Health Access California.

BettyPerry

While she hasn’t been active in the Legislature for the last several years due to her advanced age and ailing health, many remember her role as a beloved, respected “white hat” community advocate who served as the conscience of the California Legislature on many social justice issues. She would frequently testify and submit letters on a list of bills that would rival a professional lobbying firm, and also participated in administrative advocacy and agency workgroups. She was dogged and determined in her goals, both with keen knowledge, her ability to organize OWL members and allied senior and other groups to her cause, and her moral authority that in part came from her heart and values and from her previous career as a teacher.

She was the guidance counselor at McClatchy High School here in Sacramento, and so she knew many local political personalities from their childhoods, from Supreme Justice Anthony Kennedy to former state Senator Deborah Ortiz to the late Congressman Robert Matsui, who honored her in the Congressional Record. Betty was one of the few speakers at his high-profile funeral. Ever the teacher, she wasn’t shy about writing to legislators or Governors telling them when she was disappointed in their actions.

Representing OWL, Betty was a long-time board member of Health Access California, and served several years as our President. Our 25-member board is highly diverse in constituency and capacity but all were united in their respect for Betty. She ran a good meeting, as you would expect: once when I tried to prep her on a flight down to an Los Angeles board meeting, she sharply reminded me that she chaired her first meeting when she was 18, indicating she had over 60 years experience in such a role. As chair, we were proud to have her represent Health Access in meetings with Governor Schwarzenegger on prescription drugs, and in other forums.

She was a tremendous advocate for universal single-payer health care, a frequent priority of OWL and their annual “Mother’s Day Card” action and lobby day that she organized that would have been taking place about this time each year. She was very active on Medicare Part D, on health budget cuts, and women’s health, and not just with “me too” positions. Betty Perry and OWL, which had been founded by a woman who lost her coverage when she was widowed in her 50s and found she could not buy coverage at any price, took on the issue of pre-existing conditions before it was politically sexy. When few others focused on it, she worked closely with us to support and improve the state’s high-risk pool, the Managed Risk Medical Insurance Program (MRMIP). I am so pleased that she lived long enough to see the progress of the Affordable Care Act and the end of pre-existing condition denials, as well as restorations in the state budget and other goals she worked on.

Even in an advocacy community that has its divisions at times, and in a legislature of competing interests, Betty had broad respect because she represented the good and the just. Nobody questioned Betty’s motives, even those that questioned her positions (which I can’t remember ever doing). The fact that she had this distinguished second career in her retirement as a volunteer was a source of inspiration as well. I recall at least a couple career lobbyists and community leaders, after seeing her work, saying to me, “When I grow up, I want to be Betty Perry.”

We’ve missed Betty Perry the last few years, and now we celebrate all that she contributed. We will post more information about a memorial reception that is likely to be held next week, and other information from the family as soon as we find out.

UPDATE: A memorial for Betty will be held Friday, May 15, at 2:00 pm at St. Mary’s Catholic Cemetery located at 6700 21st Ave, Sacramento, CA 95820. It will be followed by a memorial/reception at the Dante Club on Fair Oaks Blvd.

 

Legislative Re-Cap: After the First Deadline…

Last Friday was the deadline for all policy committees in the California legislature to hear and report on all bills with fiscal implications–and the good news is that many key bills of interest to health care consumers have passed their first critical hearing. While some bills stalled (including almost all of those Health Access opposed but also a few that advocates supported), bills moving forward include limits and protections against unfair out-of-pocket costs; efforts at greater transparency on cost and quality in our health system; and an expansion of access to coverage for all regardless of immigration status. For details on each bill, see our weekly bill matrix

These bills still have a long path to final passage, including a June 5th deadline (only one month away!) to pass a full floor vote in the bill’s first legislative chamber, whether in the Assembly or Senate. Before then, most bills with fiscal implications go to the Appropriations Committee. In the Appropriations Committee, any bill costing over $150,000 is tagged as “on suspense,” meaning that that bill’s priority needs to be decided alongside other bills that cost money. The fate of bills “on suspense” will be decided near the end of May at the Appropriations Committee’s suspense hearing, and then they proceed for floor votes the week of June 1-5th. A handful of bills have passed both the policy and fiscal committees and are already on their way to the Assembly or Senate Floor for review.

#HEALTH4ALL; A top priority bill for Health Access and many of our partners, SB4(Lara) to expand coverage regardless of immigration status passed Senate Health Committee in April 7-0. Last Monday it was heard in Senate Appropriations Committee and placed, as expected, on suspense, awaiting a decision in late May along with many other bills. This bill, to expand Medi-Cal to all income-eligible Californians regardless of immigration status and allow undocumented Californians to buy insurance with their own money through Covered California, got support and powerful testimony from health, immigration, community, labor, and provider groups. Senators on both the Health and Appropriations Committee added their own affirmation to the bill, with many signing on as co-authors. Going forward, the biggest issue is the potential cost, and the new Appropriations analysis suggests the potential costs are a fraction of last year’s proposal–from $100-$300 million if the President’s executive action on immigration is upheld by the courts (thus covering a significant portion of uninsured immigrants). Health and immigration advocates are gearing up for a major push in late May for a potential Senate floor vote in early June.

OUT-OF-POCKET COSTS: All five Health Access-sponsored consumer protection bills to prevent unfair out-of-pocket costs have passed Health Committee…

  • Health Access sponsored legislation, AB533 (Bonta), which would prevent consumers from getting out-of-network bills when going to an in-network hospital or facility, passed out of the policy committee unanimously. Even when patients do the right thing by going to an in-network facility, they remain vulnerable to “surprise bills,” which can add up to hundreds if not thousands of dollars and put a family’s finances at risk if not prevent lower-income patients from getting needed care. Broad support for the bill came from consumer groups like Consumers Union, labor groups, and insurers. Recognizing that most stakeholders agreed with the overall goal of the legislation, Assemblyman Bonta promised to work with concerned physician groups and bill sponsors and supporters on an independent dispute resolution process to ensure a fair payment between the insurer and the non-contracting physician. Committee members appreciated attempts to improve the bill, and acknowledged the need to get the consumer out of the middle of what is ultimately a dispute between plans and providers.
  • SB 137 (Hernández) is in suspense in Appropriations Committee. Sponsored by Health Access, Consumers Union, and the California Pan-Ethnic Health Network, SB137 would set stronger standards for provider directories and establish more oversight on accuracy so people know whether their doctor and hospital are in network when they shop for coverage, change coverage, or try to use their coverage to get care.
  • AB 339 (Gordon), which builds on existing California law and federal guidance to put limits on how much insurers can shift cost-sharing for consumers for certain prescription drugs, has passed committee and is due to be heard in Assembly Appropriations. The bill would define what drugs could be placed on a high cost-sharing tier and put a monthly cap on such cost-sharing. Otherwise, under current drug benefits some consumers are expected to pay hundreds or thousands of dollars a month for a single prescription–even though the average consumer has only $2,300 in their savings account. AB339 takes the consumer out of the middle of the payment fight between insurers and drug companies.
  • Another important Health Access-sponsored bill, AB 1305 (Bonta) on limitations on cost sharing in family coverage passed policy committee unanimously. This bill ensures that the ACA individual out-of-pocket maximum (now $6,600) will apply to individual patients—even if they are in a family plan (which has an overall family out-of-pocket max of $13,200). This bill will be heard next in Assembly Appropriations.
  • Furthest along in the process is Health Access-sponsored AB 248 (Hernández), which would prohibit sale of subminimum coverage by insurers to large employers. This bill has already passed the Assembly Floor with a vote of 51-27 and is headed to the Senate for review.

TRANSPARENCY: A couple of bills to advance transparency in our health system are moving through the process. SB 26 (Hernández), which would establish and fund a health care cost and quality database, passed both the Senate Health Committee and the Senate Judiciary Committee. SB26 will make valid, timely, and comprehensive health care performance information publicly available and for use to improve the safety, appropriateness, and medical effectiveness of health care, and to provide care that is safe, medically effective, patient-centered, timely, affordable, and equitable. The author worked with Health Access and other key stakeholders to incorporate important amendments dealing with equity, the social determinants of health, and privacy. Advocates are continuing to work with the bill’s author on governance and other issues so this new database is as effective as possible.

SB546 (Leno), which would extend rate review to large group health coverage, meaning that large employers would have to justify above-average rate increases, has passed two committee hearings. Despite amendments taken in committee to remove “prior approval” rate regulation, the bill would still require important disclosures and require insurers to publicly justify their rates. With overall health care costs slowing, it’s important to ask why many premiums are still going up faster than the rate of inflation in California. While the Affordable Care Act took important steps to limit premium costs and justify rate increases, additional reforms are needed at the state level to get a better handle on premium costs.

MEDI-CAL: Several bills advanced to improve the Medi-Cal program, now covering almost 12 million Californians. AB 1231(Wood) would ensure access to specialty care in Medi-Cal through nonmedical transportation. AB 635 (Atkins) would require the Department of Health Care Services to seek federal funding to establish a program to provide and reimburse for certified medical interpretation services to Medi-Cal beneficiaries with limited English proficiency.

AB 366 (Bonta) and a companion measure (SB 243 by Hernández) would restore Medi-Cal provider reimbursement rates from the previous budget cut in the first year and bring Medi-Cal rates up to Medicare levels in future years.

TOBACCO CONTROL: A number of bills take aim at the lingering problem of tobacco use and its deadly (and costly) consequences. SB 591 (Pan), and a companion bill AB 1396 (Bonta), would raise the tobacco tax, thus improving health by reducing smoking rates and cigarette consumption in our state, and also raise funds to improve Medi-Cal rates and access. AB 1396 (Bonta) was heard in Assembly Appropriations and has been referred to the suspense file. SB 591 (Pan) is due to be heard next in Senate Appropriations. A similar measure, SB 140 (Leno), would change the definition of tobacco products to include e-cigarettes, thus subjecting such products to the same regulations as other tobacco products.

OTHER KEY CONSUMER BILLS: A full matrix of all the active bills supported by Health Access and other health and consumer advocates is available online (here), including further ACA implementation legislation like SB 43 (Hernández), which would extend the sunset date on essential health benefits standards from 2016 to 2018 and incorporate recent changes in federal guidance regarding habilitative care (services that help you keep, learn, or improve skills and functioning for daily living), passed out of committee with a unanimous vote.

STALLED: Health advocates were able to defeat most of the bad bills, but some worthy bills also stalled. The biggest disappointments for health advocates include:

  • AB 463 (Chiu) on prescription drug pricing transparency also failed in committee. This bill would have facilitated transparency on the different components or cost centers that make up the final price of specialty drugs: the cost of production, research and development, clinical trials and regulatory and acquisition costs, materials and manufacturing, marketing and advertising, and total profits. Supporters, including Health Access, consumer groups, insurers, labor unions, and business groups, hoped that such intelligence would help lay the groundwork for deeper solutions to the increasingly vexing problem of high cost specialty medications. Bill author Assemblymember Chiu intends to bring the bill back next year.
  • SB 203 (Monning), which would have required warning labels on sugar sweetened beverages, failed in committee with a vote of 4-1 with four Senators abstaining, including committee Chair of the Senator Hernández and Senator Roth, Senator Nguyen and Senator Hall. Senator Nielsen was the only No vote. Although the bill failed in committee, the sponsors (California Center for Public Health Advocacy, California Black Health Network and the Latino Health Access) are committed to bringing this bill back next year.
  • SB 346 (Wieckowski) on hospital community benefits also failed in committee earlier this week with a vote of 4-2 with three Senators abstaining, including Senator Roth, Senator Pan and Senator Wolk. Senator Nguyen and Senator Nielsen were both No votes.  This bill would have established a new hospital community benefit law to require private non-profit hospitals to complete a community needs assessment, followed by a community benefits plan. Unfortunately, the bill failed in committee with a vote of 4-2.

The LA Times weighs in…

The LA Times editorial board endorsed two Health Access California-sponsored bills this weekend to prevent surprise out-of-pocket out-of-network costs. SB137(Hernandez) would require real-time accurate and standardized provider directories; AB533(Bonta) would ensure that consumers who go to an in-network hospital or facility does not get out-of-network bills from any of the doctors or other providers they may encounter. The entire editorial is worth reading, but here’s an excerpt:

“…people want to know before they sign up for a narrow network plan whether they’ll be able to keep the doctors they like, or how far they’d have to travel to see someone willing to take new patients. And in too many cases, they’ve enrolled only to be turned away by doctors who were purportedly in their plan’s network, either because the list was inaccurate or the doctors didn’t understand their contract with the insurer.

“SB 137 by state Sen. Ed Hernandez (D-West Covina) would require insurers to publish provider lists online and update them weekly, including information about office locations, specialties, languages spoken and willingness to accept new patients. To avoid penalties, the lists would have to be at least 97% accurate and be available to anyone who’s interested.

“Even when patients arrange for care from in-network hospitals and doctors, however, they can still be hit with huge bills from out-of-network specialists and assistants. In an era of electronic payments and digital health records, it’s hard to believe that insurers can’t keep track of who’s in their networks, what services they provide and where their offices are…

“One reason it’s crucial to know who’s in a network is that the cost of seeing an out-of-network provider for nonemergency care can be ruinously high. Insurance plans cover a smaller percentage of out-of-network bills, if they cover them at all, and unlike in-network providers, out-of-network doctors don’t agree to discounted fees.

“Even when patients arrange for care from in-network hospitals and doctors, however, they can still be hit with huge bills from out-of-network specialists and assistants they had no idea would be involved in their care. In the most egregious cases, an in-network surgeon will bring in an affiliated specialist or laboratory not in the patient’s network in order to multiply the fees…

“AB 533 by Assemblyman Rob Bonta (D-Alameda) would protect patients who go to in-network hospitals from being billed at out-of-network rates for any service received there. The only exception would be for patients who agree at least a day in advance to receive and pay for out-of-network services. In effect, the bill would hold patients harmless while insurers and providers squabble over the fees for out-of-network services…

“The opposition to both measures reflects the potentially difficult adjustments insurers and providers would be forced to make in their operations. Those adjustments, however, are overdue. With the Affordable Care Act requiring all adult Americans to buy coverage, insurers simply have to deliver accurate provider lists. And providers shouldn’t be able to undermine that insurance by seeking out-of-network rates from patients who stay within their networks for care.”