Key Consumer Protections Bills Move Forward

Earlier today Senate Health Committee passed several key bills benefiting health care consumers, including two sponsored by Health Access California: AB 339 (Gordon), dealing with high cost specialty medications and AB 533 (Bonta), which halts surprise bills from out-of-network providers.

Both bills go beyond Affordable Care Act to provide improved patient protections—ensuring that the cost sharing protections apply to consumers living with chronic conditions (AB 339), and taking consumers out of the middle of disputes between health plans and providers about charges for out-of-network care.

AB339 (Gordon) presented today by Assembly Member Rob Bonta, would require insurers to cover medically necessary prescription drugs and limit cost-sharing on specialty drugs and other needed medications. This bill passed out of Senate Health on a vote of 7-2.

“Californians should not have to face discriminatory cost-sharing just because of their specific diagnosis, said Sawait Hezchias-Seyoum of Health Access, sponsor of AB 339. According to a recent Kaiser Foundation study, the average consumer has only $2,300 in liquid assets- under the current policy, a consumer with a chronic condition can burn through that in one month of co-pays alone. While some drug cost-sharing would still be high, this bill would make those costs more manageable. Since Covered California recently adopted many of the protections included in AB 339, including monthly caps on drug costs, the bill has new momentum to extend such patient protections throughout the state.

To the California Association of Health Plans and other opponents’ argument that AB 339 does not address the prohibitive and rising costs of specialty drugs, Hezchias-Seyyoum stated that it was the insurers who were best equipped to negotiate prices, not individual consumers—and AB 339 simply gets consumers out of middle of this “clash of the titans.”

The bill’s opponents argued for the need to address the underlying high costs of specialty medications—but the way to tackle this is through transparency initiatives like AB 463 (Chiu) Pharmaceutical Cost Transparency Act, which will return in January 2016 as a two-year bill.

AB533 (Bonta), which would put an end to the “surprise bills” patients encounter when out-of-network providers administer care within in-network facilities, passed on a 6-2 vote.  Surprise bills can leave consumers with as much as $12,000 in medical debt, says Betsy Imholz of Consumers Union. The bill stops this practice, and also requires health plans to pay non-contracting providers the average contracted rate paid for the same services in a similar geographic region, says Tam Ma of Health Access, the bill’s sponsor. Recent amendments to the bill address a practical problem that non-contracting providers have when they disagree with what the plan pays them. Right now, these disputes over low-dollar but high volume claims are litigated in court, explained Ma. AB 533 creates a mandatory and binding independent dispute resolution process to resolve these claims—a fair solution to the thorny issues raised by the opposition, says bill author Rob Bonta. Representing the opposition were state specialty medical societies for anesthesiologists, orthopedic surgeons, radiologists—incidentally some of the highest paid medical specialties.

To Senator Richard Roth fine question about whether patients are or perhaps should be given an opportunity to learn whether members of their care team are in or out of network, the anesthesiologists’ spokesperson said this typically happens in the pre-op meeting (before the patient goes ‘under the knife’)— that 1 in 4 consumers  have dealt with a surprise medical bill, as found in a recent Consumers Union survey, suggests this is far from the current practice.

“On AB 533 I’m going to lean with the consumers,” said Sen. Hernandez, in part “because the consumer is now required to purchase health insurance—and with that purchase they should have some confidence about who is in-network.  “We should not put the onus on patient to figure out everyone in the care team,” added Hernandez.

Another bill moving forward was AB 1102 (Santiago), which Health Care Coverage: Medi-Cal Access Program, Disclosures, supported by Western Center on Law and Poverty, Health Access, SEIU, March of Dimes, and others, would require that information on MRMIP (Major Risk Medical Insurance Program) coverage options be provided to women who become pregnant, Even after full implementation of the Affordable Care Act, this program has been preserved, explained Beth Capell for Health Access, as a safety net, for example for those who miss open enrollment. This bill passed 8-0.

Assembly Health Committee Gives Green Light to Key Consumer Health Bills

Earlier today the Assembly Health Committee voted on several priority bills impacting health care consumers and the remaining uninsured, including SB 4 (Lara)

For those who keep score, here’s how key consumer protection bills came out in today’s vote:

  • SB 4 (Lara) Health Care Coverage, Immigration Status: 10-6
  • SB 137 (Hernandez) Accurate Provider Directories 16-2
  • SB 43 (Hernandez) Essential Health Benefits 16-1

SB 4 (Lara): Allowing Broader Access to Covered California 

As amended, SB 4 (Lara) seeks to allow all Californians, regardless of immigration status, to purchase coverage through Covered California, using their own money. While the Affordable Care Act limits participation in health insurance exchanges to citizens and legal permanent residents, SB 4 directs the administration to seek a Section 1332 waiver–special permission from the federal government–to open Covered CA up to undocumented Californians. “The fact that the ACA leaves out those who can actually afford premiums is why we are running this bill,” said SB 4 author Senator Lara in today’s hearing.

SB 4 no longer includes the expansion of Medi-Cal for low-income immigrant adults—this is now addressed by a separate bill, SB 10, also authored by Senator Lara.  SB 10 has been “parked” as a “two year bill” and can be taken up again in next year’s budget and legislative session. Thanks to the final budget agreement to dedicate an initial $40 million for the expansion of coverage to an estimated 170,000 undocumented children, the scope—and cost–of SB 4 is smaller as a result and potentially more doable in 2016.

With a majority of undocumented immigrants in mixed status families, SB 4 would also allow Covered California staff to help the entire family–even those not eligible for subsidies. With Ron Coleman of California Immigrant Policy Center, Beth Capell of Health Access, and the many supporters of the bill who came forward today, SB 4 recognizes that immigrants take care of California in so many ways, and so “it is time for California to take care of immigrants.”

Despite the modest reach of SB 4 after the splitting of the bill, several groups rising in opposition to SB 4 and largely for reasons unrelated to its content, from “Save Our State” and other anti-immigrant groups, to the “Long Beach Heterosexual Resistance.” They argued, falsely, that SB4 was “back door amnesty, or that it would place stress on an overburdened health system–not acknowledging these Californians are already in our health system, but in the least efficient and most expensive ways.

Republican Assemblymember Rocky Chavez distanced himself from some of the opposition rhetoric, and the recent comments of presidential candidate Donald Trump, but still stated his opposition to the bill, saying he wanted more time to see how the ACA would play out.

While the cost of the bill is little (it allows undocumented Californians to buy in Covered California without subsidies), Democratic Assemblymember Jim Wood offered a helpful counterpoint to the cost issues raised by those speaking against SB 4. “Consider the costs burdening the health care system from having so many without coverage,” said Wood.

SB 137 (Hernandez) Accurate Provider Directories

Passing on a vote of 16-2, an amended SB137 (Senator Ed Hernández) creates better standards for provider directories and requires regular updates so people know what doctors and hospitals are in their network when they shop for or change coverage or when they seek care. The bill is needed, says bill co-sponsor Betsy Imholz of Consumers Union, because 25-50% of provider directories are inaccurate by some estimates, including a recent DMHC survey.

Beth Capell for Health Access, a bill co-sponsor, said “it is time for directories to come into the digital age.” According to Kimberly Chen of California Pan-Ethnic Health Network, also a bill co-sponsor, today’s inaccurate directories present yet another barrier to care for people of color.  It’s frustrating for consumers to have to make so many calls to find a provider that will accept their coverage…“Now imagine making those calls in a foreign language,” said Chen.

The sticking point for opposition, mostly health plans and provider groups that remain opposed or concerned about the current format of SB 137, is the timeframe for updating the directories.  The current bill defers to the Administration’s preference for a quarterly timeframe for updating the directories. This bill is still a work in progress, and we anticipate further amendments. Consumer advocates will continue to press on for this bill and principle.

SB 43 Essential Health Benefits passed 16-1

SB 43 (Hernandez) would renew and update California essential health benefits standards under the Affordable Care Act. The bill would extend the sunset on Essential Health Benefits (EHB) standard for California and updates the EHB standard in light of recent federal guidance on habilitative services (services and devices that help a person keep, learn, or improve skills and functioning for daily living). The new Federal standard for habilitative services is more generous than California’s current definition. The bill passed.

Also passing today was a SB35(Hernandez), to help implement the Medicaid waiver–but the bill doesn’t have very many details yet, given that negotiations with the federal government are ungoing.

Tomorrow is Senate Health Committee, with several other key bills up for consumption.

Key Consumer Protection Bills Face Crucial Vote NEXT WEEK

With next Friday’s (July 17) deadline for policy committees to meet and consider bills from the opposite house, critical patient protection bills will be debated and voted on in the Assembly Health Committee this Tuesday and in Senate Health Committee on Wednesday. Community groups have the next few days to mobilize networks to encourage committee members (Assembly Health Committee members and Senate Health Committee Members) to vote for the bills (find your legislator here).

For details on each bill, and where we are in the process, see our weekly bill matrix.

Also see our blog on bill hearings for the week of July 6-10


After the recent victory in the state budget covering children in Medi-Cal regardless of immigration status, health and immigrant advocates are continuing their efforts to take additional steps to #Health4All, at the county and state levels, administratively and legislatively.

Beyond the budget, the state legislative push continues for #Health4All although in a different form than previously. This week, Senator Ricardo Lara announced he was splitting his bill, SB 4 (Lara) into two parts: one bill, SB 10 (Lara), would include the capped program to expand Medi-Cal to adults regardless of immigration status. SB 4 would no longer include that part, and would proceed with technical improvements to the children’s coverage expansion and the waiver request to the federal government to allow undocumented immigrants to purchase coverage with their own money in Covered California. That part is expected to be heard in Assembly Health Committee on Tuesday, July 14th, starting around 1:30pm.

Because of the questions by Governor Brown (and the Appropriations Committee) about the potential costs of a Medi-Cal expansion for undocumented adults, even after significant offsets were identified, SB 10 will not proceed this year. As a two-year bill, It could be considered as early as January or as late as June of next year. SB10 previously served as a vehicle to help immigrants apply for DACA and DAPA deferred status through the creation of an “Office for New Americans.  Since this priority was funded in the budget, SB 10 was no longer needed. Now SB10 has another life, and a new purpose: to extend #Health4All under Medi-Cal.

SB4, to be heard in Assembly Health Committee next Tuesday, would seek a special Section 1332 waiver (a formal request to the federal government), to allow all Californians, regardless of immigration status, to purchase coverage through Covered California with their own money. A waiver is needed so that Covered California can offer California qualified health plans that are look-alike plans, identical in every respect to the products offered on Covered California—with the same insurance market rules that currently apply to Covered California products. 

Talking Points for SB 4 (and SB 10)

 -Immigrants are a fundamental part of our workforce and communities; they should therefore be fully included in our health system.

-A majority of undocumented Californians are in “mixed-status” families: it makes sense to allow the Covered California staff to help the entire family sign up for coverage, even if not everyone is eligible for subsidies at this point.

-No one should suffer or die from a treatable condition because of where they were born.


The following Health Access-sponsored bills preventing unfair out-of-pocket costs will be heard next week.

*Preventing Surprise Bills: AB 533 (Bonta), which would protect patients from “surprise” bills from out-of-network doctors when they did the right thing by going to an in-network hospital, imaging center, or other facility, passed out of the Assembly with a vote of 74-1. While that vote provided momentum, the California Medical Association and other provider groups continue to oppose the bill in print. 

Talking Points for AB 533 

-If consumers do the right thing by visiting in-network hospitals or facilities, they should not get stuck paying “gotcha” bills from out-of-network providers. 

-Consumers should not get stuck in the middle of a business dispute between health plans and providers.  It is up to the health plans to build adequate networks that include the different types of providers (radiologists, anesthesiologists, etc.) that may be seen in a given clinical encounter. 

* Limiting Prescription Drug Cost Sharing: AB 339 (Gordon): AB 339 would prevent discrimination against consumers with health conditions by setting stronger standards for cost sharing on prescription drugs. The bill passed out of the Assembly with a vote of 48-29. As recently amended, the bill would now cap prescription drug costs per month at the levels negotiated by Coverage California–$250 for everything, except for bronze, which is $500. Originally AB 339 had a cap set to 1/24th of the out-of-pocket maximum. 

Talking Point for AB 339

-People living with chronic conditions should not have to face excessive cost sharing, i.e. the current policy on cost sharing is inherently discriminatory and in conflict with the broader goals of health reform. 

*Requiring Accurate Provider Directories: SB 137 (Hernandez) would set higher standards for updated and accurate 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. SB 137 passed out of the Senate with bipartisan support (33-0) and will be heard Tuesday July 14 1:30 PM. 

Talking Points for SB 137

-Consumers need up-to-date provider directories so they can understand their options for care, get timely care, and avoid visiting costly out-of-network providers. 

-The industry (and federal law) is moving away from paper-based directories—at last. AB 533 puts higher standards in place for easily accessible online provider directories. 

The Latest on Health Care Bills

This week, the Assembly and Senate Health Committee as well as the Committees on Governmental Organization and Business and Professions heard a number of bills, including key health measures, including Medi-Cal Estate Recovery (SB 33), County Organized Health Systems (SB 260), Rate Review for Large Group Insurers (SB 546)–all passing out of committee. The big exceptions were tobacco related bills on E-Cigarettes (SB 140) and raising the smoking age (SB151).

The debate around SB 140 (Leno) was perhaps one of the most contentious debates this week. The Assembly Governmental Organization offered Senator Leno four amendments, three of which Senator Leno agreed to, but one which he said would completely undermine the intent of his bill. The amendment which was the focus of the debate would have changed the definition of tobacco to not include e-cigarettes. Senator Leno described the move to exclude e-cigarettes from the definition of tobacco as “dangerous.” Describing the position of himself and the public health and law enforcement groups in response to the amendment, “we all walk away. It is no longer our is a dangerous thing to do.” said Senator Leno. After dueling motions and bringing in the Parliamentarian, the Assembly Governmental Organization Committee ultimately voted in support of all four amendments–at which point Senator Leno disassociated himself and all supporters from the bill by urging a “no” vote. SB 140 (Leno) was held in committee. Seeing the likely outcome, Senator Hernandez pulled the other tobacco bill SB151 from this week’s agenda.

Bills passed our of Health Committees this week include AB 1073 (Ting) which would require translation of labels for prescription medications, SB 33 (Hernandez) which would limit estate recovery in Medi-Cal to the federally required minimum of long-term care services, SB 260 (Monning) which would require County Organized Health System (COHS) plans to be licensed by the Department of Managed Health Care (DMHC), SB 546 (Leno) which would bring greater transparency to health care premium rate setting for large purchasers, and SB 388 (Mitchell) which would require a health insurance plan’s summary of benefits and coverage (SBC) to be translated into non-English languages consistent with California’s existing language access requirements for other vital documents.

Bills passed last week included AB 1117 (Garcia) which would bring additional resources to the health care system to help improve California’s relatively low vaccination rates for 2-year-olds, and our bill, AB 1305 (Bonta), which would assure that no individual Californian in a family plan has a deductible or out of pocket limit higher than the individual deductible or out of pocket limit.

Key bills sponsored by Health Access California to prevent unfair out-of-pocket costs are due to be heard in Senate and Assembly Health Committee next week, including AB 339 (Gordon) which would ensure consumers get the prescription drugs they need and prevent discrimination against consumes with health conditions; AB 533 (Bonta) which would protect patients from “surprise” bills from out-of-network providers and SB 137 (Hernandez) which would set standards for provider directories. A related Health Access bill, AB 248 (Hernandez) which would address a loophole in current law that allows large employers to provide subminimum coverage to their employees, is eligible to be heard on the Senate floor as soon as next week.

Health Reform 2.0: New Efforts on Value-Based Health Care

Health Access, California Pan-Ethnic Health Network (CPEHN), and Consumers Union and other groups are teaming up to improve health and health equity for California consumers through transparency, benefit design, and Medi-Cal reforms. Through our new Value-Based Health Care initiative, supported by the Robert Wood Johnson Foundation and working with the national group Community Catalyst, Health Access and CPEHN will build on the state’s success in implementing the Affordable Care Act (ACA) to ensure that reforms to our health care delivery system lead to better health and health care and improved health equity for all Californians.


California has come a long way in implementing and improving on the ACA through consumer protections, a robust exchange, and a promising start on delivery system reforms. Together with Medi-Cal, Covered California has been successful in covering more than half of the uninsured and in reducing premium costs. Going forward it plans to step up its “active purchaser” role to ensure enrollees are getting the right care at the right time and place through delivery system reforms and transparency initiatives scaled for market-wide impact.

Pending approval by the federal government the state’s Medi-Cal 2020 waiver renewal, too, sets an ambitious agenda aimed at better care, lower costs, and quality improvement—the “triple aim”— for beneficiaries. As part of the Medi-Cal 2020 waiver request, county-level health systems would have incentives to find efficiencies in delivering care, and reorienting indigent care programs to provide primary and preventive care outside of hospital systems.

In California many challenges impede our ability to achieve the triple aim. California has persistent disparities among LGBTQ people, people of color, immigrants, and those with limited English proficiency. Given California’s diversity, it will be impossible to achieve triple aim goals without directly addressing disparities. The project therefore adds a fourth dimension to the triple aim, equity, to keep the focus of triple aim initiatives on opportunities to track and reduce disparities by race, ethnicity, income, sexual orientation and gender identity (SOGI), and other key demographics.

Transparency: Consumer Driven Tools; Improved Data Collection, Analysis & Reporting

The project will make the most of Covered California’s emerging efforts to collect and analyze claims data to ensure that enrollees are getting the right care and the right time and place. California is also in the beginning stages of setting up a statewide Cost and Quality Database (called “All Payer Database” in most states) or collection point for all data on claims, charges, payments moving through the health care system. The aims here are similar: to pinpoint waste and inefficiency in the health care system and to collect demographic data to help identify disparities and promote equity, among other goals

Better data is also needed with regard to complaints. As the state shifts more Medi-Cal patients into managed care and more consumers are enrolled in Covered California and private insurance, it becomes that much more challenging to analyze complaints by insurance plans as well as to identify disparities and develop solutions to address them. Plans need better standards for data collection and direction on how to make meaningful use of these standards to address quadruple aim goals. A recent Consumers Union survey found that 87% of consumers do not know the state agency tasked with filing complaints. As we work to improve the use and accountability of complaint processes, we will make sure they, too, are configured to meet quadruple aim goals.

Value-Based Benefit Design (VBD)

Insurance benefit designs can help reduce costs for consumers and improve health care outcomes, or they can limit access to care, shift costs to consumers, or discriminate against patients with chronic illness. Because chronic conditions disproportionately impact communities of color and low-income households, such discriminatory practices could exacerbate disparities. The project will provide data and evidence to further standardize benefit designs to simplify plan choices; minimize the use of co-insurance; track problems that result from excessive cost sharing or poorly designed transparency initiatives or wellness programs; and support consumer-friendly VBDs such as lower cost sharing for clinically proven medicines.

Medi-Cal Reforms To Focus on Equity, Population Health, and Consumer Engagement

Communities of color are the overwhelming majority of Medi-Cal beneficiaries, and close to one-third are limited English Proficient (LEP). Diverse communities have a greater incidence of preventable illnesses, and social and environmental factors play a decisive role in determining who gets sick, who gets care, and who benefits from treatment. As the single largest purchaser in the state, Medi-Cal should be a model for reducing disparities through data collection and meaningful use of data; population health measures, and a patient-centered medical home model of care. Through the 1115 waiver process, our efforts will translate to better health care and health outcomes for Medi-Cal enrollees. Additionally, just as the last Medi-Cal waiver, “Bridge to Reform,” connected uninsured patients to a medical home before the Medi-Cal expansion, our goal is for the new waiver to facilitate access to comprehensive care for the remaining uninsured.

In California, we have made important commitments to covering all uninsured Californians, including immigrants who are left out of the ACA altogether–or to groups whose health status calls for stronger consumer protections than were codified in the ACA. Beyond those commitments, we have many worthy uses for our health care dollars—issues not addressed in the final budget signed last month by Gov. Brown like reimbursement rates and restorations of service like full adult dental services or audiology. Thus each time we are reminded of the estimated 30-50% of health care spending that is wasteful, harmful or of no value to patients, we affirm our resolve to go after that waste and improve efficiencies in ways that benefit patients, starting with those who stand to benefit the most from a more responsive and equitable health care system.


To Celebrate the SCOTUS Decision: LGBT Health Roundtable with HHS Secretary Sylvia Burwell

In tribute to today’s Supreme Court ruling in favor of full marriage equality for LGBT Americans, Health Access presents this report from Kate Burch, Network Director for the California LGBT HHS Network. Health Access joins with many others in celebrating today’s historic ruling, even as we are mindful of the work still needed to ensure better and more equitable health and health care for all LGBT Americans.

Last Friday, June 19, Health and Human Services Secretary Sylvia Burwell met with about 25 LGBT health advocates in Washington, DC to hear about the health care needs of LGBT communities around the country. After brief mention of the Affordable Care Act and the importance of addressing transgender health inequalities, Secretary Burwell opened up the floor. Advocates raised a number of issues and recommendations for HHS to consider. Underlying everything was the urgency to accomplish as much as we can during the Obama administration, and to put lasting measures in place that will continue, no matter what happens in the 2016 election.

Affordable Care Act

Nondiscrimination remains a huge issue when it comes to LGBT communities and the Affordable Care Act. Transgender “young invincibles” in many states aren’t signing up because their health care needs, including transition-related treatments, aren’t covered by the insurance they can get through the marketplaces.

Section 1557 of the Affordable Care Act prohibits discrimination, and advocates are eagerly awaiting the regulations that will explain how that section should be implemented. The regulations should soon be open for public comment. Advocates hope that the regulations will address these areas, among others:

  • The prohibition against discrimination based on sex and gender should include gender identity and sexual orientation.
  • The regulations should include concrete examples of discriminatory practices that should be prohibited, such as benefit design that excludes care for transgender people based on gender identity, and prescription drug tiering that places HIV medicines on the most expensive tier, consequently steering HIV+ patients away from choosing those plans.
  • And the regulations should include definitive statement that transgender patients need to be able to access medically necessary services that are available to non-transgender people.

California is ahead of the curve on health care for transgender patients. The Department of Managed Health Care and the Department of Insurance affirmed in 2013 that insurance plans have to cover medically necessary care for transgender people and are not permitted to have transgender-specific exclusions. This applies to all plans sold through Covered California, as well as to those sold outside of the marketplace.

California is also leading the way on protecting consumers from discriminatory benefit design by regulating prescription drug costs. AB339 (Gordon), which is currently awaiting a vote by the Senate Health Committee, would make high-cost prescription drugs much more affordable to consumers, and would prohibit plans from placing all of the drugs available to treat a condition on the highest cost tier. In a separate process, Covered California took action in May to place a monthly cap on individual prescription costs.

Data Collection

Comprehensive data collection about sexual orientation and gender identity (SOGI) is critical to a systematic approach to improving LGBT health. The ability to count LGBT people, document the disparities that exist, and identify successful interventions will allow for high-impact strategies to improve LGBT health.

  • The federal health insurance marketplace should begin to collect SOGI data on all their applications. Advocates recently sent a letter to CMS asking to add SOGI questions to the application, and will meet with CMS soon to discuss the issue.
  • CMS should allow states with a state-based marketplace to add SOGI questions to their applications if they want to, and include those questions with other demographic questions that are already on the application. Advocates will meet with CMS soon to discuss the issue.
  • As the federal government urges more providers to move towards using Electronic Health Records (EHR) and as EHR platforms and protocols are developed, it is important to include SOGI data collection in electronic health records and to ensure meaningful use of these data over time. To this end, advocates recommend that sexual orientation and gender identity be standard data fields included in the EHR, while it remains optional to put any data in those fields. Currently most EHR vendors don’t include data fields for SOGI, so providers don’t even have the option of including that data.
  • The National Health Interview Survey has taken steps towards including a sexual orientation question. Advocates would like to see questions about gender identity included on national surveys as well.

FDA Blood Ban

The Food and Drug Administration released draft regulations in May that lifts the blanket ban on blood donation by any man who has had sex with a man since 1977. The draft regulations would allow men who have sex with men to donate blood if they are healthy and haven’t had sex with a man in the last year. While this is a huge improvement, it is still a practical ban on any sexually active gay man. The proposed regulations don’t go far enough and don’t adhere to what studies have shown about HIV transmission. HHS will get numerous comments from advocates expressing this during the open comment period. Comments are due July 14, and can be submitted here.

Medicare and Medicaid

  • Medicare cards still have a sex marker on them, which is completely unnecessary. This forces many transgender people to be “out” every time they use their Medicare card, including with a receptionist at the doctor’s office or at the pharmacy when they pick up medication. There is no need for the sex marker on the Medicare card, and advocates would like the marker removed when new Medicare cards are issued.
  • While it is fantastic that Medicare has done away with the categorical exclusions of gender affirming surgeries, people still aren’t able to actually get these surgeries. There are network adequacy problems, as well as foot-dragging by Medicare contractors who simply aren’t following the World Professional Association for Transgender Health standards of care.
  • In Medicaid, around 40 states still have categorical bans on providing such necessary care to transgender people, either in practice or written into the law. A letter to state Medicaid directors clarifying that section 1557 of the ACA prohibits categorical exclusions would go a long way towards improving health care for transgender people. Medi-Cal, California’s Medicaid program, does cover transition-related health care for transgender people.
  • Given that 20% of LGBT Americans live below the poverty level (compared to 17% of non-LGBT people living alone) and that transgender people arefour times more likely to have incomes under $10,000 per year, the fact that many states still haven’t expanded Medicaid is a huge problem for LGBT communities.

HIV/AIDS Medications

  • Coverage for HIV medications needs to be improved; the current copays are too high and many plans simply don’t include important HIV medications on their formularies—indirectly avoiding risk.
  • There are plans that include PrEP or PEP (the only two medications effective at preventing HIV infections) on their formularies, but too many routinely deny coverage when the medication is prescribed. While this can be appealed, delay of PEP coverage is particularly problematic because it needs to be taken within 72 hours to be effective. Guidance to plans from HHS would be helpful in addressing this issue.

Additional Issues

  • Not enough health funders are putting money into LGBT health – they need encouragement to put money into LGBT health work.
  • The Model States Vital Statistics Act of 1992 went through the beginnings of a revision process in 2011. This model act provides guidance to states as they consider revising their own Vital Statistics Acts. The proposed revision included great steps forward on how to properly respect transgender identities on birth certificates and death certificates. The revision has been held up somewhere for reasons unrelated to identity markers and respecting transgender identities, and it would be great to get that moving again.
  • Our nation’s foster care and adoption systems need to be fundamentally reformed. Currently, there are no protections in place federally for LGBTQ youth, so youth often stay in the closet or are mistreated based on sexual orientation or gender identity. Additionally, many states don’t have nondiscrimination requirements for their foster and adoption agencies. This results in some agencies turning away prospective parents (same sex couples, single people, and gender non-conforming people) even if state law allows them to be adoptive parents.

Photo credit: Transequality

President Obama: “The ACA Is Here To Stay… The ACA Is Working…”

Here’s President Obama’s statement on the Supreme Court’s upholding of the Affordable Care Act:

For another more exuberant reaction, here’s a tweet that shows, from the steps of the Supreme Court, the response of our colleague Ron Pollack, executive director of Families USA. While California would not have been impacted, we are relieved for the millions of Americans who have continued coverage because of the Affordable Care Act, with even more security that such coverage and financial assistance won’t be taken away.

Supreme Court Upholds Obamacare Again!

Once again, the Supreme Court ruled this morning to uphold the Affordable Care Act (ACA) on a 6-3 vote in the King v. Burwell case, which challenged the subsidies available in the states that have federally facilitated marketplaces under the five-year old federal law. The case was based on four words of Section 1311 of the ACA, which argues (contrary to any literal and contextual reading of the law) that subsidies are only available to people in state-based exchanges.

ACA IS HERE TO STAY: Now that the Supreme Court has upheld the Affordable Care Act once again, we hope we can stop debating a five-year old law and discuss additional ways to reduce health costs and provide more health and financial security for American families. Californians never needed to worry, since our exchange is state-based, even as we were concerned about the impact on millions of Americans in other states. This ridiculous challenge should have never been taken, since it was based on a hyper-literal willful misreading of four words of the Affordable Care Act, going against virtually all evidence of Congressional intent and judicial precedents.

CALIFORNIA MOVING FORWARD: While this case attempted to rewrite history, California has been looking to the future in implementing and improving health reform. Previously the epicenter for the uninsured crisis in America, California have already cut our uninsured rate in half, and provided new consumer protections for million. In one of many efforts to not just implement and improve upon the Affordable Care Act, California just committed to cover all children regardless of immigration status. Pending bills would use the ACA as a platform to provide additional consumer protections against unfair out-of-pocket costs. California shows how we need to be discussing additional steps to provide health and financial security for all Americans, and not re-debating a five-year old law.


Senate Health Committee Passes AB 248 (Health Insurance Minimum Value) Out on 6-1 Vote

Today, the Senate Health Committee heard AB 248 (R. Hernández) and passed it out on a 6-1 vote, with Senator Nielsen voting no and Senator Nguyen abstaining. Sponsored by Health Access, AB 248 would close a loophole created by federal guidance that allows insurers and health plans to sell subminimum coverage to large employers.

Specifically, AB248 protects California workers by holding health insurance sold to large employers to a minimum standard in terms of value. Federal and state law already hold insurance sold to small employers and individuals to a basic standard (60% actuarial value), but insurers are free to sell large employers “junk” plans. When large employers offer such plans employees are stuck between a rock and hard place: with unmanageable costs for benefits that are not covered or thousands of dollars in out-of-pocket costs (see Health Access’s fact sheet for details).

Here’s the rub: if an employee accepts an employer’s coverage, even if it is subminimum coverage, the employee is automatically ineligible for premium subsidies through Covered California—and the employer gets off the hook on the employer responsibility penalty.

Speaking in opposition to the bill in in today’s robust committee discussion were California Association of Health Underwriters and the California Association of Small Employer Health Plans. Both groups opposed the bill, arguing that it would make health care premiums even more expensive for large employers if there was a requirement for employer-plans to hit the 60% minimum value threshold before other products can be added.

Health Access and consumer advocates argue that subminimum plans don’t reduce health costs, but simply shift those costs onto workers. They pointed to the deleterious consequences of current loophole for consumers: Consumers may not know or even be told the cost implications of whatever offer of coverage they are accepting–much less what it’s actuarial value is (how many of us can explain what that is?), which leaves them vulnerable to medical debt or bankruptcy from a single visit to the emergency room.

Other bills were also considered: AB 635 (Atkins), a bill that would provide for interpretive services in Medi-Cal was also heard in committee today and passed out successfully. AB 1114 (Bonilla) which clarifies that Medi-Cal and Covered California renewal forms and notices be translated into the thirteen Medi-Cal threshold languages, was on consent and will be moving to Appropriations along with AB 248 (Hernández) and AB 635 (Atkins).