Assembly Budget Committee Chair Noreen Evans (D) and others assailed the administration Monday for making cuts to a breast cancer screening program for low-income women against the Legislature’s wishes.
The Department of Public Health in December decided to reduce access to the “Every Woman Counts” early detection program by freezing enrollment until June 2010, and limiting enrollment to only women 50 and older.
For the past decade, the program had offered annual breast cancer screening to low-income women who lacked health insurance and were at least 40 years old. Statewide, 1.2 million are eligible for the program through about 1,000 locations, including community health clinics. The program served 249,000 in fiscal year 2006-2007; 270,000 in fiscal year 2007-2008 and then 310,000 in 2008-2009.
With the demand increasing, however, the Schwarzenegger Administration decided to shift some EWC funding to other programs, thus freeing up some money to help plug the growing budget deficit. This was done even though the Legislature had rejected the cutbacks outlined by the administration during budget negotiations after the governor submitted his May spending-plan revision.
At a hearing well-attended by breast cancer survivors and supporters, an irked Evans told bureaucrats that “It’s unacceptable to me that these screenings won’t take place…In my opinion, we’ve had way too much testosterone in the budget talks….and enough of the macho knife-waving, alpha-male politicians in the process. How many Californians will have to die for budget negotiators to see it’s time for us to grow up?”
Despite having been told by Evans that the planned program cutbacks would not be approved by the Legislature, the Department of Public Health “suddenly and surprisingly changed” the program, Evans said.
Assemblyman Hector de la Torre (D) added, “The administration is not allowed to run around making unilateral decisions. There is a checks-and-balances thing going on here.”
A round of applause broke out in the hearing room after Assemblyman Sandre Swanson (D) said the cutbacks in services would cause greater expenditures in the final analysis, as women get sicker and require extensive treatment. “You’re just shoving these costs off onto other programs – and you are costing lives, too.”
Several medical experts and community providers testified that women who are diagnosed with breast cancer in their 40s are more likely to have aggressive forms of the disease and therefore need early detection to survive. Many also testified that the age-group accessing services through Every Woman Counts are more likely to be women of color with few economic resources.
The hearing came after a bake sale held by Evans, other legislators and breast cancer awareness representatives to raise money and awareness about the program cutbacks. Following the hearing, a large rally was held outside, where several other legislators, including Senate President Pro Tem Darrell Steinberg, declared their opposition to the cuts and support for restoring the program. The rally ended ended with the Capitol being bathed in pink light, a color of significance for breast cancer survivors. Meanwhile, two bills -- with a third likely to come -- have been proposed to reinstate the program, Evans said.
Republican legislators are viewing President Obama's invitation to the White House with skepticism. I don't doubt the President's sincerity in wanting to take into consideration and even adopt their best ideas. As frustrating as that may be to some of his supporters, he is a consensus builder and organizer, and that is who he is.
But that doesn't mean the Republicans shouldn't be worried. Because I don't think the President is going to give up on his proposals. And because the Congressional Republican leadership doesn't have a comprehensive solution to the health care crisis. The spotlight that the President has put on alternative reforms has shown them to be ineffective, but ones that provide less security and stability, not more.
Change can be scary, especially when there's an entire political party feeding that fear and mistrust. Consumers don't like the status quo, but it can be seen to be comforting compared to the unknown. If it's a fight between a complex reform with both benefits and burdens (and any reform of health care is going to be complex) with the status quo, the status quo has a distinct advantage.
President Obama wants to make this a fight between the change you want, versus the change you don't. Reformers make the point--correctly--that the status quo isn't an option, since the current health system is unravelling.
The summit will counterpose not change vs. the status quo, but what kind of change is appropriate. And the comparison isn't close: * Jonathan Cohn of the New Republica analyzes the Republican plan for health reform in their “Roadmap for America's Future,” a much more radical privatization of Medicare than people realize. * Ezra Klein of the Washington Post examines the Republican ideas that are already in the health reform bills * Greg Sargent at the Plum Line shows how the GOP response so far is a rejection of bald-faced rejection of any negotiation or compromise.
FYI, I'll be on a panel at the Insure the Uninsured Project conference this Wednesday, February 10th, in Sacramento. Should be an interesting conference, with the mix of anticipation and uncertainty around reform right now.
Maybe this is how we get some rate review after all.
U.S. Department of Health and Human Services (HHS) Secretary Kathleen Sebelius today sent a letter to Anthem Blue Cross of California urging it to publicly justify its premium hikes for its California individual market customers--hikes that are as much as 39 percent.
Here's the letter:?
February 8, 2010
Leslie Margolin President, Anthem Blue Cross
Dear Ms. Margolin,
One of the biggest pressures facing families, businesses and governments at every level are skyrocketing health insurance costs. With so many families already affected by rising costs, I was very disturbed to learn through media accounts that Anthem Blue Cross plans to raise premiums for its California customers by as much as 39 percent. These extraordinary increases are up to 15 times faster than inflation and threaten to make health care unaffordable for hundreds of thousands of Californians, many of whom are already struggling to make ends meet in a difficult economy.
Your company's strong financial position makes these rate increases even more difficult to understand. As you know, your parent company, WellPoint Incorporated, has seen its profits soar, earning $2.7 billion in the last quarter of 2009 alone.
I believe Anthem Blue Cross has a responsibility to provide a detailed justification for these rate increases to the public. Additionally, you should make public information on the percent of your individual market premiums that is used for medical care versus the percent that is used for administrative costs. Policy holders in the individual market deserve to know if their premium increases would be invested in better medical care or insurance company overhead costs like salaries, profits, and advertising. I am aware that the State of California is investigating this matter, and urge Anthem Blue Cross to cooperate fully. In the meantime, I will be closely monitoring the situation.
At a time when health care costs are a critical threat to families as well as the nation's economy, I hope you appreciate the urgent nature of this request. I look forward to your prompt reply.
Sincerely, Kathleen Sebelius Secretary of Health and Human Services
If you have been impacted by this premium increase, visit www.sickofbluecross.com, and tell your story to us...
An article by Tom Kisken in the Ventura County Star explores how doctors' offices, HMOs and PPOs are preparing to implement the new "timely access" state regulations requiring providers to see patients within a reasonable amount of time.
Meanwhile, advocates for health care reform are not sitting back and waiting passively for the logjam to break in Washington. A big push -- with public events and rallies -- is being launched nationwide on February 17th. Keep an eye out for events scheduled in your area, and add your voice to the masses demanding change.
Health reform continues, at federal and state level...
HEALTH ACCESS UPDATE Monday, February 8, 2010
PRESIDENT OBAMA RECOMMITS TO HEALTH REFORM, SCHEDULES BIPARTISAN SUMMIT * In Renewed Push, Obama To Host GOP at White House on CSPAN on February 25th * President Cites Anthem Blue Cross of California Increasing Premiums up to 39% * New Process Launched for Medi-Cal Federal Waiver Input * Other Items: Some State and Federal Budget Dispatches on our Health Access Blog. * Join Us on Facebook! Follow Us on Twitter!
PRESIDENT OBAMA RENEWS HEALTH REFORM EFFORTS: This weekend, President Obama made a couple of pronouncements renewing his call to pass comprehensive health reform. At a meeting of Democrats in a snow-bound Washington, DC, he said, "Let me be clear: I am not going to walk away from health reform," bringing the audience in the hotel ballroom to their feet. "We can't return to the dereliction of duty," Obama said. "America can't afford to wait, and we can't look backward."
On Sunday, he indicated in an CBS interview before the Super Bowl that he would be inviting leaders from both parties to the White House on February 25th to go over the "best ideas" on health reform, to inform the final negotiations in reconciling the House and Senate bills. The meeting, to be televised on C-SPAN, will likely provide a forum for Republican opponents of the current health reform proposals to provide their alternatives, and to point to parts of the proposals where Republican input has already been taken. Under this schedule laid out by President Obama, the expectation of action on health reform would be possibly in March.
ANTHEM BLUE CROSS HIKES PREMIUMS: In stressing the need for reform, President Obama cited the reasons why the status quo is unsustainable, including the premium increases by Anthem Blue Cross in California, the state's largest insurer. The Los Angeles Times, in an article by Duke Hefland, reports that Anthem Blue Cross -- a subsidiary of Wellpoint in Indianapolis -- is increasing premiums 30% to 39% for the second year in a row for California customers of its individual policies.
Increases are set to take effect March 1, policyholders learned last week. In the Feller household in San Rafael, for instance, that makes the family's health care policy more expensive than their mortgage payment. The Fellers will pay 39% more, driving their annual premium up to $19,896; and then there's a 38% increase for their 26-year-old daughter, adding another $1,572 a year to the Feller's bill.
The letter detailing the increase hints at more hikes to come. It says: "Anthem Blue Cross will usually adjust rates every 12 months; however, we may adjust more frequently in accordance with the terms of your health benefit plan."
If you've got a story about your health insurance premium increases, Health Access would love to hear it. Please contact us directly, or visit www.sickofbluecross.com
SHOULD WE PAY FOR PROBLEMS?: In this memorable past week, we found out that health care spending accounted for more than 17% of the nation's gross national product.
Alan Weil, the executive director of the National Academy for State Health Policy, argues that we can bring down the costs of health care through common sense: Simply pay providers less when they mess up. Weil was in Sacramento for a policy discussion sponsored by the Center for Health Improvement and the California HealthCare Foundation. He argues that providers should face monetary penalties not just for so-called "never" events (mistakes "that should never happen") but for mistakes that are perhaps less drastic such as hospital-acquired infections. Weil calls these "a shouldn't-happen-very-often-event."
It makes us think of a recent article by HealthLeaders Media that began with the question, 'Why do hospital teams unintentionally leave more than 30 types of surgical tools or other items inside their patients, a category of hospital error that California officials say is the second most common preventable adverse event in acute care?"
The Legislature is scheduled to consider launching a study of the phenomena later this year. Either way, the Center for Medicare and Medicaid Services plans to no longer reimburse hospitals for the cost of caring for a patient's injuries, such as hospital-acquired infections, resulting from a "retained foreign object."
GETTING THE BALL ROLLING WITH STAKEHOLDER INPUT ON THE MEDI-CAL WAIVER: The process continues to develop a renewal for California's Medicaid waiver with the federal government. This past week saw the beginning of "technical workgroups" with some stakeholders set to give their input to the California Department of Health Care Services on proposed changes to Medi-Cal, which covers 7 million Californians.
With a focus on ensuring that consumer protections are in place for the Medi-Cal patients affected by the federal waiver request, Health Access is one of several organizations represented, with our Executive Director Anthony Wright (awright@health-access.org) sitting on two stakeholder groups: one on local coverage initiatives, the other on the changes to coverage for seniors and persons with disabilities.
These workgroups and a broader stakeholder advisory committee will consider these issues as the state moves toward submitting a final waiver request to the federal government this coming fall. We'll post more on our blog in the near future.
Got suggestions for future Health-Access Update news items, or notes? Please feel free to send them to updates@health-access.org
This past year's health reform debate went through major holidays, so it isn't a surprise that news is made on the secular holiday of Super Sunday.
In an interview with Katie Couric before the Super Bowl, they talked health care:
Politico has the story. The White House will host a meeting on February 25th, televised, with both Democratic and Republican leaders of Congress to discuss their best ideas on health reform. It's not an attempt to start over, the White House says, but to incorporate the best thoughts a final agreement. It'll be one more proof that the President has tried to pursue a bipartisan course, only to face solid opposition.
Lots of people may have thoughts, but one thing is sure: this kind of high-profile effort isn't what a President or Congressional leaders do if they are seeking to drop the issue.
Update: Why won't President Obama walk away from health reform? He cited the increases by Anthem Blue Cross of California in his answer:
It's not like Captain Renault is going to burst into Anthem Blue Cross' boardroom and announce he's "shocked!...shocked!" to see more consumer-gouging taking place.
We doubt that anyone is surprised to see Anthem Blue Cross seizing the day and aggressively hiking fees in California -- again -- for individual policy holders.
Never mind that containing costs of health coverage has been a major part of the national conversation for a year now. What matters to Anthem's parent corporation, Wellpoint, located in Indiana, is that the conversation is now down to a hushed whisper, thanks to the Party of No in Washington D.C.
And when it comes to reading political tea leaves, "no" means "yes" to Anthem Blue Cross, which for the second year in a row is increasing premiums by 30 to 39 percent. For Century City podiatrist Mark Weiss, 63, that means his and his wife's annual health insurance bill rises from $20, 184 to $27,336. Wow.
Weiss, who has been a member of Blue Cross for 30 years now, thinks "it's just unconscionable." So do a whole lot of other people -- who need to continue speaking up about it.
BUDGET ACTION HEATS UP AT STATE & FEDERAL LEVEL * Chiang Tells Budget Committee of Cash Crisis, Urges "Credible" Action * Obama's Federal Budget Includes Health Reform and Help for California * Other Items: CBP Report on Growing Need for Services; Single-Payer Bill Advances
* Read Our Health Access Blog for updates on state budget, the latest in D.C. * Join Us on Facebook! Follow Us on Twitter!
ASSEMBLY BUDGET COMMITTEE REVIEWS THE BIG PICTURE: Budget Chair Noreen Evans (D) led committee members Wednesday in a sharply focused Q-and-A with State Controller John Chiang, Legislative Analyst Mac Taylor and representatives with the state Department of Finance.
Not since July 12, 2007, has California actually had cash on hand, Chiang said. Since that date, the Department of Finance has relied on "external borrowing and internal borrowing" from various special funds. In answer to lawmaker's queries, the controller said the state's finance department has identified 710 of the state's 1,000-plus special funds from which it can borrow internally.
Repeatedly, Chiang told legislators that California "needs credible and sustainable budget solutions" that do not include past-year gimmicks such as proposing to sell off the state compensation fund, or EdFund (the state's guarantor of student loans) or the state Lottery -- all of which were said by the administration to be worth far more money than they actually were, and attracted no buyers anyway.
Chiang was firm in telling the budget committee that members needed to make "tough choices" to buck up the state's economic and educational future, as well as to ensure its quality of life does not decline sharply. "We've lost 1 million jobs.... We need to decide what kind of state do we plan to have -- and if we are going to fund essential services, we really need to address the question of revenue."
Both Republicans and Democrats made remarks indicating they've had enough of cutting state services for taxpayers, the disabled, the elderly, and K-12 students as well as university-bound students. Assemblyman Jim Silva (R) said as a teacher he is tired of "seeing students are getting short-changed. I get my back up with I hear that California students are at a disadvantage in getting university educations."
Assemblywoman Diane Harkey (R) noted that she only joined the Legislature about a year ago, but already she'd been through three cycles of closing budget deficits. "We're not just in a budget problem. We are overloaded with debt." Others, including Democrats Jerry Hill and Robert Blumenfield, pointed out that some of the harsh health care service cuts that Gov. Arnold Schwarzenegger is championing will cost the state more money in the long-run as people seek care in emergency rooms or long-term care facilities.
Chiang said Wall Street financial experts do not consider the governor's demand for $6.9 billion from the federal government an intelligent answer to California's perennial deficit woes. "When the governor issued his '6.9 billion solution,' it was not viewed as a totally credible solution, leading Standard & Poors to downgrade California's rating from A to A-."
"We're going to have to educate our students for new economies," Chiang said, "Your actions can make the difference in setting this generation on the right fiscal path. For too long, when people don't make tough choices, students, the aged, disabled and taxpayers all end up suffering."
Evans, the committee chair, said sub-committees will begin meeting next week to scrutinize details of the governor's budget proposal. Regarding an unprecedented Department of Finance letter requesting blanket authority to defer payments to various state creditors, Evans said "I will clean up my language from what I said when I first saw this request for the Department to have legislative authority. I'm extremely skeptical and I suggest you come back with an actual plan." Vice Chair Jim Nielsen (R) joined Republican colleagues in attempting to distance himself from the administration's request for open-ended authority to defer payments. "This is a breath-taking application," Nielsen said. "To just ask us to give you a blank check ... we can't afford that anymore."
PRESIDENT OBAMA PUTS FORWARD FEDERAL BUDGET PROPOSAL: Earlier this week, President Barack Obama released his proposed federal budget. The proposal attempts to balance short-term economic stimulus with long-term efforts at deficit reduction. In attempting to reducing the deficit by $1.25 trillion over 10 years, the proposal lets the Bush-era tax cuts expire, and prioritizes the passage of pending health reforms in Congress. To deal with the immediate recession, the budget proposes a variety of provisions, such as continuing COBRA subsidies to help the unemployed purchase health coverage. It would also extend enhanced Medicaid federal matching funds from the stimulus for six additional months to states, providing $25.5 billion nationally, and at least $1.5 billion to California in the budget year through June 2011.
The Office of Management and Budget has a specific fact sheet on the federal budget and California. Health Access has more about the federal budget on our blog.
CUTS PROPOSED AT TIME OF GROWING NEEDS: The cyclical, seemingly never-ending state budget grind has Gov. Arnold Schwarzenegger stuck in a rut, still swinging away with an ax at the safety net at the time it is needed most. That's the basic message that comes through from a report released Tuesday by the California Budget Project.
California has lost 1,000,000 jobs since the start of the recession, the report says. People need help, families need help, whole communities need help as they scramble against the tide of economic devastation. Cuts, the CBP says, will only further weaken the economy and could impede the national recovery.
The CBP report says that 100 prominent economists of all ideologies recently warned that,"It is economically preferable to raise taxes on those with high incomes than to cut state expenditures [during a recession] ... Steep state budget cuts will exacerbate the economic downturn."
The report noted that California now has 3.6 million more working-age individuals than 10 years ago, but is now down to approximately the same number of jobs as 10 years ago. More than one in five working-age Californians -- or 21.4 percent -- were either unemployed or underemployed in December 2009. (The calculation includes 354,000 jobless people who want and are able to work, but who are left uncounted in official statistics because they have not searched for work in the last month.)
As need grew, California unfortunately responded by cutting off programs -- suspending enrollment in Healthy Families, for example, even though the number of children whose low-income families bought coverage through the program increased steadily by nearly 100,000 kids from July 2007 to July 2009, the report says. To read it and view helpful charts and graphics, go to www.cbp.org.
SINGLE-PAYER, OTHER LEGISLATION STARTS TO MOVE AGAIN: With the new year, bills are starting to move again, including SB 810, the single-payer health reform bill authored by Democratic Senator Mark Leno of San Francisco. That bill looks to be headed to the Governor's desk again this year. It's onto the Assembly after passing the Senate last week, the last week a bill was eligible to pass out of its house of origin. While it still faces the barriers of a two-thirds vote for financing, and a probable gubernatorial veto regardless, it does keep a broad range of health reform options in the policy conversation, and highlights the deteriorating status quo of our health system. If anything, some advocates hope it will provide a lesson from state legislatures to their federal counterparts, that they should not quit just because of a setback.
For more information about anything in this update, contact its author, Cynthia Craft, at ccraft@health-access.org.
The media still is debating the question of whether health reform is dead or alive. Some publications predict its demise one day, and then get another headline the next line proclaiming its resurrection. It's appropriate today is Groundhog day, given the regularity of this pattern.
Several dozen health advocates were in Washington, DC, last week, and I think many of us come away with the feeling of that comprehensive health reform will happen. Democratic Congressional Representatives and their Hill staffers were depressed, but committed. With the loss of the 60th vote in the Senate, it took some time to figure out a procedural path to passage--and it still is. Congressional leadership stepped up and Speaker Pelosi has made sure it will continue. At the annual conference of Families USA, many of us watched President Obama's State of the Union speech, which further energized all of us in the rooom.
The House of Representatives isn't going to pass the Senate version as is, but will require changes to be made by the Senate through the budget reconciliation process. Some things can be changed, others can't. But with President Obama, Speaker Pelosi, and Senate Majority Leader Reid, there seems to be movement forward. Let's keep the pressure on them!
Here's the opening of an article by Brian Rokos in the Riverside Press-Enterprise on the potential local impact of Gov. Arnold Schwarzenegger's proposed cuts into programs for individuals and families in need of adult day health care and home-care health services:
"Frail, elderly people and mentally ill adults could be forced into hospitals and nursing homes if day-care services close because of the state's budget cutting, care providers say."
But the article goes on to explain that there's a whole lot more involved than just the black-and-white scenarios: There's a domino effect of consequences should clients lose access to adult day health care. There's also the physical and emotional toll on the elderly and frail. Many may not survive a relocation from their own homes.
And, significantly, there's the stress placed on relatives at home who may have no choice but to restructure their lives to care 24-7 for their loved ones. When adult clients no longer are able to attend day-care health centers, the tasks of providing oversight and activities fall on family members who may have to give up their jobs and free time to provide the care.
The article is illuminating when it comes to explaining this toll on caregivers, some of whom are apparently outlived by the person they attend to, due to the added stress: One man told the Riverside P-E that he grew frustrated reinventing himself as a housewife and a cook and keeping an eye on his wife at all times: "There were times I just wanted to go out and yell," the man said. Without having a day-care health program to take his wife to, "I'd be back to the old daily going crazy." With the service as an option, he's been able to gain some of his free time back -- making life easier on him and his wife.
State budget drafters should always consider the multi-tiered human impacts of cutting deeper and deeper into health and human services programs. Represented on the spreadsheet, the programs may look like numbers yet, in actuality, they represent people. And not just people, but whole neighborhoods, cities and -- in the final analysis -- our level of empathy for fellow Californians.
Here's the Center for Budget and Policy Priorities' inital commentary, which states, "The President’s budget reflects both the short-term priority of boosting the economy and creating jobs and the longer-term priority of bringing deficits under control while meeting important national needs... The budget would reduce deficits by $1.25 trillion over 10 years, compared to what they would be by continuing current policies."
In the budget, President Obama reiterates that he is “committed to ensuring that every American has access to affordable health care,” and his FY 2011 budget proposal continues investments to this end in the health care of Californians. Specifically, California would receive $29.4 billion to provide health coverage to low-income families [Source: OMB factsheet]. In addition, other funding would be used to improve and increase the public health workforce, encourage health centers and providers to provide care to underserved populations, fund initiatives to achieve higher quality care at lower costs, and strengthen regional and local partnerships in rural areas.
STATE RELIEF FOR MEDI-CAL COSTS
Of particular note to those of us who deal with the state budget, there is some continued state relief through Medicaid.
Under the economic stimulus package (ARRA) passed last year, the federal matching rate for California’s Medi-Cal expenditures was increased from 50 percent to 61.6 percent. This totaled $1,991,907,534 for the two quarters from October 1, 2008 through March 31, 2009. In all, California was allotted $11.23 billion for the increased Medicaid match rate that is set to expire on December 31, 2010. [Source: http://www.statehealthfacts.org/]
President Obama’s FY 2011 budget proposal includes about $25.5 billion to extend the increased Medicaid matching rate for another six months until June 30, 2011 [Source: OMB]. This means California could receive an addition $2 billion to $3 billion in federal Medicaid relief under the President’s proposal, depending on actual expenditures and the formula for apportioning the grants to states.
This six-month extension of enhanced Medicaid matching funds is one of the requests for additional federal funding that Governor Schwarzenegger requested, and one that has also been included in other legislative vehicles, including health reform and jobs. However, Governor Schwarzenegger's state budget requested many other funding increases and policy changes, totaling nearly $7 billion. Given the political and procedural barriers in Washington, DC, some are more likely than others, but getting the enhanced Medicaid matching funds is a good first step.
It's still worth sharing more tidbits from the Senate Committee on Budget and Fiscal Review, chaired by Sen. Denise Moreno Ducheny, (D) earlier this week. Though the hearing was scheduled to last three hours, it ended up being twice that long -- such was the passion of the stakeholders and the complexity of the fiscal topic.
A few of the governor's proposals were raked over the coals, in some cases because the math didn't add up to equal the level of hardship the administration would impose by cutting crucial programs. Other proposals, glimpsed through the lens of recent history, seemingly deflated on the basis of that historical fact alone.
Consider the governor's persistence on the matters of zapping Proposition 10 and Proposition 63. Remember, these were two propositions placed before the voters in the true Democratic tradition of a) allowing folks to vote yea or nay, and b) tallying up the results and c) committing the results to official record.
Proposition 10, otherwise colloquially known for creating the First Five Commission, established programs that Californians believed were needed to help our kids get the leg-up on a world, not to mention a nation, that has been swiftly overtaking us in educating our next generations. California voters first approved it in 1998, rejected overturning it in 2000, and then later once again reiterated their approval of the program to begin nurturing and schooling children ages birth through age 5 in preparation for a robust education.
Proposition 63, the Mental Health Services Act, was approved by the voters and, then again, last May,was also protected when voters rejected the budget initiative to raid the mental health fund to help cover the general fund deficit.
Certainly, in Yogi Berra's terms, as someone pointed out in committee testimony, the governor's proposals are looking like "deja vu all over again."
County spokespeople testified it cost them $68.1 million to put the budget initiatives on the ballot last May -- only to see voters reaffirm what they said they wanted in the first place. Lo and behold, that $68.1 million has yet to trickle down to the counties as reimbursement from the state for holding the May 2009 special election, though one county spokeswoman testified hopefully, "It's in the governor's budget now. . . for that we are grateful."
When we get health reform, Speaker Nancy Pelosi of California will be a major reason. The New Republic's Joanthan Cohn commented that she "has been nothing short of heroic over the past week" on keeping health reform alive as legislators remembers that despite a special election in a specific state, the need and urgency and political imperative of passing health reform has fundamentally not changed.
As reported by Carolyn Lochhead of the San Francisco Chronicle, Pelosi had strong words today keeping the momentum up. She said that while some parts of health care reform may be done piecemeal, but "That doesn't mean that is a substitute for doing comprehensive. It means we will move on many fronts, any front we can."
"We will go through the gate. If the gate is closed, we will go over the fence. If the fence is too high, we will pole vault in. If that doesn't work, we will parachute in. But we are going to get health care reform passed for the American people for their own personal health and economic security and for the important role that it will play in reducing the deficit."
President Obama on health care & more: "We don't quit."
Wednesday, January 27, 2010
Health reform is alive. Speaker Pelosi has indicated she can pass the Senate bill in the House with the appropriate Senate changes through budget reconciliation. But President Obama set the new tone tonight at the State of the Union:
Now let’s be clear – I did not choose to tackle this issue to get some legislative victory under my belt. And by now it should be fairly obvious that I didn’t take on health care because it was good politics.
I took on health care because of the stories I’ve heard from Americans with pre-existing conditions whose lives depend on getting coverage; patients who’ve been denied coverage; and families – even those with insurance – who are just one illness away from financial ruin.
After nearly a century of trying, we are closer than ever to bringing more security to the lives of so many Americans. The approach we’ve taken would protect every American from the worst practices of the insurance industry. It would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. It would require every insurance plan to cover preventive care. And by the way, I want to acknowledge our First Lady, Michelle Obama, who this year is creating a national movement to tackle the epidemic of childhood obesity and make our kids healthier.
Our approach would preserve the right of Americans who have insurance to keep their doctor and their plan. It would reduce costs and premiums for millions of families and businesses. And according to the Congressional Budget Office – the independent organization that both parties have cited as the official scorekeeper for Congress – our approach would bring down the deficit by as much as $1 trillion over the next two decades.
Still, this is a complex issue, and the longer it was debated, the more skeptical people became. I take my share of the blame for not explaining it more clearly to the American people. And I know that with all the lobbying and horse-trading, this process left most Americans wondering what’s in it for them.
But I also know this problem is not going away. By the time I’m finished speaking tonight, more Americans will have lost their health insurance. Millions will lose it this year. Our deficit will grow. Premiums will go up. Patients will be denied the care they need. Small business owners will continue to drop coverage altogether. I will not walk away from these Americans, and neither should the people in this chamber.
As temperatures cool, I want everyone to take another look at the plan we’ve proposed. There’s a reason why many doctors, nurses, and health care experts who know our system best consider this approach a vast improvement over the status quo. But if anyone from either party has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. Here’s what I ask of Congress, though: Do not walk away from reform. Not now. Not when we are so close. Let us find a way to come together and finish the job for the American people.
More on the budget hearing from Jessica Rothhaar, who directs our budget organizing for Health Access California:
The hearing room was overflowing with Californians from around the state. The big turnout conveyed the severe impact of the cuts absolutely clear.
Senators Ducheny, Leno and Lowenthal also repeatedly expressed disbelief that the LAO was recommending adoption of the Governor’s cuts without accounting for the additional costs of consequences they admitted would happen, such as additional ER admissions, uncompensated care, homelessness, HIV/AIDS infection rates, etc. or the political impossibility of others, such as the taking of Prop. 10 and Prop. 63 money to backfill other programs. On the flip side, Senator Ducheny did ask several times whether less drastic cuts might be possible to several of the programs under discussion, such as to Healthy Families vision coverage.
Among the groups speaking against the cuts at yesterday's hearing included: AIDS Healthcare Foundation; Alliance of Californians for Community Empowerment (ACCE); AltaMed; Alzheimers Association; The ARC; Asian Pacific American Legal Center (LA); Bayview Adult Day Health Care; CA Alliance of Retired Americans; CA Association of Adult Day Services; CA Association of Family Health Centers; CA Association of Health Plans; CA Association for Health Services at Home; CA Association of Public Hospitals and Health Systems; CA Commission on the Status of Women; CA Disability Community Action Network; CA Hospital Associationl CA Immigrant Policy Center; CA Medical Association; CA Primary Care Association; Casa Pacifico ADHC; Children Now and the 100% Campaign; Children’s Specialty Care Coalition; County Health Directors Association of CA; County Mental Health Directors Association of CA; County Welfare Directors Association of CA (CWDA); Developmental Disabilities Council of Alameda County; Easter Seals; Elderday ADHC; Futures Explored; Graceful Senescence ADHC; Hemophilia Council of CA; Loma Linda University Medical Center; National Alliance for the Mentally Ill; Oral Health Access Council; Para Los Ninos; Placer Independent Resource Services; Planned Parenthood Affiliates of CA; Resources for Independent Living; Sacramento CARES; San Diego Council of Community Clinics; San Francisco AIDS Foundation; United Association of California Care Providers (UACC); and Western Center on Law and Poverty.
There was particularly awesome turnout and testimony organized by the California Association of Adult Day Services, which had members there from just about every district represented on the Budget Committee, including San Diego, San Bernardino, Santa Cruz, San Francisco, Contra Costa and Los Angeles. Let's keep it up!
There was no escaping the sharp wit and quick tongue of Sen. Denise Moreno Ducheny (D), chair of the Senate Committee on Budget and Fiscal Review, on Tuesday as the panel heard its first airing of the rationale behind the governor's budget proposals to drastically slash taxpayer-funded health services -- for the second year in a row.
Again and again, Ducheny offered succinct retorts that, in effect, signaled to the admininstration that Gov. Arnold Schwarzenegger's ideas amounted to little more than glasses-half-empty. In nearly every area of cuts described, Ducheny demanded more data before moving forward on the governor's punishing health-care cuts for California's most vulnerable populations at a time when the prolonged recession continues to drag down the state's economy.
More than once, Ducheny and other senators questioned why revenue-raising options were not considered as alternatives to decimating services to taxpaying, lower-income citizens. "Most of these programs were started in the first place with the theory that they would save us Medi-Cal dollars in the long run," Ducheny said, demanding more concrete figures from the administration's Department of Finance as it outlined proposed cuts in adult day health care, Healthy Families coverage for children, mental health programs, HIV-AIDS drug assistance and more.
"It's a pig in a poke, is what it is," Ducheny said, chiding the finance department and the Legislative Analyst's Office representatives for not presenting more details to support the claim of potential savings. "It's a bit of an irony that, if we're the seventh-richest state in the union, why the people who put us there couldn't help us more, by paying a [higher] Vehicle License Fee, for example."
Said Sen. Mark Leno (D-San Francisco): "When the governor talked about 'Sophie's Choices,' he didn't suggest revisiting the tax breaks for revenues. He didn't say that was one of 'Sophie's Choices.'"
Still, time and again, both the LAO and DOF representatives fell short in their explanations of how the puzzle pieces of the governor's proposed budget cuts fit together in a way that made sense in helping Californians weather the tsunami of a persistent recession.
Those offering testimony against the governor's cuts raised the discussion to a blunt level not frequently heard in such a formal setting. They spoke of the elderly and the frail expiring before being able to find a bed in a long-term nursing home. They spoke of children being left behind to fail in classrooms; they spoke of more and more people becoming homeless, hopeless, ailing and unjustly relegated to being second-class citizens. Phrases like "fiscally foolish," "morally reprehensible" and "appalling and horrific" replaced the more polite, mutually beneficial language that advocates typically offer up in legislative hearings.
Regarding the proposal that Healthy Families vision care benefits be dropped for children whose low-income parents pay 150% more in premiums than they did a year ago, Ducheny said, "How are the children going to 'Race to the Top' if they can't read?"
Senator Roderick Wright, a Democrat from Los Angeles, provoked the most heated discussion in dismissing what he called "the euphemisms regarding 'reduction of services.'"
Should the governor's proposals be adopted, Wright said, "We are voting to let people die. If we don't face the consequences of these cuts, if we don't face the fact that we are discussing life or death for some folks. . .we are doing a disservice to the public."
We'll have more reports about health reform from DC through the week. But one message: this is *totally* doable.
There is a path for health reform. Some call it "two-step," others call it "Senate plus reconciliation." But it's the same path, and perhaps the only path: The House passes the Senate bill, and a package of improvements that would be passed by the Senate through a limited budget reconciliation process. This still takes two final floor votes, needing 218 votes in the House, and 51 in the Senate.
This is a situation where the best policy and best politics align.
We need comprehensive health reform, and failure to pass such a broad reform (or passing a dramatically scaled back version of reform) won't begin to solve basic issues: getting insurers to compete based on cost and quality, rather than avoiding sick people; having people pay for coverage based on what they can afford, rather than how sick they are.
But other options are also politically problematic. Small reforms and/or starting anew wouldn't work, would not provide the necessary political benefit, and would bring up all sorts of new issues, new opponents, and take much more time and effort.
That's the procedural path is clear. The only question is the political will.
He noted he is uninsured—by choice. And that he is concerned about the waste and barriers to coverage by insurance companies—and he may have been overcharged—all issues addressed in the health reform bills. Rush said:
I'm not gonna get health insurance. I'm not going to inflate my bill by 35%. This cost me 30% less than had insurance been involved here. There was not one bureaucrat determining whether or not I was gonna get treatment. There wasn't a death panel here.
He seems to be referring that a lot of insurance premium dollars go to costs beyond patient care. That’s why the health reform bills set minimum medical loss ratios—the industry’s term for the money that is “lost” to care, rather than administration, marketing, and profit.
He also seems concerned about insurance bureaucrats denying care. The health reforms also include independent medical review—a component of a patient’s bill of rights package that has been passed in many states but stalled at the national level until now—so that if an insurer does deny coverage for medically necessary care, patients have the ability to get a third party to review, and possibly overturn, the decision.
His solution to insurance industry abuses is to not get insurance. As a multi-millionaire, Limbaugh had the ability to pay, as he said, just using a credit card.
But for the rest of us, health coverage is not just a good idea, it is essential. It's not an option to be on the hook for thousands (or possibly tens or hundreds of thousands of dollars) if we get sick.
How much did he pay for his short stay? He indicates it’s around the price of a car.
In the first place, you don't need to make $33 million a year or $50 million to afford what happened. I'll put it to you this way. My expenses were less than the cheapest car that you will go out and buy today other than one of these little bubble smart cars. It was five figures less than the average car. Yet for some reason it's immoral for people to have to pay for that. I don't have insurance. "I'm sure he has insurance." No. I pay cash for it and it was less than the price of a car. And just as is the case with a car you could finance your health care coverage. You don't have to come up with the whole lump sum, hospitals, doctors, work with you on this.
As someone who is uninsured, self-pay patient, Limbaugh probably gets charged on average of three times what insurers and public programs pay, for exactly the same service.
That’s because hospitals have a “chargemaster,” or sticker price, for their services that are inflated well beyond the actual cost of providing care. Insurers and public programs, with their market power, have the ability to negotiate the rate down. The uninsured, without that bargaining power, are stuck with the inflated rate.
The cruel irony of our health care system is those with the least are charged the most. In California, the average hospital charge is four times what most insurers pay. I’ve worked with patients who a 3-hour visit to the ER cost $12K; a one-night stay for an appendectomy cost $26K; and people who have racked up six figures in debt. These are the kinds of numbers that force regular middle-income people—however responsible they are—into collections and bankruptcy.
There have been class-action lawsuits about these unfair billing practices, and California and a few other states now cap how much hospitals can charge uninsured within certain incomes. (We have a website, www.hospitalbillhelp.org, to help Californians struggling with high hospital bills.) The Senate health reform places some oversight over hospital pricing policies, which has been a longtime interest of Senator Grassley.
But the ultimate way to prevent this practice of overcharging is to get people into group coverage, where they have the purchasing power to negotiate the best rate. Coverage provides a way for people to share in the risk and cost of health care: even if you are healthy today, you have financial security when (not if) those chest pains, or another ailment, comes upon you, you don’t have the additional shock of a huge bill. And that’s the heart of health reform.
So Rush’s alternative to health reform seems radical: he's not just against health insurance reform, but against health insurance. For most people who can’t absorb a five or six-figure trip to the hospital, that’s a prescription for financial ruin—or worse.
A lot of people say, "Rush, you're really running a risk here of sounding out of touch when you talk about how you can pay for this.”
Yep. Before we agree with those opposing health reform, we should understand what their proposal is.
California’s performance ranking in five key areas, including health care, dropped a grade on the annual report card issued by Children Now, leaving the Golden State with its most tarnished marks in the 20-year history of the advocacy group’s rating system.
Due mainly to brutal cuts in the state’s FY09-10 budget by the Legislature and the governor in children’s programs, California “earned the worst grades ever” for 2009, said Ted Lempert, president of Children Now. Lempert, a former state legislator, summed up the state’s dire performance during a legislative briefing held in the Capitol on Monday afternoon for staff members of the Legislature.
Still, Lempert, joined by vice president Wilma Chan and Kelly Hardy, associate director of health policy for Children Now, tried to emphasize the possibilities for improvement in coming budget discussions. “There are lots of opportunities to move forward this year on children’s health,” Hardy told the group. The silver lining in getting California’s children through the tough budget cuts last year came in the form of an unprecedented financial boost from the federal government.
The increase in federal matching funds did not pull California out of its economic doldrums, however; it merely helped keep pace somewhat with the increased need brought about by the loss of job-based health coverage as more and more parents became unemployed, Hardy said. The areas in which California performed worse than in previous years were:
Children’s oral health: the state’s marks dropped from a “C to a D” Infant health: the state’s marks dropped from a “B- to a C+” Adolescent health: the state dropped from a “B- to a C+” K-12 education: the state dropped from a “C- to a D” Integrated services: the state dropped from a “D+ to a D”
In response to legislative staff questions about the methodology of Children Now’s assessment, Lempert responded that the organization examined statistics, policy program decisions and also took a broad view of the outlook for the 9.4 million children currently living in California. In the final analysis, he said, “The methodology was similar to the academic grading process in that it was somewhat subjective.”
There was widespread recognition in the room that things will not become rosier overnight. “We know this is going to be another bad year for children in the California budget,” Chan said. “But people in this building have to make kids a higher priority – so our children and our economic future won’t become sicker.” The report card can be found online at the Children Now website, reports and research section.
California health reform advocates have seen health reform proposals die, whether by a veto or a vote. This just doesn't seem to be one of those times.
The only other path, short of complete abdication, is a drastically scaled back, unrecognizable proposal that would reopen all sorts of difficult conversations, and may provide some help to specific folks but no one would call it close to health reform.
This week, many of us will be in Washington, DC, and may have additional insights into what is going on. As always, we'll have reports on health reform and the California budget, from DC and Sacramento.
This morning, Saturday, Janaury 23rd, at 11:00am, keep the push on for health reform!
IN SAN FRANCISCO: San Francisco Federal Building, 90 7th St., San Francisco 94103 (Meet at 7th and Mission)
Californians will hold umbrellas – rain or shine – to illustrate the need for better coverage and honk for health care signs calling on Members of Congress not to leave consumers at the mercy of the insurance industry.
IN LOS ANGELES: Clinica Romero, 2032 Marengo St., Los Angeles, CA 90033
Los Angeles community members performing street theatre to illustrate abuses by insurance companies and why health care reform efforts are needed to be to assure affordable, secure health coverage for all.
Some have interpreted Speaker Nancy Pelosi's remarks as a signal that health reform is dead. Here's a transcript of some of her statements today, where she expresses the need and urgency for health reform. She's says her caucus can't pass the Senate bill as is. But it seems like it's a path for moving forward, but with changes. One way is to use the budget reconciliation process to make amendments. Read it for yourself:
PELOSI: Many of you have asked many questions about where we go from here. Let me congratulate the new Senator, Senator Brown from Massachusetts. While the results of the Massachusetts election may have diminished by one in the number of Senators in the Senate, last year this time there were 58 Senators, I remind you, 58 Democratic Senators, now there are 59. It has not diminished the need for affordable quality health care reform and for health care to be available to all Americans. As a right not a privilege.
The need for us to address health insurance reforms to end discrimination based on preexisting conditions, to stop rescissions, that when people are sick even though they have health insurance their policy has a rescission, to say that if you pay your premiums and do so on time and you get sick your plan will not -- your insurance will not be canceled. The list goes on and on. The idea of medical loss ratio that insurance companies should pay five percent of the premiums they collect on benefits. These and other issues to hold the insurance companies accountable. The McCarran-Ferguson, repealed McCarran-Ferguson exemption to the antitrust laws for the insurance company. As I say, these and other needs are still there.
There are still 30 million people in our country without health insurance. But the most important point I think is that the present system is unsustainable. We can not afford an upward spiral of cost. Families can't, businesses can't, our economy can't in terms of our international competitiveness, and certainly the Federal budget cannot. So we are going to have to continue to go in a forward direction to lower cost, to hold the insurance companies accountable, to make sure what we do is affordable to the middle class and to -- as we expand access to quality affordable health care. It is still a very exciting initiative, ranks right up there with Social Security and Medicare. And we are meeting with our Members on every level -- as a Caucus, in different groups of the Caucus, to hear how they perceive as the best way to go, how they would prefer to go forward, but we will go forward.
QUESTION: Madam Speaker, given the fact that there seems to be widespread unease in your Caucus about taking up the Senate bill and passing it and fixing it, is that option being discarded at this point?
PELOSI: Nothing is discarded, everything is on the table. You characterize it correctly; "unease" would be a gentle word in terms of the attitude of my colleagues toward certain provisions of the Senate bill. Let me remind you that over 80 percent of that bill, our two bills, are similar. So there are important initiatives in the Senate bill. But there are certain things that members just cannot support. For example, the Nebraska piece of it. And so what they would want to see fixed is that there be equity among states, more fairness, and that that policy shouldn't be made on the basis of one Senator, but on the basis of one country for -- to name one example. There has always been unrest in our Caucus about the excise tax on so called Cadillac benefits and so, you know, just to name a few.
So in its present form without any change, I don't think it is possible to pass the Senate bill in the House. There is some part of our Caucus that would say let's just take these pieces. We recognize health care has to be done -- health care reform has to be done, let's take some pieces of it and go forward. Others are saying let's just get it done and move on. But everybody recognizes that something needs to be done.
QUESTION: Madam Speaker, does that mean the Senate bill in its present form you will not pass?
PELOSI: I don't see the votes for it at this time, no. I mean, the Members have been very clear in our Caucus about the fact that they didn't like it before it had the Nebraska provision and some of the other provisions that are unpalatable to them. But there is a recognition that there is a foundation in that bill that is important. So one way or another, those areas of agreement that we have will have to be advanced, whether it is by passing the Senate bill with any changes that can be made or just taking pieces of the bill. But everything is on the table. In other words, what we are doing now is very calm, we have to get a bill passed. We know that, that is a predicate that we all subscribe to. We have to pass legislation.
QUESTION: But passing the Senate bill and then trying to fix it later is not an option?
PELOSI: There are some fundamentals in there that that make it problematic for our Members. And some Members say, and I respect this, some of the concerns that were expressed in Massachusetts were about certain provision of the Senate bill. We want obviously to hear and heed what was said there and what is said across the country. What was said in Massachusetts was not news to anyone, it was just expressed in an election. But it is hard it say, well, we don't like the special provision for [Nebraska] -- and that had a lot of resonance around the country, again most recently expressed in Massachusetts. So they don't see why something that wasn't even a fundamental part of the bill to begin with, that has been rejected by the American people is something they should be called upon to vote for. That doesn't sound like they heard the message of Massachusetts.
QUESTION: Just to be clear on that, you are ruling out passing the Senate bill unchanged, but are you not...
PELOSI: We are not ruling out anything. I am saying to you we are ruling out -- everything is on the table and everything, every decision that we have to make -- now we are legislating here now, so this may be more on the subject than you want to know. But in legislating, we have to know what our possibilities are, and that means in both Houses and with the White House. And every time you make a decision, you have to make a choice; you don't like this but is it better than that. I am saying to you right now that the Members -- in every meeting that we have had there would be nothing to give me any thought that that bill could pass right now the way it is.
QUESTION: You mentioned that as an option, the pieces. Given the unease among your Members about the Senate bill and trying to fix that, is that a more likely option?
PELOSI: Well, I don't think anybody disagrees with, "Let's pass the popular part of the bill," but some of that popular part of the bill is the engine that drives some of the rest of it. But again, we are not in a big rush; pause, reflect upon what our possibilities are, see what the support is in the Caucus. We have to always go where we can build consensus. So certainly there would be great consensus to take the most popular part of the bill and advance it, but I don't know what -- and that would be positive, but we have serious other structural things that have to be done, systemic changes that have to happen to again hold the insurance companies accountable. [Sound of clock chiming.] Have we, did we get a new clock? Or have we not been here at this time of day? Oh, it is 10 o'clock? It must be Eastern time, Western, some time, other time.
But again, however we achieve it we must arrive at accountability of the insurance companies, and I talked about that package earlier, any discrimination of preexisting conditions, no rescissions, stopping them from canceling policies even though people have paid their premiums but because they get sick their policies cancel. The list goes on, medical loss ratio, McCarran-Ferguson, repealing the exemption that they have to antitrust laws. Again in the Senate bill good language that talks about if the insurance companies raise rates in this next couple of years before the exchanges are established, then they would not be able to participate in the exchange. You know, those kinds of things -- accountability. Affordability is very important. Affordability for the middle class. That is one of the main purposes of bill is to make it affordable to the middle class. And so to the extent that any one of these initiatives, or the decision may be to proceed with the full bill, I don't know, but there isn't a market right now for proceeding with the full bill unless some changes are made in the Senate.
President Barack Obama was interviewed by ABC News today. He made clear that he heard the anger of Massachusetts votes, but he didn't back away from health reform. In fact, he made the case for continuing the effort. Neither is Speaker Nancy Pelosi backing away:
The need and urgency for health reform that was true last year and last week is still true today and this week and this year. Families continue to wonder if their coverage is going to be there for them if they need it.
The urgency for health reform does not change because of one special election in the state where health reform least mattered, since they already adopted many of reform's benefits, from regulating insurers so there are no denials for pre-existing conditions, to providing subsidies to low and moderate income families to afford coverage. Even the candidate opposed to national health reform did not oppose the policies in Massachusetts once they were adopted.
Given the extent of California's health crisis, Californians need health reform more than ever, and to pass a final proposal quickly. Californians are more likely to be uninsured, face a higher cost-of-living, are at greater risk to be denied for coverage for pre-existing conditions, and are less likely to be offered on-the-job coverage. Health reform would disproportionately help Californians, providing new choices for the uninsured, more security for the underinsured, stability for our safety net, and savings for our state budget.
We thank the President and Speaker Pelosi for her leadership in continuing the effort to solve the pressing problems that patients face. We look forward to working with them, especially our California Congressional delegation led by Speaker Pelosi, to pass health reform and to continue to improve our health system in the months and years to come.
“Health Care for America Now is committed to winning a guarantee of good, affordable health care we all can count on, and we will continue to push aggressively to get the best health care reform bill possible to the President’s desk for his signature as quickly as possible.
Tuesday’s vote was not a referendum on health care reform. It was a referendum on a particular candidate in a climate in which people, hard pressed by the economy, are impatient for change. When it comes to the need to make good health care affordable, nothing is different today than it was yesterday. Congress must keep going and finish reform right.
Fixing health care now is vital to fixing our economy. In survey after survey, voters continue to voice strong support for forcing health insurers to stop excluding people with pre-existing conditions, guaranteeing everyone has access to good, affordable coverage, and requiring health plans to spend premiums on medical care, not profits.
The people of Massachusetts already have benefit from health care reform. It’s time the rest of the country had the same access to good, affordable care.
We are on track to pass a strong bill, and we will stay focused on that until the President signs the bill into law.”
I would add that we at Health Access are pleased by Speaker Pelosi's continued leadership on this issue. And maybe that comes from the fundamentals: After all, the need and urgency for health reform from last year and last week didn't change this week and this year, because of a single result of a special election in a specific state. The election in question was in the state where health reform least mattered--as opposed to California, where it matters possibly most of all, given our large percentages of uninsured, lower-wage workers, people at risk of being denied for pre-existing conditions, etc. Even in Massachusetts, the candidate in opposition to national health reform did not dare oppose the identical state reforms already in place.
And that's the lesson. Pass a bill--a good bill--and health reform won't be the political issue it is now.
CALIFORNIANS WIN FIRST-IN-NATION CONSUMER PROTECTIONS SETTING STANDARDS FOR TIMELY ACCESS TO CARE * CA Department of Managed Health Care Announces New Standards Today in LA * HMO Patients Can Expect Quick Phone Advice; Urgent Care within 2-3 Days Routine Appointments within 2-3 Weeks * Timely Access Rules To Help Prevent Health Problems From Getting Worse; and Reduce Unneeded Trips to Emergency Rooms
* Read Our Health Access Blog for More on the Massachusetts Senate Election, and How Health Reform Can Advance, and Why It Must * Join Us on Facebook! Follow Us on Twitter!
SACRAMENTO--California consumers will have greater assurance of getting appointments and care when they need them. New first-in-the-nation consumer protections are being put in place this week by the California Department of Managed Health Care. As a result, consumers should get a primary care appointment within 10 days, an appointment with a specialist within 15 days and urgent care much more quickly.
Taking effect January 17th, these new regulations to ensure timely access to care implement a 2002 law (AB2179, authored by Assemblywoman Rebecca Cohn, and sponsored by Health Access California), and respond to common consumer complaints about their inability to get health care advice or appointments within a reasonable amount of time.
These groundbreaking consumer protections will help ensure that HMO patients get the care they need, when they need it. Consumer advocates argued that care delayed is often care denied, leading to worse health outcomes or unnecessary visits to the emergency room. These new first-in-the-nation patient rights will provide consumers with clear expectations about how quickly they should get in to see a doctor or specialist.
The new rules ensure that when managed care consumers agree to a limited network of providers, insurers fulfill their promise that their networks of doctors and specialists have the capacity to take care of their paying patients. While the concept of timely access to health care was one of the cornerstones of the original Knox-Keene Act of 1975 that established and regulated managed care in California, it remained largely unrealized and unenforced.
For the first time, the new consumer protections detail specific time-elapsed standards by which patients can expect to get a telephone questioned answered, an urgent care appointment, or a routine appointment for a primary care doctor or specialist.
Here are some examples of the new Consumer Time Elapsed Standards contained in the regulation:
* Triage or screening by telephone 24-7 * Waiting time for telephone triage no longer than 30 minutes * During normal business hours, waiting time to speak to a plan’s customer service representative no longer than 10 minutes * 48 hours for urgent care appointments that do not require prior authorization * 96 hours for urgent care appointments requiring prior authorization (including specialists) * 10 business days for non-urgent primary care appointments * 15 business days for non-urgent appointments with specialists * 10 business days for non-urgent appointments with a mental health care provider * 15 business days for non-urgent appointments for ancillary services (x-rays, lab tests, etc.) for diagnosis or treatment of injury, illness, or other health condition
For Dental Plans * 72 hours for urgent care * 36 business days for non-urgent care * 40 business days for preventive care
Consumers who believe they have been denied timely access to care, should promptly complain to their health plan. If that doesn’t resolve the issue, they should file a complaint with the Department of Managed Care (DMHC) at the HMO Help Line at (888) HMO-2219 [(888) 466-2219] or (877) 688-9891 [TDD] or at www.hmohelp.ca.gov
These new first-in-the-nation consumer protections have several benefits for individual patients and for the health system:
* Patients will get some clear standards for how long they should—and should not—wait to see a doctors or specialists. They also have a place to com * Patients will get better guidance about when and where to get treated, through telephone triage and urgent care appointments within 1-3 days. This may reduce inappropriate use of emergency rooms, where patients face long waits and expensive cost-sharing. * Emergency room overcrowding may be eased, since the recent increases have been with *insured* patients—who likely could not get in to their doctors in a timely manner.Health outcomes can improve if problems are caught early and before they grow, when there are more and usually less expensive options for treatments. * New attention to wait times can expose broader issues with a health insurer’s lack of an adequate network of provider, lack of appropriate financial resources to patient care, regional shortages, insufficient accountability or oversight of providers, or financial insolvency. * In an era of health reform, when people have been scared about talk of waiting lists and rationing, these rules provide reassurance that patients get the care they need, and that the reforms work to reduce, rather than expand, waiting times.
Consumer groups, including Health Access California, Western Center on Law and Poverty, and the California Pan-Ethnic Health Network, were pleased that the Department did not adopt industry proposals to allow health plans to determine their own standards, or to exempt providers offering language interpretation services.
The rules will be officially unveiled at a press conference today at Cedars-Sinai Hospital in Los Angeles. More information, including fact sheets, is available at http://www.health-access.org, and at http://www.dmhc.ca.gov.
First of all, it isn't news that Bay State voters have the ability to pull the lever for the GOP. Before the current Governor, the last Democrat in the statehouse in Boston was Michael Dukakis, when I entered college at Amherst a generation ago. Since then, Republicans have run the state for the last 17 of 20 years.
The Massachusetts Senate election has now been won by an opponent of health reform.
But was health reform what the election was about? Yes, in part. It was also about the economy, bank bailouts, unemployment, the conviction record of that state's attorney general, and (strangely) what team Curt Shilling roots for.
Don't get me wrong, it was also about health reform, although it was in the state where the bill least mattered, since they had already put in place some (though not all) of the reforms, from regulating insurers so there are no denials for pre-existing conditions, to affordability subsidies so low- and moderate-income people can better afford coverage.
Let's remember that the rest of the country voted for President Obama, who explicitly ran on health reform; the rest of the country voted for the remaining 59 health reform-supporting Senators; the rest of the country voted for the majority of the House of Representatives.
There were no exit polls today. But according to Rasmussen polling tonight (which tends rightward), 53% of MA electorate today approves of Obama, 38% disapproved. President Obama polled well ahead of the candidate in Massachusetts.
The need for health reform was real and urgent last week, and those same factors make it necessary and urgent next week. It's momentum and urgency was not based on how popular or easy it was--although it was popular, and likely will be again. That's the case with past programs and reforms--but only once they pass and their benefits are known.
There are options for moving forward. The House can pass the Senate version, putting in place a framework that then can be improved in the future--especially through the budget process, which takes a simply majority of 51 votes rather than 60. And it can be improved not just at the federal, but at the state level as well.
It will take those who voted for health reform to have the courage of their convictions, and to push reform forward not just because it is the right thing to do, but because those who voted for reform have a better case to make when they run on something rather than nothing. And that after listening to voters, there are improvements to make.
Now it is up to Speaker Pelosi to make that case to her members, that the Senate bill isn't the end of the effort, but the beginning... and that there is political reward in the continuing campaign to make it better.
It was there that a 2006 reform got people talking again about health reform in a big way. (Maine and California got some attention in 2003 for reforms, but not as much.) The Massachusetts law was widely scrutinized (including by us at Health Access), either as a reform to emulate or to indicate what was missing.
So it is strange that the election in that state tomorrow for U.S. Senate matters so much. After all, Massachusetts voters already have had a very similar health reform for a couple of years, and have shown no sign of seeking to repeal it.
The concern is that if the Democrat loses, then supporters of health reform only have 59, rather than the needed supermajority of 60 votes. There may be other options, from trying to pass something before a new Senator is seated (there's been lots of lame duck sessions over the years), to simply having the House adopt the Senate bill as is (as Jon Cohn describes here). As Ezra Klein writes, there should be no question that the health reform push needs to go on, regardless of what happens.
As tweeted at @healthaccess and @sovernnation, Speaker Nancy Pelosi told KCBS today that she was not worried about Massachusetts Senate race, she was confident Coakley will win... and that they will pass health care "one way or another."
In order to secure stimulus funds from Washington, D.C., the Senate Health Commitee, chaired by Sen. Elaine Alquist (D), voted on Wednesday to advance a bill to officially undo the state's requirement for semi-annual reporting for Medi-Cal.
As a condition of receiving enhanced federal funds, states must refrain from efforts at reducing Medicaid enrollment, such as using semi-annual reporting, which has been shown to create a barrier for people trying to access the state-and-federally funded program.
"It makes sense to support this common-sense measure to keep 174,000 kids covered with health insurance, " Elizabeth Landsberg of the Western Center on Law & Poverty told committee members.
Also speaking in favor of the bill was Beth Capell for Health Access California, the California Medical Association, Molina Health Care of California, and advocates for the disabled and children's access to health care.
The bill must pass the full Senate by the end of the month to advance to the Assembly. Committee member Sen. Dave Cox (R ), was the only one to vote against it, while Vice Chair Tony Strickland (R ) joined Democrats in voting to pass the bill.
In other action, the Senate Health Committee also voted to send SB270 (Alquist) along to the Appropriations Committee. The measure would create a health information technology advisory panel to advise the Governor and the Legislature on health information technology in California.
Back in DC, legislative leaders from both the House and Senate have been in long negotiations at the White House for over five hours. There's a rumor that President Obama has urged them to stay in until the framework of a bicameral health reform deal is agreed to.
If we had our druthers, the House would prevail in most of the differences. I participated with a panel of experts, convened by Jonathan Cohn of The New Republic, that came up with the same result. Cohn has also been busy explaining the negotiation to "Fresh Air" public radio listeners.
Fingers crossed on our Congressional leaders coming to a good and equitable resolution. Many of my thoughts on federal health reform have found a forum on Cohn's blog at The New Republic, called The Treatment. I have appreciated having the platform on national health policy issues (and the editing), and have now posted there 20 times in the past year. Here are the posts, many of which are still very relevant to the current debate:
That's how Assemblywoman Noreen Evans began her statement as chair of the Assembly Budget Committee, as they started deliberation.
She was clear that the budget proposal was not acceptable, that "there was a lot of sacrifice, but it isn't shared." She said that since the Governor's proposal wasn't acceptable, the Legislature would not use the Governor's budget as a framework, and would have to take it upon themselves to craft somthing that then the Governor would respond to.
Senator Mark Leno, the current author of the bill, was joined at the rally by its previous author, Senator Sheila Kuehl. Other speakers included Jim Kahn, President of the California Physicians Alliance, labor leaders, and others.
The bill, SB810 (Leno) is expected to come up for a full Senate vote this month.
Our Facebook (www.facebook.com/healthaccess) page has some of the many news clips from the eleven events last week from around the state by health and human service advocates.
There will be more to come in the weeks ahead. Budget hearings are starting this week...
It's worth repeating, at the beginning and the end of the health reform discussion: Affordability is paramount. As the House and Senate begin their negotiations over a final health reform bill, that needs to be the central question: does the bill provide people the help they need to afford coverage? This is important for people and for policymakers, as policy and as politics.
That's the subject of the letter was signed by more than 750 organizations, organizational leaders, congregations, clergy and local and state elected officials, from 46 states, representing more than 100 million people.
The United States is closer than ever before to making quality affordable health care available to all families.
Yet, health care reform can only succeed if it makes coverage truly affordable for ordinary families who are finding it more and more difficult to get the care they need. Requiring people to purchase health insurance that costs too much and covers too little would frustrate the fundamental goals of health reform and undermine the public support needed to pass and sustain reform.
The House of Representatives has passed health reform legislation that would cover 36 million people, 96 percent of all legal residents. The House covers five million more people than the Senate. We urge you to support the coverage provisions in the House bill, so that millions of Americans are not left uninsured after the passage of comprehensive health reform.
On the critical question of making coverage affordable, the House legislation sets premiums and out-of-pocket costs at levels that are likely to be affordable to lower-income working families. The House does a much better job in protecting lower-income people. The Senate approach provides somewhat better protections for middle-income workers, but would require lower-wage workers to buy insurance that costs many thousands of dollars more than the House legislation. We urge you to take the best elements of both approaches to create legislation that would protect all families from costs they cannot afford.
The letter was sponsored by our partner groups Community Catalyst, PICO, SEIU, Center for Community Change, and many other groups. We were pleased to be work with and be joined by dozens and dozens of key California leaders in this effort.
GOVERNOR ANNOUNCES BUDGET FOR MORE "MONSTER" FY10-11 CUTS * Gov. Schwarzenegger Has Budget Proposal Similar--but More Severe--Than Last Year * Millions of Californians Could Lose Coverage and Care; Dramatic Impacts * Details Below on $2.9 Billion in Health and Human Services Cuts * An Additional $3.5 Billion of HHS Cuts Would Be Triggered Without Federal Funds
* For News on the Budget, Read Our Blog! Join Us on Facebook! Follow Us on Twitter!
With California bogged down by a $19.9 billion deficit for the next 18 months, Gov. Arnold Schwarzenegger on Friday once again proposed balancing the state’s budget not with new revenues back with devastating cuts to the state’s least-fortunate -- including up to 6.4 billion dollars of cuts in health and human services. Under the cuts, over 1.5 million Californians, and likely many more, would have their coverage eliminated, other key services would be scaled back, and California would lose jobs and federal matching funds.
As he has in last year's budget cycles, Schwarzenegger proposed severe cuts to health and human service programs, the kinds of safety-net services Californians expect their government to extend to the public in times of deep need, that provide help in getting the state and its people back to work.
In some of the governor’s harshest budget scenarios threatened to shut down altogether a range of existing essential health and human services if the federal government did not respond favorably to his demand for $6.9 billion in federal tax dollars.
“Tough times still lie ahead,” Schwarzenegger proclaimed in announcing a package of budget proposals that included some “monster” cuts that would either lead to “real reform” or a continuation of “the budget roller coaster.” Schwarzenegger said he would declare a fiscal emergency and call a special session of the Legislature so lawmakers would be forced to focus on solutions to the deficit.
Afterwards, Democratic Assembly Speaker Karen Bass succinctly said of the governor’s proposals: “I call this budget a big pile of denial.” Bass said the governor’s budget plan was simply and plainly “a non-starter” because “it’s calling for the virtual elimination of the safety net.” Besides Bass’ comments, early indications were that Schwarzenegger’s plan had fallen flat with the Legislature’s Democratic leadership, whose cooperation the governor will need to adopt the state’s annual budget.
Senate President Pro Tempore Darrell Steinberg opened his statements to reporters with a blunt: “You’ve got to be kidding me.” He later noted that the governor’s budget solutions lacked “creativity.” Senator Denise Ducheny, chair of the Senate Budget Committee, said she saw in the budget “a recycling of exactly the same proposals he’s had before.” The main difference, Ducheny said, was that previously Schwarzenegger tended to blame the Legislature for a lack of fiscal solutions and, on Friday, the governor focused on blaming Washington D.C.
Indeed, Schwarzenegger did everything but identify the federal government as a foe, leaning heavily on the theme of fiscal fairness. This lead Bass to note that the governor struck a nearly inappropriate tone: “Typically he threatens the Legislature. Now he’s threatening the president of the United States.”
The governor pledged to fly to Washington D.C. with all four partisan legislative leaders to demand the $6.9 billion he said the federal government owes California. Schwarzenegger made the case that, for every $1 Californians pay in federal taxes, the state only gets an average of 78 cents back. (Ironically, his cuts would cause California to lose even more in federal matching funds.)
The governor is also seeking more reimbursement funds for Medi-Cal expenses, saying California receives only 50 cents on the dollar, while the average for states is 57 cents. Chief among the governor’s deep cuts are those that would eliminate coverage and care to millions of Californians, ironically forgoing substantial matching federal fund dollars as a result.
The Governor plans to ask for a $2.9 billion cut in health and human services (including $1.1 billion in Medi-Cal), and an additional $3.5 billion cut in health and human services if California does not get the federal money he seeks.
But even with a massive infusion of federal funds, the Governor would still propose to eliminate coverage to hundreds of thousands of Californians, including children. Health experts say these devastating cuts would further unravel the health care system that we all rely on, where we have already seen services scaled back and full clinics close. Health Access recently released an assessment of the health cuts in the 2009-10 budget, six months in.
THE GOVERNOR'S PROPOSED "TRIGGER" CUTS
The following is a list of proposed cuts and eliminations that the governor proposes to be "triggered" if additional federal funds are not forthcoming:
* Eliminate coverage and benefits for millions in Medi-Cal ($532 million), including: * Reduce Medi-Cal eligibility to the minimum allowed under current federal law (about 72% of the Federal Poverty Level for most adults and 133% FPL for children and pregnant women). For example, this would reduce eligibility for low-income parents from an income of up to $18,310 for a family of three to around $13,000. While this tightening of eligibility standards would not be allowed under the stimulus package until January 1, 2011, it would eliminate coverage for 250,000 Californians in the first six months, coverage for 450,000 in the year after that, and hundreds of thousands more in future years. * Eliminate many Medi-Cal programs (including the Family PACT program for family planning services, the CHDP Gateway for transitional children's coverage, Breast and Cervical Cancer Treatment Program, and the Medically Indigent long-term care program). * Eliminate many remaining optional benefits (including medical supplies like diabetic test strips, prosthetic limbs, orthotics, wheelchairs and other durable medical equipment, hearing aids and other benefits).
* Eliminate the Healthy Families Program, affecting all 874,762 children currently enrolled ($126 million); * Eliminate various health services programs, (including Access for Infants and Mothers, MRMIP's high-risk pools for those denied coverage for pre-existing conditions, Every Women Counts, Asthma control program, and Expanded Access to Care Program), funded by Proposition 99 (tobacco tax) funds, subject to voter approval ($115 million); * Eliminate mental health services funded by Proposition 63 (Mental Health Services Act), shifting the $847 million to fund existing mental health services; * Eliminate CalWORKS, the state's welfare-to-work program ($1.044 billion); and * Eliminate the In-Home Supportive Services programs that provides home care to those not able to assist themselves. ($495 million)
BASE BUDGET PROPOSAL (REGARDLESS OF WHETHER FEDERAL DOLLARS ARE FORTHCOMING) Specifically, as described below, the budget proposal makes a number of cuts to health and human services programs, redirects funding from other sources to health care programs, and relies on significant receipt of federal funds.
Cuts to Medi-Cal: · $750 million in cuts to Medi-Cal by placing limits on services and applying utilization controls, increasing cost-sharing for Medi-Cal beneficiaries, and making “other programmatic changes,” potentially affecting the 7 million Californians on Medi-Cal; · $118 million to eliminate Medi-Cal coverage for recent legal immigrants, effective March 1, 2010, affecting about 90,000 legal immigrants; · $104 million to eliminate the Medi-Cal adult day health care benefit, effective March 1, 2010, affecting about 35,000 frail adults; · $55 million to delay payment to Medi-Cal institutional providers, requiring doctors and hospitals to “float” the state; · $26.4 million from aggressive elimination of fraud in Medi-Cal; and · $28.7 million to rescind a rate increase for Medi-Cal family planning services.
Cuts to the Healthy Families Program: · $85.3 million (including $10.5 million for the current fiscal year) by tightening eligibility requirements for the Healthy Families Program from 250% of the federal poverty level (FPL) to 200% of the FPL, effective May 1, 2010, affecting roughly 225,000 children, plus an additional corresponding $3.9 million cut to the California Children’s Services program for Healthy Families-eligible children; · $21.7 million by eliminating vision coverage from the HFP benefit package and increasing monthly premiums in families 151-200% of the FPL, effective July 1, 2010, affecting 167,000 children.
Other cuts to Health and Human Services programs: · $950.5 million in reducing eligibility, payments and services in the In-Home Support Services (IHSS) program; · $146.1 million by reducing benefits for CalWORKS recipients; · $306.9 million by reducing benefits for recipients of SSI/SSP; · $60 million by eliminating the California Food Assistance Program; · $200 million by reducing support for Regional Centers; · $18 million by eliminating the Substance Abuse Offender Treatment Program.
A redirection of funding to avoid more health care cuts: · Reduce $240 million from children’s health coverage to be replaced by newly enacted hospital fees; · Reduce $36 million from Medi-Cal to be replaced by one-time Proposition 99 (tobacco tax) reserve funds; · Reduce $25 million from the Access for Infants and Mothers (AIM) program to be replaced by one-time use Proposition 99 (tobacco tax) reserve funds; · Reduce $550 million in General Fund expenditures on high-priority health and social programs serving children to be replaced by state and local Proposition 10 (California Children and Families Act) funding, subject to voter approval; and · Reduce $452.3 million in General Fund expenditures on EPSDT services for children and mental health managed cared to be replaced by Prop 63 (Mental Health Services Act) funding, subject to voter approval.
A reliance on federal funding to avoid more health care cuts: · $1 billion from federal funds owed to the state for disabled Medicare-eligible individuals and the rate of Medicare Part D coverage · $1.8 billion from increasing the standard federal matching assistance percentage (FMAP) for Medi-Cal from 50 to 57 percent; · $1.5 billion from continuation of an increased FMAP (through June 30, 2011) as part of ARRA, the economic recovery act.
On the Health Committee, there are 9 members, 6 Democrats. This means that if a bill is to pass Health Committee, and all Republicans oppose it, it can't lose more than one of the Democratic votes.
Governor Schwarzenegger released his proposed 2010-11 budget today, which includes severe cuts and no new revenues.
As part of the cuts, the Governor proposes a $2.9 billion cut in health and human services (including $1.1 billion in Medi-Cal), and an additional $3.5 billion cut in health and human services if California does not get a major infusion of federal funds.
The Governor proposes shocking cuts eliminating coverage and care for millions of Californians, which will have dramatic impacts on not just these families but on the health system on which we all rely. Even *with* a massive infusion of federal funds, the Governor would still propose to eliminate coverage to hundreds of thousands of Californians, including children.
This is an anti-jobs budget that not just harms California families and our healthcare system, but our economic recovery. The most effective way to create jobs is invest in Californians, and in their health and in services to help all of us get through a tough time. This proposal completely undermines our economic recovery efforts.
The economic impacts of these health and human service cuts would be multipled because we would not just lose jobs but billions in federal matching funds.
Governor Schwarzenegger's office came out with a statement accusing Health Access California of "twisting the facts" and comparing "apples and oranges" about the Governor's stance on health reform. Carla Maranucci at the San Francisco Chronicle has the back-and-forth. We stand by our statements, and here's the facts:
Two years ago, as part of his health reform proposal, ABx1 1, the Governor was willing to raise the revenues to expand the same Medicaid program to the same population, and was willing to raise the revenues to do it, with a 50% of the cost paid for by the federal government.
The current health reforms will expand the same Medicaid program to the same population with the federal government paying for 100% of the expansion population for the first several years, and over 80% from the eighth year on. Much of that small cost to the state--much smaller than what the Governor projects--would be offset by savings elsewhere.
This isn't apples and oranges. The comparison isn't even apples and apples. We are talking about the very same apple.
To be clear: we support and prefer the House health reform proposal that would provide even more assistance to states, by having the federal government pick up over 90% of the cost of the newly eligible population in the eighth year on. That would be a productive means of advocacy for the Governor, rather than attacking the overall health reform package that would provide a new infusion of billions of dollars in needed subsidies to California families, small businesses, and yes, the state of California.
2010: THE NEW YEAR BRINGS MORE CUTS TO CONTEST * Gov. Schwarzenegger To Unveil FY10-11 Budget Proposal on Friday, 11:30 a.m. * Health Access Reveals "The Damage Already Done" Six Months Into 2009-10 Budget * Stakeholders Meet for First Medi-Cal Waiver Committee Meeting
* 2010 Promises to be a Big Year! Join Us on Facebook! Follow Us on Twitter!
BUDGET TO BE ANNOUNCED FRIDAY: California Governor Arnold Schwarzenegger announces the release of his new FY2010-2011 budget around 11:30 a.m. on Friday. All expectations are that the budget proposal will include more painful cuts in programs vital to California's health and struggling economy. Health Access will review and report later tomorrow on the proposal's impact on health and human services, with quick reactions on our blog and on Twitter.
ASSESSING "THE DAMAGE ALREADY DONE" BY CUTS BEFORE CONTINUING: In anticipation of that announcement, Health Access California today released a new report detailing the six-month impact of nearly $2 billion in cuts already made to the state’s healthcare system in the current budget year. Entitled “The Damage Already Done: A Report on the Impacts of the 2009 Health Care Budget Cuts, Six Months In,” the report documents many of the effects these cuts have had on individual patients, families, health providers, and our economy.The finding? Just six months into the 2009 budget, hundreds of thousands of Californians have been denied care or coverage for key services, and we see indications of the health system we all rely on is crumbling, with five clinics closing. These cuts are starting to ripple through the health system and our economy, as we lose health jobs and federal matching funds, and people don’t get the help they need to get through these tough times. Six months into those cuts, families are suffering harmful impacts of being denied access to a range of critical services such as dental care, basic prevention and affordable health care options. We hope this assessment informs the discussion about whether the state can afford to cut more.
THE GOVERNOR'S ANTI-JOBS, ANTI-HEALTHCARE STATE OF THE STATE: But the indications are not positive. Yesterday, the Governor presented his State of the State address. The Governor focused on jobs, but by suggesting tax breaks and credits that would only make the deficit bigger and force additional cuts. He conveyed that the budget will include painful cuts, but did not acknowledge the lost jobs and lost federal funds that would result.
The Governor took the opportunity to oppose the health reform proposals in Congress, completely contrary to the health plan he supported merely two years ago. Health Access believes his reasoning is based on faulty assumptions, and has very different numbers of the fiscal impact of Medicaid expansions in health reform on California. Beyond that, California--with its large percentage of uninsured people and low-wage workers--is likely to disproportionately benefit from the billions of federal dollars to help families and small business, and the state, afford coverage.
MEDI-CAL WAIVER STAKEHOLDER PROCESS STARTS: In this busy week, Thursday marked the first gathering of the stakeholder committee appointed to help guide the state Department of Health Care Services in its 1115 Medi-Cal federal waiver process. The renegotiation of our state's Medi-Cal waiver with the federal government will provide challenges and opportunities regarding the Medi-Cal coverage of 7 million California children, parents, seniors, and people with disabilities. More information is at the Department of Health Care Services website.
A REQUEST FOR THE NEW YEAR: From fighting budget cuts to fulfilling the promise of health reform, 2010 will be a very busy year. We’ll need your help, so resolve to join and contribute: Consider contributing to the Health Access Foundation!
The Damage Already Done by the 2009-10 Health Cuts...
As Governor Schwarzenegger is poised to release his proposal for next year’s state budget, the proposal is expected to include a slew of additional cuts to health and human services.
In anticipation of that announcement, Health Access California today released a new report detailing the six-month impact of nearly $2 billion in cuts already made to the state’s healthcare system in the current budget year. Entitled “The Damage Already Done: A Report on the Impacts of the 2009 Health Care Budget Cuts, Six Months In,” the report documents many of the effects these cuts have had on individual patients, families, health providers, and our economy.
The finding? Just six months into the 2009 budget, hundreds of thousands of Californians have been denied care or coverage for key services, and we see indications of the health system we all rely on is crumbling, with five clinics closing. These cuts are starting to ripple through the health system and our economy, as we lose health jobs and federal matching funds, and people don’t get the help they need to get through these tough times. We deserve a budget that supports, not undercuts, the health of our communities.
Since the Governor signed the budget in July 2009, slashing nearly $2 billion from the health care system, some cuts have been partially averted through various actions. The delay and uncertainty, however, have generated grave consequences. In many cases, cuts were made, resulting in very real human hardships and economic impacts for Californians.
Those impacts include:
* Almost three million low-income adults have lost ten important benefits, such as dental care, vision care, speech therapy, and psychological services – in the last six months, over 450,000 Californians in poverty have either had to forego or pay for dental care; another 240,000 have lost coverage for prescriptions eyeglasses; * About 93,000 children waited uninsured for Healthy Families coverage until the cut was averted by non-government donations and higher cost sharing for 269,000 children on the program; * Five community clinics in the state have already been forced to shut down and hundreds of workers have been laid off, an additional 10 clinics are on the brink of closure; * Thousands of AIDS/HIV patients have been denied access to needed services and affordable medications they rely on; * About 300,000 low-income women no longer have access to life-saving breast cancer screenings; * Six domestic violence shelters were temporarily closed while the Legislature passed a bill to find ways to keep shelters open, and even afterwards, most have been forced to reduce services;
The ripple effects of these cuts will continue beyond these short six months, as we see more layoffs and closures of services, and the impacts of people not getting care or preventative services comes to back to haunt us.
“The Damage Already Done” will be distributed at multiple press conferences this week held to address the broader topic of health and human service cuts. Events are scheduled for San Francisco, San Bernardino, and Sacramento this Thursday morning as well as Bakersfield, San Diego, Los Angeles, Fresno, and Modesto on Friday, January 8th.
After much anticipation throughout the fall, we are finally having the first stakeholder meeting around the new Medi-Cal waiver.
As you may know, the current agreement between the state and federal government about the administration of Medi-Cal runs out in September of this year. There's lots to discuss, from areas of agreement to issues of contention. In this process, there's lots for California, for low-income patients, and for our health care system to gain, and lots for us to lose.
The first meeting is today, Thursday, January 7th. It is public, starting at 9:30am – 12:30pm at the Sacramento Convention Center, Room 204. All the materials for the festivities are at the Waiver Renewal website of the CA Department of Health Care Services: http://www.dhcs.ca.gov/provgovpart/Pages/WaiverRenewal.aspx
Governor Schwarzenegger's State of the State speech today was anti-jobs and anti-healthcare.
The most effective way to create jobs is invest in Californians, and in their health and in services to help all of us get through a tough time. The investment's impact would be multiplied because of federal matching funds, further helping our economic recovery.
Yet the Governor proposed tax cuts and credits that would force even deeper reductions in health and human services, resulting in not just more lost jobs but also lost federal matching funds needed for our economy. And the Governor opposed a healthreform that would actually provide significantly more money for California families, our health system, and our economy.
THE FACTS ABOUT HEALTH REFORM: The pending health reforms in Congress would provide billions of dollars in new and necessary help to California families and small businesses struggling to afford their premiums. As a state with a high uninsured rate and large population of lower-wage workers, California will likely disproportionately benefit.
Health reform would also expand Medicaid for 1.5 million low-income uninsured Californians in 2013 or 2014, with the federal government picking up the full cost of that expansion for the first several years. Only eight years from now--two Governors from now--would there be any additional cost to the state of California, and those dollars will be matched at more than a 4:1 rate.
For California, health reform is a benefit, not a burden--and its a bargain to boot. Any additional costs are minimal and don't even take effect until eight or nine years from now, and would be offset by savings in other areas. And in return for such investments, our state would cover over 1.5 million more low-income Californians through Medi-Cal, with the federal government picking up over 80% of the tab--a better match than our current programs now.
The Governor's hypocrisy on health reform is stunning. Two years ago, the Governor was willing to raise the revenues needed to expand Medicaid to cover the same population--with the federal government contributing 50% of the cost. Now, the Governor opposes the same expansion when the federal government is offering well over 80% of the cost.
In the health reform bill, some states do better than California, some do worse. We support additional federal assistance for California, but the way to argue for more money is not to misrepresent the bill. And the best way to get more money from our health care system, and our economy, is to make the health care investments now that will bring in the federal money that is already sitting there with our name on it--and prevent the cuts that make us lose even more jobs and federal funds.
Health Access refutes the Governor's numbers about the fiscal impacts of health reform on California, which are based on faulty assumptions. Health Access recently published an analysis of the cost of implementing national health reform in California, which show the dramatically different estimates than what the Governor has stating. The cost to CA in the year 2019 ranges from a savings of almost $200 million under the House bill with moderate take-up rates to costs of about $800 million under the Senate bill with high take-up.
The Governor’s estimate of $3 billion assumes that outpatient Medi-Cal provider rates would be 80% of Medicare and that 100% of those eligible for Medi-Cal would enroll. While Health Access supports Medi-Cal provide rate insurances, federal health reform does not require Medi-Cal provider rates to be 80% of Medicare. Health Access supports maximizing enrollment in Medi-Cal but CBO assumes that only half of those eligible will enroll. The Governor also ignores the fact that for the first several years, the federal government will pick up 100% of the cost of newly eligible populations.
We'll tweet some intial thoughts about the Governor's State of the State today, at www.twitter.com/healthaccess, with more on this blog later. I'll be on KPCC later this afternoon with some reaction as well.
There's lots of charts on the web comparing the House and Senate bills. But not only is this one (posted by Politico) really good and detailed (11 pages!), it is written by the House staffers of the three committees of jurisdiction. That means these are the folks who worked to write the House version, and know why they made the choices they did when crafting it. It gives some hints about what the negotiators are thinking about what they are looking to improve the Senate version.
While vacationing in Hawaii, conservative radio talk show host Rush Limbaugh had chest pains and as a result had a stay at the Queens Medical Center--which is the hospital where Barack Obama was born (as was my wife as well.) But that's not the only irony.
At a press conference talking about his stay, he made comments which were widely interpreted to take a dig at efforts to reform the health care system, saying he was availed of "the best health care the world has to offer." Limbaugh continued, "Based on what happened here to me, I don’t think there’s one thing wrong with the American health care system. It is working just fine, just dandy.”
My post takes a look at some of the new research about the Hawaii Pre-Paid Health Care Act of 1974, and its central requirement for employers to provide health coverage to their workers: it shows positive results in improving access with no measurable impact on jobs. If Rush Limbaugh is endorsing an employer mandate, the House and Senate leadership may want to take another look at beefing up its requirements.
One lesson from Hawaii beyond Limbaugh's visit and unintended endorsement of reform I want to spotlight:
* Beyond the level of the assessment, the structure of the employer assessment is key, so there aren't broad loopholes that allow employers to avoid any contribution whatsoever. In this regard, the Senate's complicated "free rider" provision needs to be fixed. The House version has a simple test of whether an employer is providing adequate coverage, and the assessment for those that don't is a percentage of payroll, based on a sliding scale capped at 8%. The Senate is more convoluted, and the most problematic part is that employers could avoid much of the penalty by shifting workers to part-time status.
As Elise Gould and Ken Jacobs writing for the Economic Policy Institute indicate, "Studies of Hawaii’s health insurance mandate have found that the state has a disproportionate number of employees working slightly under 20 hours a week, the number of hours at which that requirement becomes effective. The 30-hour cut-off in the Senate Finance bill is more likely to encourage reductions in work time, since it is easier to restructure work to fewer than 30 hours a week than to fewer than 20 hours a week." As the researchers note, work shifts in this range are common in the restaurant, retail, and nursing home industries--the very ones that are less likely to provide coverage and leave their workers uninsured. The experience from Hawaii is strong evidence that the final employer responsibility provisions should be closer to the House than the Senate.
This issue of the structure of an employer requirement---and especially how to cover and pay for part-time workers---was a crucial unresolved issue in the California debate around health reform in 2007. The House bill gets this right--and better than what we had in the final Schwarzenegger-Nunez negotiated bill, partially because we didn't have the constraints of ERISA. The Senate version, however, needs to be fixed in order for it to work as intended.
For those who stopped paying attention since the Senate passed its version of health reform on Christmas Eve, here's some links of articles to catch up:
On the process from here, the likelihood in that the House and Senate do not go into a formal conference--which would simply let the Republican opposition put up more procedural roadblocks. Instead, the House and Senate leadership would hold informal negotiations, and they would amend an existing bill to be a final compromise to then get the two final floor votes--the 218 votes in the House and the 60 votes in the Senate. Jon Cohn at The New Republic has more about this game of "ping pong," and David Dayen of FireDogLake (formerly of Calitics) has a detailed report and quotes from CA Representative and House Energy and Commerce Chairman Henry Waxman.
The political blog Calbuzz was kind enough to print my response to their editorial about health reform. My main point is that we can't give up now: health reform is too important that we have to keep working on it... and we have to keep working to make it better.
Yesterday, we put out a quick "year in review" for 2009. Many are taking the opportunity to look back at the decade of 2000-2009 (even if technically the decade goes into 2010.)
It is striking to see how the conversation has evolved from ten years ago. In California, the health policy debates were focused on (and that Health Access was active in) was the establishment of the HMO Patients Bill of Rights (and the creation of the Department of Managed Health Care to enforce them), and the implementation of the new Healthy Families program for low-income children. Although in the case of Healthy Families, the issue back then was that the program was undersubscribed, and the state was not taking advantage of 2:1 federal matching funds, and so efforts were focused on boosting enrollment like simplifying the overlong application and training application assisters. (Governor Davis didn't run on health issues, but he highlighted both children's coverage and patients' rights as part of his re-election bid in 2002.)
These issues are still with us: * The Department of Managed Health Care recently implemented language access regulations and will officially put in place standards for timely access to care in a few weeks. They've begun a regulatory process on regualting so-called discount health plans. * Healthy Families has grown steadily and been a success story in reducing the number of uninsured children--although there are still hundreds of thousands of children without coverage that are even eligible but unenrolled. Yet as opposed to a time of budget surplus, the budget crisis has meant that simply keeping the program's doors open is a victory. State funding for those application assisters has been zeroed out, and the entire program was proposed to be eliminated last year.
The boom times allowed for incremental improvements in access to health care. What was not in the conversation was the major health reforms and expansions in the debate now--perhaps there was still a caution and a recovery from the failure to pass major health reform in the early Clinton years. The 2000 presidential election between Vice President Gore and Governor Bush did not focus on health care issues--and when it did, it was about issues like incremental expansions of children's health coverage and passing a national version of an HMO Patients' Bill of Rights. Both elements are parts of the much bigger reform package that is being discussed now.
At the beginning of the decade, California started an effort to invest and get federal money to expand our Healthy Families program to cover the parents of those children--but when we finally got federal permission, an economic downturn--along with 9/11 and the energy crisis--caused a budget crisis we have never really recovered from. Our budget crisis was not helped by the various reductions in revenues that were approved--from the vehicle license fee that Governor Schwarzenegger campaigned on to win the recall to the corporate tax giveaway in the last budget. So much of this decade has been about preserving existing health care public programs through tough budget times. And the last budget--that eliminates various Medi-Cal benefits and much more--is more of a blow because it is a defeat after a decade of defense.
But at the same time, California provided the template for the broader reforms we had now. In 2002, a health care options process generated some ideas on health reform. In 2003 saw the first reintroduction of a single-payer bill, SB921 by Senator Sheila Kuehl--and the passage of an employer mandate, SB2 by Senate President Pro Tem John Burton. That bill was signed by Governor Davis days before his recall in 2003, which set the stage for a referendum campaign in 2004. While unsuccessful, the close vote (49.2%) showed that health reform was achievable, which led to other efforts, like the successful passage and implementation of Healthy San Francisco. Governor Schwarzenegger opposed Prop 72, and vetoed both universal children's coverage (AB442 in 2005) and single-payer bills (SB840 in 2006), before putting forth his own reform proposal in 2007.
Whatever people thought of the details, the final proposal negotiated with Assembly Speaker Nunez was ambitious, and has similarities to what it now being discussed in Washington, from much bigger Medicaid expansions to insurance reforms including guaranteed issue. We have also seen, however, that a failure means that politicians can quickly move on to many other issues.
So ten years later, some things haven't changed, but a lot has. We have made some progress, in policy (like HMO consumer protections), and also in what is politically possible. The question is whether, despite the budget and other barriers, we can build on that base for the next ten years.
2009 YEAR IN REVIEW ON HEALTH ACCESS ISSUES * The Hope of Federal Health Reform: Further Than We've Been Before * California's Budget Blues: Medi-Cal Benefits Eliminated, Clinic Funding Zeroed * Some Progress on State Consumer Protections...
For health care in California, the year 2009 was the best of times, and the worst of times.
The year began with the hope and excitement of new Obama Administration—especially, for health advocates, for a new president that made health reform a central part of his campaign. The good news from Washington, DC, started quickly, with the reauthorization of the SCHIP program that covers low-income children, which had been vetoed in previous years.
But the California budget crisis loomed, with nothing more symbolically showing the disconnect between the federal possibilities and state problems than Governor Schwarzenegger’s budget proposal to eliminate the state’s SCHIP coverage for a million low-income children in its entirety—and actually have that program, Healthy Families, close enrollment and be a week away from sending out hundreds of thousands of disenrollment notices. That roller coaster continued as the same Governor and Legislature that approved steep cuts in the program earlier in the year then passed a fix to temporarily prevent kids from being kicked off coverage—and then wait with concern about federal approval. Given everything, it’s gratifying that at year’s end, Healthy Families’ waiting list has been cleared and children are being covered and enrolled—even if some families are now paying more, and future funding in uncertain.
The work started in 2009 is not yet finished, but here are some other highlights:
HEALTH REFORM: It’s not done, but comprehensive health reform has never made it so far in the legislative process, going through five policy committees and full floor votes in both the House of Representatives and the Senate. It’s not finished, but the final product is likely to provide more security and stability for people with health coverage, and include be the biggest expansion of health coverage (both public and private) ever, to around 30 million Americans—and nearly 4 million Californians.
Health advocates, including the state's Health Care for America Now! campaign, succeeded in having our two Senators be champions on key issues, and getting all Democratic Representatives from our 53-member House delegation—including all 7 “Blue Dogs”—to vote for the House version of reform. With the exception of the anti-abortion Stupak amendment, the House reform is a very strong bill that meets consumer advocacy principles, from affordability and employer responsibility to providing a public health insurance option. Californians took the lead in the House, and were in leadership positions—Chairmen Miller, Waxman, and Stark—in each of the three House committees of jurisdiction. From Speaker Pelosi to the chairs of the key Asian, Black, and Progressive caucuses, the House did its job and is looking to make final bill better than what passed the Senate, which needs improvement in key areas.
The work for health advocates now is to help our sizable California House and Senate members improve the final bill while passing it in early 2010, and then begin the longer effort to implement and improve it here at the state level, through legislation and regulation.
CALIFORNIA'S BUDGET CRISIS: In both February and July, the Legislature passed and the Governor signed two budget packages to solve a combined $60 billion deficit—with many cuts, including to health care—for the year-and-a-half period of January 2009-June 2010.
The first February package of $42 billion included significant health and human service cuts that were "triggered"—including the full elimination of ten benefits for three million adults with Medi-Cal coverage, including dental, vision, podiatry, speech therapy—as well as some temporary taxes. The package also placed six propositions on the May ballot, including a spending cap (and two others to divert funding away from mental health services and health and social services for young children). The only one that passed was to prevent increases legislator salaries in deficit years.
A July package was needed to address over $20 billion more in deficits, and that led to even steeper health and human services cuts, and no new revenue. The reductions in health included cuts to coverage, hospitals, AIDS and mental health programs, and the zeroing out of state funding for community clinics.
For 2010, a new $20 billion hole is projected for the next year-and-a-half. Health Access plans to release a report next week, “The Damage Already Done,” to start to document the effect of the cuts in just six months. This will be part of sustained coalition efforts this year to detail the impact of these budget choices on California families, on our health system, and on our economy.
As for state legislation that was considered, the budget did take up much of the attention and energy. Key legislation was passed and signed into law, attempting bring in more federal money for children’s coverage, hospital Medi-Cal reimbursement, and individual’s COBRA coverage.
Some consumer protection bills were vetoed, on issues like insurers rescinding coverage, and proposals to mandate key benefits, from maternity coverage to mental health parity. But a few good bills were passed and signed into law, including a prohibition on gender rating—which will stop insurers from charging men and women differently.
Since the Senate is seen as a more delicate compromise, some people think the final product would look much closer to the Senate version. While it is important to be realistic, I think there will be some significant improvements from the Senate. There are some compromises that have been made which were very contentious, and probably won't get reopened. But as the opponents tell us, it is a 2,000+ page bill, so there lots of opportunity for improvements in other areas. The House, which by passing their version earlier already exerted some influence on the Senate bill, has a political imperative to put its stamp on the final bill. Also, the House version didn't pass with lots of extra votes, and their members are all up for re-election next year, so they have as much reason to ask for adjustments.
* Affordability, Affordability, Affordability: Required insurance could still be too expensive for many. Both bills require many Americans to have insurance. In the Senate bill, the caps on how much we're expected to pay are too high, and the subsidies for working families are too low. Many are working to fix this, but it's going to be a significant fight.
* Employer responsibility: The Senate bill’s requirement on employers has major loopholes for large employers who don’t provide coverage to their workers. Also, this complex and confusing “free rider” provision has potentially negative workforce impacts, encouraging part-time rather than full-time work. The Senate also needs to apply basic benefit standards to all employers, including large ones. The House bill has simple standard for large employers, who would either provide coverage to their workers, or pay a flat percentage (sliding scale up to 8%).
* Progressive Financing: Though the House bill is financed through progressive options like a surcharge on wealth individuals and families, the Senate bill includes an excise tax on high-cost health plans. We advocate a variety of progressive revenue options to offset a repeal or narrowing of the excise tax.
* Immigrant inclusivity: While both bills prohibit the use of federal funds to fund coverage of undocumented workers, the Senate bill excludes undocumented workers from using their own wages and money from being able to buy coverage in the national insurance exchange. Another issue is that the bills continue a 5 year waiting period for recent legal residents who would otherwise be eligible for Medicaid. We are urging Senators to support an amendment being offered by NJ’s Senator Menendez to lift this restriction.
* Abortion: While both bills adopt the current law that federal funds not be used for abortion coverage, the House bill goes beyond that in restricting reproductive rights. The Stupak provision House bill virtually prohibits anyone purchasing insurance in the Exchange from buying a plan that covers abortion—even if paid for with their own money. The Senate leaves the issues to the states. We need to work against a rollback of reproductive rights.
* State consumer protections: The new Senate bill did remove the permission of "nationwide plans" that seriously threatened state-based consumer protections. However, both bills do allow "interstate compacts," where states can allow insurance plans from another state without having to abide by their consumer protection laws. We are advocating for this provision to be removed.
* Public health insurance option: While the House passed health care with a public option, the Senate does not include one. We need to continue to advocate for a public health insurance option. The public option would provide competition for private insurance—and we need to continue to support its inclusion, even after a bill is signed into law.
If you read this blog, you know the remarkable moment we are in, both in terms of the challenges and opportunities. We have much we can win, and much we can lose... and that's why we need your help.
We are on the cusp of history. Congress is poised to pass landmark legislation to provide more security and stability for those who have health coverage, and to dramatically extend access to affordable, comprehensive health care for those who don’t. It would prohibit insurers from denying coverage for pre-existing conditions, or placing arbitrary caps on coverage.
But there is so much more to do to fulfill the promise of reform in 2010. Health Access needs your help to make the promise a reality.
Health Access will continue to lead efforts in California—including the Health Care for America Now campaign in our state—to pass health reform, and the right reform. Across the state and in Washington, DC, Health Access provides information and analysis to elected leaders to help them understand the impact and implications of the reforms they are working on. We are continuing organizing and advocacy efforts to include the strongest possible provisions on everything from affordability to consumer protections. If you read this blog, you know we also educate the public about what these changes will mean for them individually, and why comprehensive reform is so important California and the nation. Hopefully, you've looked at our materials, and hopefully they have been helpful to you.
We need your help not just to help pass reform, but to do the all-important work afterwards. We will have major opportunities to implement and improve health reform to make sure it works well here in California--from putting in place the right regulations to protect patients from insurance company abuses, to pursuing a public health insurance option for California.
But with these opportunities come significant challenges. Under California’s budget deficit, Governor Schwarzenegger threatens to undermine our progress by proposing massive cuts to existing programs like Medi-Cal and Healthy Families. Health Access has been on the front lines of the fight to prevent these ugly cuts to the safety net and the health system on which we all rely; to offer alternatives to cuts; making sure that the real cost and impacts of these cuts are understood, and working with grassroots groups to make sure the voice of their constituents are heard.
Your year-end gift to Health Access Foundation will help us finish the work of passing the best possible health reform at the national level; start the work of fulfilling the promise of reform here in California; and guarding against significant setbacks of budget cuts that threaten to cripple our health system, our families, and our economy.
“I have long supported fixing our broken health care system with comprehensive reform. But, I still believe both the House and Senate bills fall short and need additional work. Congress must ensure states are not strapped with unfunded mandates and unfair costs that will only lead to larger budget deficits with unsustainable services. I remain committed to working with Congress and the President as the two houses move forward on reforms that are balanced and focus on slowing the growth in health care costs, improving the quality of care and providing health insurance coverage for the uninsured, while ensuring states can sustain the expansion of programs like Medicaid. This is a historic opportunity and I urge members of Congress and the Obama administration to come together and work through these issues to fix our broken system.”
The Governor took the opportunity of this health reform vote to refocus attention on his letter urging "flexibility to meet current obligations within the revenues available to states." In other words, he wants more money for California, and the ability to make cuts to health programs--seeking authority to make cuts to Medi-Cal and Healthy Families eligibility, benefits and reimbursements to providers.
We're not the only ones who think such actions are very unbecoming, especially at Christmas. Assemblyman Dave Jones, chair of the Assembly Health Committee, called him on the substance of the letter seeking cuts, and on the timing:
“It’s the day before Christmas and like Ebenezzer Scrooge, Governor Schwarzenegger wants to take poor Tiny Tim’s crutch away. And deny him any healthcare. Bah humbug, Governor!
The Governor has asked Congress to allow him to make cuts in healthcare for Californians.
Here we are in the worst recession since the Great Depression. Record numbers of Californians have lost their jobs outright or had their income cut. Record numbers of Californians are without health insurance. They are not able to see a doctor or get treatment for themselves or their loved ones. And the Governor’s response is to look for ways to deprive even more Californians of healthcare, so more Californians will get sick and die.
The Governor, in writing to Congress, is not speaking for Californians or California. California needs Congress to expand healthcare coverage and to increase payments to California to help pay for it. But the answer is not, as Governor Scrooge requests, to turn our backs on those who rely on California for medical care or to cut the already too low reimbursements to our doctors, nurses, hospitals and other medical providers who provide that care.
In a word, what the Governor proposes is worthy only of Scrooge. Lets hope that the Governor is visited by several ghosts tonite who will cause him to see the error of his proposal to cut healthcare for Californians.”
Today at 4:15AM California time, the United States Senate passed its health reform measure 60-39.
We watched live on C-SPAN while our colleague, Elizabeth Landsberg, advocate for Western Center on Law and Poverty, watched from the Senate gallery. She was a little late getting there because Vice President Biden was entering the Senate chamber to preside but she saw Majority Leader Reid' speech and the vote itself. This blog post incorporates her eye witness report.
California Senators Barbara Boxer and Diance Feinstein called out their Ayes loud and clear. Senator Byrd of West Virginia said he was voting Aye for his friend Ted Kennedy. And Majority Leader Reid accidentally voted No, and then corrected himself to the laughter of all assembled, including even the clerks at the desk.
Elizabeth reports that Senators seemed very happy that the measure had passed the Senate. We also observed the milling around the clerk's desk and what looked like very happy Democratic Senators.
Next--Merging the House and Senate Bills The next step is to merge the House and Senate bills. There are significant differences between the two bills--and we much prefer the House bill--but the big difference is between the status quo and either bill.
More to follow. posted by Beth Capell | Permalink | 6:14 AM
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60, even though they didn't need it...
It was early morning Christmas Eve, 4am for those of watching from the West Coast. Vice President Joe Biden presided for the final vote of HR3590, the Senate's version of health reform. Senate Majority Leader Harry Reid gave appreciation to staff, and final arguments were given by both Republican Leader Mitch McConnell and Reid.
McConnell was defiant. He gave clear indication, that this fight is long fron over. "We will do everything in our power to stop it from becoming law."
Reid comments were touching, invoking Ted Kennedy and saying, perhaps hopefully, that "facts will always defeat fear." He asked the assembled to think of those who were just when Truman made his call to the U.S. Senate to pass health reform, and who because of inaction, became uninsured during their life. Those babies are now months away from Medicare. As Reid said, that's a gong time to wait, to get the commitment to provide health coverage.
To no surprise at this point, all Democratic and Independent Senators voted in support, including our California Senators @Barbara_Boxer and Dianne Feinstein. All Republicans in attendance (Sen. Bunning was not present) voting no. They only needed 50 votes (plus Vice President Biden) for this final vote but got the 60 that allowed the vote to take place. There was applause in the gallery, including from Senator Kennedy's widow, who was in attendance, and Congressman John Dingell--two figures who indicated the long legislative history of attempts in this area. Many Senators gathered afterwards with handshakes and hugs.
Readers of this blog probably already have links to the early morning commentary of Jon Cohn and Ezra Klein. But if not, they are worth reading. Talking Points Memo has other response from across the political spectrum. There wass lots of commentary on the blogs and on Twitter, even by allies in California like @CPEHN, @CALPIRG_mike, and others, sometimes with the whimsical hashtag #cspanatdawn
The most important responses, however, are those of the members of the House of Representatives that have to negotiate with the Senate for a final bill. The three chairmen of the three main House Committees, including Californians George Miller and Henry Waxman, released this statement that suggests their positioning, pointing to similarities and differences:
“We commend our colleagues in the Senate for this crucial vote, which brings health reform closer to reality than at any time in the past 70 years. While there are clear differences between the bills passed by the Senate and the House, both bills will bring peace of mind and fundamental health care coverage to millions of Americans who are currently uninsured.
“Both bills will slow the growth of out-of-control health care costs and reduce the deficit by over $100 billion in the first ten years – and by much more in the second decade. Both bills will make unprecedented reforms to the insurance industry to hold insurers accountable and protect consumers from delays or denials of care based on pre-existing conditions, from rescissions, and from exorbitant out-of-pocket expenses that bankrupt far too many Americans. Both bills will protect and expand peoples’ choices of doctors and health plans. And both bills will offer relief to small businesses getting crushed by spiraling health costs.
“Now that the Senate has cleared this critical legislation, we look forward to working with them and the White House to reconcile and further improve our bills. We are committed to producing a final bill that incorporates the best reforms for middle-class families, small businesses, seniors and our fiscal health, stays true to the values of our members and delivers on the changes the American people desperately need.”
Finally, here's yesterday's statement, from Politico, from two other California Congresswomen, Lynn Woolsey, the chair of the Congressional Progressive Caucus, and Barbara Lee, chair of the Congressional Black Caucus, on what they are seeking in the final negotiations.
"Now that the Senate is poised to pass its version of a health care reform bill, it is time to turn to reconciling it with the House legislation... For Congress to achieve true health care reform we must have a meaningful conference process that integrates both bills into the best possible piece of legislation for the American people."
They list top prioirities:
"A public option — If the bill requires people to buy health insurance, there must be a public option to bring down costs by providing lower-cost competition to private insurers and choice to consumers."
"Affordability protections — The legislation must protect lower and middle-income individuals by ensuring that subsidies make coverage affordable and that Medicaid patients have access to primary care physicians."
"Tighter market regulations — New regulations must keep premiums reasonable and end abusive practices. Insurance companies should no longer be exempt from anti-trust laws and any premium increases must be reviewed before they take effect."
“Employer mandates — If individuals are required to buy insurance, employers should be required to provide it."
“Tax surcharges — Health care reform should be financed by tax surcharges on the wealthy not excise taxes on health insurance plans offered to many workers and union members.
The final product will be better than the Senate bill, and I think by more than what the conventional wisdom suggests. For political and policy reasons, the House will not simply take what the Senate has passed. And while there are some specific areas where it will be hard to revisit hard-fought compromises, there's still leaves lots of room for refinement and improvement. The pressure will be the timetable to get this done quickly.
But California advocates are especially important here, to communicate and advocate and organize with our key Congressional delegation what our priorities are for the final negotiations. We can't disengage now--or at the very least, we need to get right back to work after the holiday break!
So finally, here's the reaction from our ally and partner Richard Kirsch, National Campaign Manager, Health Care for America Now:
"With passage by the Senate, the nation has moved one big step closer to comprehensive health care reform. Health Care for America Now will work to get the strongest bill to the President's desk, one that provides good, affordable coverage to all and holds insurance companies accountable. To realize the promise of reform, we need to be sure that employers are required to help pay for good coverage for their workers, that premiums are affordable to families, that we do not tax benefits, that we enact tough insurance regulations, and that we offer the choice of a public health insurance option. We will urge President Obama to work with leaders in both houses of Congress to agree on legislation that meets these goals, guaranteeing good health coverage we can count on."
We have watched much but not all of the Senate floor debate on health reform. We enjoyed Roland Burris' version of the Night Before Christmas, which closed with "health care for all, even our friends on the right".
But I was most taken aback to hear Sen. John Ensign (R-Nevada) cite favorably a US Supreme Court case that overturned child labor laws as the constitutional basis for opposing health reform. This is like citing Plessy v. Ferguson, the case in which the Supreme Court upheld state laws on segregation, as a justification for opposing Medicaid and Medicare, saying that the states should be responsible for health care for the poor and seniors just as the Supreme Court allowed states to set their own standards for segregation.
Overturn child labor laws? Eliminate the minimum wage? Why? Because the federal government should not interfere in the rights of the states to regulate the right of children to work or minimum wage. This parallels one of the fundamental arguments that is made by the opposition to health reform: the federal government should stay out of health care--except of course for Medicare (which Chuck Grassley and John Ensign now claim to support).
Just as it seems presposterous to think that the federal government cannot prohibit child labor or set a minimum wage, it should be preposterous to think that the federal government cannot reform health insurance. After all, regulation of insurance is a right reserved to the states under federal law, now long uncontested, the McCarran Ferguson Act. And if the federal government gave states the right to regulate insurance, then Congress and the President can act to change that.
But it gives us a glimpse into the world that the opponents of health reform seek--a world where there are no child labor laws to kill jobs for children, where there is no minimum wage to deny low-wage workers the chance to compete for the lowest wage, where there is no guaranteed Social Security benefit so seniors and the disabled live on whatever their family can help with. Today this is the world of the uninsured who are entitled to just as much health care as they can afford out of their own pocket.
We have written lots (and will write more) about how the health reform proposals now pending in Congress can be improved but here's what we know: if we do health reform right, it is the equivalent of creating Social Security for retirement, the minimum wage for wages and yes, child labor laws to protect the most vulnerable among us.
And what we also know is that the fight still goes on to protect Social Security, to increase the minimum wage and yes, even more sadly but thank goodness more rarely, to protect children from being forced to work. Americans have a right to Social Security, they have a right to a minimum wage, and children have a right to go to school, not to work--and we should have a right to health care. So we agree with Senator Ensign that the fight for health reform is like the fight to outlaw child labor---but we think the federal government should outlaw child labor and he apparently does not.
More on the Governor's letter and budget threats...
This morning numerous media stories featured the threat by Governor Schwarzenegger to eliminate the IHSS program unless California is given "flexibility" to cut Medi-Cal eligibility from 106%FPL for parents to 70% (about $850 a month for a single mom with one child), to cut provider rates (already 51st in the nation), and to reduce other benefits.
The Governor blames restrictive federal rules and the cost of health reform. He alleges that the federal health reform will force California to spend $3 billion annually on Medi-Cal.
Creative arithmetic: The Governor says that federal health reform includes "required spending" that would increase Medi-Cal outpatient provider rates to 80% of Medicare. While Health Access supports improving Medi-Cal provider rates, nowhere in any of the federal proposals is California required to increase all outpatient rates to 80% of Medicare. The federal proposals do require an increase in reimbursement for primary care but provide enhanced federal reimbursement for that purpose.
The Governor also assumes that 100% of those eligible for Medi-Cal will sign up. In contrast, the Congressional Budget Office assumes that only half of those eligible for Medicaid will sign up. Health Access hopes we could get closer to 80% enrollment or take-up but that would take lots of changes in our Medi-Cal program (more on that over the next few months).
What happens when? The Governor is correct that both the House and Senate versions of health reform impose a "maintenance of effort" requirement on Medicaid/Medi-Cal and CHIP/Healthy Families. This "MOE" requirement would preclude California from reducing eligibility for these programs from now until full reform kicks.
But the Governor in his rhetoric ignores that the expansions of Medicaid do not occur until 2013 (the House) or 2014 (the Senate) and that for the first two or three years, the feds pick up the entire cost of the expansion.
And then in 2018 or 2019, California would be on the hook for 9% (yes nine percent) of the cost of the expansion (under the House bill) or 18% (the Senate bill). So instead of the 1:1 match we usually get, California would get either a 9:1 match or a 4:1 match for the newly eligible. And that would be almost a decade from now!
What did we find? Under the House bill, if half of those eligible for Medi-Cal enroll, then California actually saves $200 million and covers about 840,000 of the 2 million eligible for Medi-Cal under the House bill. Under the Senate bill, if 80% of those eligible enroll, then Californian needs to commit about $700 million to cover 1.3 million of the 1.7 eligible for Medi-Cal. And that is in 2019.
Better deal for California: We agree with the Governor that the existing federal matching formula for Medicaid, known as the FMAP, should be revised to reflect more accurately the need of Californians for an adequately funded Medicaid program that serves 7 million Californians and that should be expanded to serve more. However, we bet the Governor would get further with this idea if he was willing to step up and increase revenues to close California's budget gap instead of making the budget gap worse by sponsoring bond measure after bond measure that imposes additional debt obligations on the General Fund.
Governor Arnold Schwarzenegger used to be the champion of health reform. He supported a reform model on the basis of "shared responsibility"--the state would do its part, but he'll ask contributions from individuals, employers, providers, and local, state and federal governments, etc. He proposed raising revenues--both legislatively and going to the ballot--to expand programs like Medi-Cal and Healthy Families, as a way to get more of the 50/50 federal matching funds that were available to use, but we were not taking advantage of because of our lack of investment.
Things have changed radically. This past year, he proposed to cut Medi-Cal and eliminate Healthy Families. He refused to consider revenues to save these programs he appropriately sought to expand merely two years ago.
And now, he's been badmouthing health reform as a burden to states. For the last week, GOP Senators have invoked him in their opposition to health reform in floor speeches. For all practical purposes, he has emerged as an opponent to health reform, highlighting the cost to states.
Yesterday, the Governor sent a letter to the California Congressional delegation, circulating a $3 billion figure as the cost to the state of California. It's hard to account for how highly inflated that number is. It includes a Medi-Cal provider rate increase that is not required, an assumption that every single person eligible will sign up, and neglects that it will take nearly 8 years--a couple of Governors from now--for full implementation and any costs to materialize.
Here's the short version: the state gets savings of a couple hundred million dollars in the first several years. Even when the Medicaid expansion for 1.5 to 2 million low-income Californians takes into effect in 2013 or 2014, the federal government will pick up 100% of the cost of newly-eligibles for 2-3 years. Finally, there is a cost to the states--but not with the normal 50/50 split, but with either 82% or 91% of the bill being picked up by the feds. That's somewhere between a 4:1 to a 9:1 match--much more generous than the current matches in Medi-Cal (1:1) or Healthy Families (2:1).
For states, that's not a burden, that's a bargain.
So much for "shared responsibility." What really seems to get Governor Schwarzenegger is that he won't be able to make additional cuts on both Medi-Cal and SCHIP, because there would be "maintenance of effort" requirements that states continue what they have been doing. In his letter, he threatens the complete elimination of In-Home Support Services, CalWORKS and other programs.
I understand that every Governor wants to bring in more federal dollars. But misrepresenting our situation won't help. In order to get federal funds to solve our budget woes, he is ready to take hostages--whether that be IHSS or CalWORKS at the state level, or health reform at the federal.
That can't be the only or best way to get the added federal funds we agree we need.
As we have written previously, the manager's amendment to the Senate bill that was adopted earlier today makes a number of changes to the Senate bill.
Our California Senator Barbara Boxer, as well as Senator Dianne Feinstein, won a significant improvement for California as well as six or seven other states, including Idaho, North Carolina and Michigan.
It is easy to figure out that Nebraska (and Hawaii) got something in the Medicaid provisions because those two states are mentioned by name.
We guessed that California met the following: "If the State is not a low DSH State described in (5) (B) and has spent more than 99.90 percent of the DSH allotments for the State on average for the period of fiscal years 2004 through 2008, as of September 30, 2009, the applicable percentage is 35 percent."
What is that and why do we care? DSH or Disproportionate Share Hospital funding is a key part of Medicaid funding for hospitals. In some states, DSH helps to make up for low Medicaid reimbursement rates. In other states, including California, DSH helps to cover the cost of care by hospitals for the uninsured as well as improving low Medicaid rates.
DSH is a big deal in California both because we are 51st in Medicaid reimbursement and because we have such a high proportion of uninsured.
So what did our Senators win for us? The earlier version of the Senate bill cut DSH funding in half once the rate of uninsurance drops. The new version would cut DSH funding by only 35%.
This moves the Senate bill much closer to the House version in terms of the DSH cut, at least for California, Idaho, North Carolina, Michigan and several other states.
An end of the year bonus—and one that we really earned!
On Friday, December 18, 2009, Health Access received word that the timely access regulations will be final effective January 17, 2010.
We have worked on this issue for more than a decade. The original HMO Patient Bill of Rights, a package of more than twenty bills, included timely access inAB497 (Wildman). AB497 was vetoed in the face of bitter opposition from the HMOs and the Wilson Administration. The legislative staff for the Department of Corporations which was responsible for regulating at that time told us that whatever an HMO decided was timely access was the standard. That was not nearly good enough for Health Access.
AB497 set specific standards for timely access, standards that are remarkably similar to those that are now in effect. AB497 required that: * A telephone call be answered within four minutes * A non-urgent appointment be provided within ten days * A medically urgent appointment be provided within 48 hours
And what do we have in the regulations just finalized? * A physician, registered nurse or other appropriately licensed health care professional must provide telephone triage within 30 minutes * A non-urgent appointment must be provided within ten days * An urgent appointment must be provided within 48 hours Plus a variety of other standards for mental health services and dental care.
Well, maybe four minutes was a bit of a stretch but the notion that every consumer can get triage in time to get to an emergency room within the so-called golden hour, if needed, is now part of the requirements for all physicians who contract with DMHC plans, which is virtually every practicing doctor in California.
Timely access was not part of the package of legislation adopted in 1999 that we usually refer to as the HMO Patient Bill of Rights. Instead, timely access (AB2179 Cohn) and language access (SB853 Escutia) were adopted later along with standards of prescription drug coverage (SB842 Speier), all enacted in 2002 or 2003. And the strategy for both timely access and language access was the same: the law required the DMHC to adopt regulations that specify how HMOs and PPOs would meet the obligation to provide care in a timely manner and in the language spoken.
Language access regulations were completed prior to those for timely access but the timely access regulation ties down one key piece of language access: that the requirements for interpretive services run concurrent with the timely access requirement—that is, when you show up for the doctor’s appointment within ten days, they should be prepared to provide care in the language you speak.
We have worked on this issue for more than a dozen years. The enactment of the regulations are a major milestone. But our work is not done—now we will look to see whether HMOs and providers comply and how vigorously the regulations are enforced.
SENATE VOTES TO MOVE HEALTH REFORM THIS WEEK * "Manager's Amendment" Make Changes--Good and Bad--to Health Reform Bill * New Language Secures 60 Votes in Senate to Llimit Debate, Have Final Vote by Christmas Eve * Next Step: Negotation over Key Differences between House and Senate Bill * Public Hearing at NAIC, Updates on Twitter.....and other news for the week...
60!: Earlier around 1am East Coast time this morning, the U.S. Senate held a key vote, mustering the required 60 votes needed to cut off the debate and proceed to subsequent votes later this week to pass major health reform from the Senate floor. California Senators Barbara Boxer and Dianne Feinstein both joined all 60 Democratic and Independent Senators to vote for the motion; All 40 Republican Senators voted against it.
Further votes are expected Tuesday, Wednesday, and final passage Thursday, December 24th, Christmas Eve. That would then start negotiations to reconcile the Senate bill with the House health reform measure passed earlier in the year. The expectation is that those talks will go into January, but with a goal of a final agreement, and one final vote in the House and Senate, by the end of January.
The 60 votes were secured largely through changes made through a 380+ page "manager's amendment." The full text of the bill, and the amendment, is available at: http://www.democrats.senate.gov/reform/
The Health Access blog has a list of some of the changes, and other commentary as well. For health advocates, the changes are both negative--like the removal of the public health insurance option as well as those that are positive, like more funding for community clinics and the institution of new, higher medical loss ratios for insurers so that more premium dollars go to patient care rather than administration and profit. Especially if there is no public option in the final deal, than the level of insurance company regulation is essential--as some blog posts describe.
The advocacy done in the next few weeks, especially with key California Congressional members, will help determine the final shape of the bill.
ADVOCATES CONTINUE TO PUSH ON HEALTH REFORM & THE RIGHT REFORM: Lat week, Health Care for America Now! events around the state mobilized hundreds in several locations to advance health reform, and to push to improve provisions that are pending as we speak. These efforts included actions at hospitals where workers and patients called their Senators, to visiting offices of key Congressional members. For more information about these events, contact Patrick Romano at promano@health-access.org.
HUNDREDS MARCH IN SAN FRANCISCO: People for meaningful health reform took to the streets of San Francisco, carrying candles in a vigil to honor the 45,000 Americans who die each year for lack of health insurance. The procession of about 350 people, walking from Yerba Buena to Union Square, moved silently out of respect for the deceased. Health Access, as the lead California organization working on behalf of Health Care for America Now, joined in coordinating the march, which attracted the notice of radio, TV, and print media.
ADVOCATES ON ALERT: The upcoming holiday season differs from many others because of what's at stake for health reform -- in the U.S. Senate, the governor's upcoming state budget, and the state Department of Health Care Services' Medi-Cal waiver proposal to massively restructure the program that provides coverarge to nearly 7 million Californians. Health Access encourages you to keep in touch with each other -- and us -- through Twitter, our Facebook page, and our blog. Don't miss any opportunities to make calls, march or speak out on behalf of real reform!
MAKING THE CASE ON TELEMUNDO: The case for equitable health reform is being heard again and again on YouTube, as it was recently on Telemundo. The Spanish-language television network reported on how the needs of legal immigrants fit into the health care debate. One of the community advocates interviewed was Health Access' Nancy Gomez, an organizer in our Los Angeles office. Watch it here, on YouTube.
AND THEY CALLED IT A PUBLIC HEARING...: Two of Health Access' experienced policy experts attended a public forum in San Francisco recently of the National Association of Insurance Commissioners. Elizabeth Abbott and Beth Capell were in attendance to gather/share information and concerns about the huge changes in health care delivery our nation is about to embark upon-- the biggest shift since Medicare and Medicaid were enacted 45 years ago. They were concerned at what they found. Read about their watchdog reports on our blog.
Any suggestions about the update format, or questions about its content, should be directed to Cynthia Craft at Health Access, at ccraft@health-access.org.
With those changes, Senator Ben Nelson of Nebraska announced his support for the health reform proposal. This means that barring a surprise, the Senate Democrats have the 60 votes necessary to pass the bill off the floor and into conference committee. Given the wide ideological spectrum in the Democratic Party, this is a significant feat--and a bill that is necessarily a compromise.
Here's a list from Senator Reid's office of the components of the manager's amendment, with editorial comments from HCAN's Blog:
* Stronger medical loss ratios. Health insurers will be required to spend more of their premium revenues on clinical services and quality activities, with less going to administrative costs and profits - or else pay rebates to policyholders. These stricter limits will continue even after the Exchanges begin in 2011, and apply to all plans, including grandfathered plans. (Ed note: Reportedly, these require group insurance plans to pay 85% of premiums to health care, and individual plans to pay 80%. These would go into effect in 2011. In 2012, the ratios would be based on the average medical loss ratio in the Exchange.) * Accountability for excessive rate increases. A health insurer's participation in the Exchanges will depend on its performance. Insurers that jack up their premiums before the Exchanges begin will be excluded - a powerful incentive to keep premiums affordable. * Immediate ban on pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage of pre-existing conditions for children. Patient protections. Health insurers will have to abide by a set of patient protections that, for example, protect choice of doctors and ensure access to emergency care. * Ensuring access to needed care. The use of annual limits on benefits will be tightly restricted to ensure access to needed care immediately, and will be prohibited completely beginning in 2014. * Guaranteed opportunity to appeal coverage denials. All health insurers will be required to implement an internal appeals process for coverage denials, and states will ensure the availability of an external appeals process that is independent and holds insurance companies accountable. * Multi-state option. Health insurance carriers will offer plans under the supervision of the Office of Personnel Management, the same entity that oversees health plans for Members of Congress. At least one plan must be non-profit, and the plans will be available nationwide. This will promote competition and choice. (Ed note: At least two plans will have to be offered, one of which must be non-profit. OPM can negotiate medical loss ratio, profits, premiums and other terms.) * Free choice vouchers. Workers who qualify for an affordability exemption to the individual responsibility policy but do not qualify for tax credits can take their employer contribution and join an exchange plan. * Children's health. Support will be extended for the Children's Health Insurance Program and the adoption tax credit. Foster care children aging out of Medicaid will be able to retain its comprehensive coverage. * Rural and underserved communities. Access will be expanded through funding for rural health care providers and training programs for physician and other types of health care providers. * Revised abortion language, including state opt-out of abortion coverage (Ed note: details here)
How will health reform prevent the insurance companies from unjustified rate increases and consumer abuses?
That was one of the main rationale for the public health insurance option, which is still in the House bill and not in the Senate version of health reform. It's not the only mechanism with this goal. Noam Levey at the Los Angeles Times has a good story today focusing on the regulation of insurers in the bills.
It's a topic that has gotten little attention in the media, and so people assume there's little of it in the bill. But the list of new consumer protections is long, both of ones that people have heard of, and ones that people haven't. A partial list of new or improved insurance regulations (compared with the status quo in California) includes:
* Rescissions prohibited on day one. (Thousands rescinded in CA; Settlements with insurers have been negotiated but regulations and legislation stalled.) * No denials or discriminatory pricing based on pre-existing conditions. (Hundreds of thousands denied in CA now.) * No denials or discriminiatory pricing based on gender. (Just banned in CA to go into effect next year.) * A limit of any pricing difference based on age of 3:1 from the oldest to the youngest on a 3:1 basis. (No limit in CA now; practially the pricing difference on age is 9:1) * The establishment of a basic benefit package for all health coverage (Some mandated benefits in CA now, but not even all the basics in Department of Insurance plans: there's not even a requirement in CA that coverage include both doctor and hospitals) * A minimum actuarial value for all plans, and labeling of products based on their comprehensiveness. (No minimum in CA, and lots of "junk" plans that pay out very little are sold in CA) * Standardized definitions between plans of product services (CA health plans are not consistent even within a company over what counts for a "deductible," for example.) * No arbitrary annual caps on coverage (No limits in CA on Dept. of Insurance plans.) * A maximum cap on out-of-pocket costs of $5000 or $6000--and less for lower-income families--so even a plan with higher cost-sharing will at least prevent bankruptcy (No limits in CA on Dept of Insurance plans.) * No cost-sharing for preventative services. (No regulations in CA.) * Minimum medical loss ratio so that money goes patient care rather than administration and profit. (Existing MLRs exist at DMHC and DOI, defined differently. Legislative efforts in CA to increase the MLR have stalled.) * Regulatory review of insurance rate increases. (No process now; CA legislation stalled.)
The article describes the predicament of how to describe what's in the bill. At one level, we appreciate the significant insurance oversight in the bills that goes well beyond our current framework, but will it be sufficient?
Here's two lines from the article that sum it up:
"In any other year, these changes would be cause for a White House signing ceremony with bands and fireworks," said William Vaughan, health policy analyst for Consumers Union.
Like any regulatory framework, however, this one has holes.
Some of the holes are specific and have been identified. As Brian Leubitz of Calitics reports, a majority of the California Congressional delegation--led by Reps. Jackie Speier and Susan Davis, former state legislators that sponsored state consumer protections that Health Access sponsored and/or supported back when--wrote to their leadership to fix a concern about provisions that would make it easier for plans to be sold in one state from states with weaker patients' rights law.
Other holes are one about degree--is it enough? And that's why we need to push hard in conference committee to make it better.
For example, California's Senator Dianne Feinstein has been championing a “rate authority” amendment that would beef up the rate review sections of the bill. Health Access California joined several groups in support of her proposal. We'll see how that effort fares.
We hear Senator Majority Reid's "Manager's Amendment" will include a higher medical loss ratio, incorporating a popular amendment by Senator Al Franken.
But that suggests an issue in other provisions: what is enough? I am pretty sure that the minimum actuarial values proposed in the bills are too low, especially in the Senate. There are those who defend a lower actuarial value, as providing consumers a choice of a lower premium product, even if it provides a lower value. I would argue that a product that ends up only covering on average only 60% of a patient's health expenses shouldn't be called coverage--as a someone said on Twitter, that's just splitting the bill.
But even the mere fact of having a standard on actuarial value, on out-of-pocket costs, on other issues, is a major reform. Would it have been worth it to pass a minimum wage, even if the wage were to be set lower than was really needed? Or does it provide some protection to get rid of the worst abuses, and provide a policy construct for the future? Or it the standard that is set so low as to be meaningless?
Either way, we need to continue to press for strengthened insurance oversight.
Final thoughts: When focusing on a public option and on regulatory oversight, the LA Times article neglects a third strategy regarding insurer accountability regarding insurance company abuses and unjustified rate increases, by using government as a regulator, a negotiator, and a competitor. Without the competitor of a public health insurance option, there needs to renewed focus on the other two strategies.
The strategy of negotiation should merit attention. The new health insurance exchanges are seen as a way to bring individuals and small businesses together, to get both the efficiencies and group purchasing power of large purchasers. The combined Senate bill includes Senator Kerry’s “active purchaser” language--which is similar to the House—to allow the exchange to negotiate with health insurers for the best possible price. Large employers and purchasers typically get better rates and insurers have less overhead and profit. The House is even stronger in this regard, and that’s what we hope can come out of conference committee. It’s another piece of the effort to control costs.
The key point is that these accountability strategies are not either/or. Given that no consumer protection is airtight, there is a need to try multiple efforts to provide the security that families so desperately need. That's why, in addition to the provisions in the bills, and the improvements being attempted, we need to continue to work for a public health insurance option, even if we doesn't get included in this package.
Word has come that the federal government will permit, for a limited time, California to take advantage existing federal rules to implement AB1422 (Bass) which would help to fund the Healthy Families program.
This is a great relief. Until now, we heard very discouraging words from those in DC about the prospects for approval of federal matching funds through the extension of the gross premiums tax to Medi-Cal managed care plans.
As you may recall, the health coverage of almost a million children was put at risk as a result of the budget adopted by the Legislature and the further line item vetoes by the Governor back in July. AB1422 was a last ditch effort supported by both the insurers and the advocates to find a way to end the waiting lists and avoid disenrollment of hundreds of thousands of children in the midst of the great economic downturn.
When we learned of the difficulties at the federal level, in a matter of days, an impressive coalition of 20 California groups signed a letter of support for the implementation of AB1422 for Obama Administration.
The federal Centers for Medicare and Medicaid Services will pursue a formal rule making process that is likely completed in June 2011 or later.
Nobody wants a lump of coal in their stocking, least of all the children of California---and in the land of sunshine and oranges, every kid should have health care—and now a million of them will have that chance.
Two years ago today, December 17, 2007, there was an Assembly vote on a comprehensive health reform in California, the result of a year-long negotiation between then-Assembly Speaker Nunez and Governor Schwarzenegger. The bill went on to defeat in the state Senate.
There was a debate about whether the bill was worthy of support. Many consumer and constituency groups supported it, but some didn't.
The political situation before us is both strikingly similar, and radically different. Same goes for the policy proposal itself.
One big difference is that the bill in 2007 was a final product, in more ways than one. A companion ballot measure had been filed, and so the Senate was being asked to ratify it without changes. Were the ballot measure to pass, key parts would not be easily changeable.
The situation now is different--the bill is still in flux, and there are things to win, and to lose: the next week the Senate is considering to move an amended health reform bill, to go to a conference committee. It will need to be melded with a House bill, which is a very good bill, before final votes in the House and Senate in January. Even after passage, there will be opportunities to improve the bill in the years ahead, at both the federal and state level.
My take: we only lose when we give up. And we shouldn't give up. Others who have concerns with the Senate bill are echoing similar themes.
So I am concerned that some seem to be giving up on the current process. There's been a back-and-forth on the positioning of the Senate health reform bill, where Nate Silver of FiveThirtyEight has asked "20 Questions" for those who would kill the Senate health reform proposal; bloggers at DailyKos and FireDogLake have responded; and FiveThirty Eight followed up.
New facts about why health reform is needed in CA...
Under all versions of health reform currently pending in Congress, millions of Californians would get significant help in affording their coverage and/or in improving the comprehensiveness of their coverage, according to three new studies just released by UC-Berkeley and the University of Chicago. The studies also indicate the important differences between the House and Senate versions, as they head into conference committee.
The data puts into context the millions of Californians who would get help under health reform--and not just the uninsured. Many who have coverage would get more stability and security.
Here are some of the key findings from these three important studies that have been just released about the impact of health reform on California.
* Californians' Access to Coverage under the Health Reform Proposals This data brief finds that nearly 4 million Californians who are without health insurance, covered in the individual market or enrolled in unaffordable job-based coverage, would be eligible for Medicaid or subsidized coverage under the national health reform proposals. The brief analyzes both the House and Senate legislation to compare how they differ in their impacts on Californians. * Close to 2 million Californians who were uninsured, in the individual market or had unaffordable employer sponsored insurance in 2007 would qualify for Medicaid under the House bill, compared to 1.74 million under the Senate bill. * 1.93 million Californians would be eligible for subsidies in the exchange under the House bill and 2.19 million in the Senate. * 95 percent of California businesses, employing 44 percent of all workers would be eligible to purchase coverage through an exchange by 2015. * One out of five businesses would be eligible for tax credits towards the purchase of that coverage.
* National Health Reform Requirements and California Employers This issue brief analyzes the impact that the House and Senate health reform proposals would have on the 18.4 million Californians who are enrolled in employer-based insurance. While the vast majority of employees work for firms that currently comply with most of the new requirements for employer-based insurance included in the bills, reform legislation, if passed, would increase protection for many insured workers and their families in California. Many workers would have their coverage improved under these bills. They include those who's coverage now is less than comprehensive: * 23 percent of workers with employer-based insurance are enrolled in a plan either without an out-of-pocket limit or a limit exceeding $5,000. * Over 40 percent of insured employees are enrolled in a plan with a lifetime limit. * About 10 percent of California insured workers are enrolled in a plan where preventive benefits are subject to a deductible.
* How Would Health Care Reforms Change the Spending of California Families Without an Employer Plan? This report uses simulated claims data to project out of pocket costs at different cost sharing subsidy levels for the House and Senate bills, and provide a comparison to costs in the current individual market in California. Among the findings: * Californians with an income of $16,245 a year would save $5,053 on average on premiums and out-of-pocket costs under the House bill compared to what they would spend in the current individual market; they would save $4,116 under the Senate bill. * Those with an income of $43,320 a year would save $838 a year under both plans compared to what they would spend in the current individual market. * California families of three with typical health care use earning less than $59,000 would spend significantly less under the House bill than the Senate bill, while those earning between $59,000 and $73,240 would spend less under the Senate bill.
We have worked with Ana for years, from when she staffed for Senator Deborah Ortiz on one of the first bills to prevent hospital overcharging, to her time staffing health legislation working for the Governor's office. She emerged as a smart and tough-minded negotiator for the Governor in the final efforts in late 2007-08 to pass a state health reform measure.
She has served this Governor loyally; no one should mistake her appointment as a signal of the content of the budget, despite the facts that she is the first Latina to hold the post, her Democratic beginnings or familiarity with health and human services. All indications are she will be a familiar face for a truly awful budget, given not just the severity of the budget situation, but the direction that the Governor has taken in the last year against the additional revenues needed to prevent cuts, even proposing to eliminate Healthy Families, CalWORKS, and other key health and human services.
What might be in the next budget that the Governor will announce sometime before January 10? We will likely revisit and even go beyond the cuts that were rejected last year as too severe--and given the cuts that were made, that's saying something. Some of those cuts had literally life-and-death consequences.
Much more on the budget to come...but for the moment, congratulations and condolences to Ms. Matosantos.
I am perplexed by the line among some in the blogosphere, where some, including Howard Dean, are arguing to stop the Senate health reform bill.
But it's clear we still have an opportunity to make it better, as it goes to the House of Representatives--especially on issues like affordability, employer responsibility, and insurance regulation. We here in California have an important voice to tell the leadership and the rank-and-file to stand strong on the range of issues.
If there's a moment to make a final assessment of a final product--to assess the positives and negatives and make a final decision--this isn't it, not when we still have the opportunity and obligation to fix it.
Senator Jay Rockefeller, who has been a champion on health reform for decades, rebuffed Dean's argument below. He also makes a point that once we pass the framework, there is opportunity for improvement in subsequent years as well. If health reform fails, then we are stuck with the old system and politicians will run from the issue for a generation. If we pass a framework, there will be opportunities and efforts to make changes every single year. As the health policy enthusiast he is, he exclaims, "I love that."
Today, there was a rally and "die-in" in Washington, DC by "tea party" opponents of health reform, chanting "kill the bill." One of the speakers was Rick Scott, the disgraced former CEO of Columbia/HCA and now head of Conservatives for Patients Rights. Other speakers were talk radio hosts, Dick Armey, the former Republican Majority Leader of the U.S. House, and current elected officeholders like Representative Michele Bachmann and Senator Jim DeMint.
Judging from watching the rally on C-SPAN, the news of the removal of the public health insurance option in the current Senate bill may have gotten a few Senators votes, but did nothing to minimize opposition from these speakers.
Why not?
Maybe because they recognize that there is more at stake than the public health insurance option.
For those of us who think the public health insurance option is important, we need to continue to advocate for it--there's still conference committee, and there will be opportunities in implementation, both in DC and here in California.
But a public health insurance option as envisioned really only works if it is in the context of a broader framework like proposed in this bill. A public health insurance option, to be successful, needs to operate by the same rules as the private insurers it competes with. So if insurers are allowed to deny patients for pre-existing conditions, the public health insurance option will have to follow suit. It's only in the context of a framework of a regulated exchange with guaranteed issue and modified community rating, like the current health reforms provide, that a public health insurance option can both thrive on its own, and be a competitor for insurers rather than a dumping ground.
It's an entire framework that would change the health system we have. One that would: * Makes almost 4 million uninsured Californians eligible for coverage * Means that when you lose your job or get divorced, you don’t lose your health insurance * Requires insurance companies to take everyone * Prevents insurance companies from dropping you when you get sick * Makes health insurance more affordable for millions of Californians * Begins to reduce health care spending overall * Imposes rate review on insurers * Says the insurers must spend at least 80 cents out of every premium dollar on health care * And provides for the largest expansion of public programs (still) since Medicare and Medicaid were created.
But there are other aspects of the framework that the Senate bill is deficient, in some cases seriously so. How much do we ask of low- and moderate income families in terms of getting affordable coverage? What is the minimum level of coverage that a health plan should provide? Should all large employers contribute into the health care system? How is this financed? Are we going to impose cumbersome verification procedures for people to buy coverage that make it harder for people to get coverage?
As evidenced by the opposition rally today, the opponents of health reform aren't done in there efforts to either stop the process or make the bill worse.
We can't let up. Our task is to continue to work to both move the process forward, and to make it better.
There's been a lot of commentary in the last 24-48 hours about the fate of the public health insurance option, and/or the idea of a Medicare buy-in. Health Care for America Now details the often-shifting positions of Senator Joe Lieberman, who has opposed the public health insurance option with at least three Democratic Senators. Nate Silver at Five Thirty Eight reminds us of how hard the challenge was and far far the idea came, even getting a majority of Senators on board. We'll have more analysis and commentary once we see where the dust settles.
Ezra Klein of the Washinton Post has a post that details the situation, and especially the timing moving forward: Votes starting as soon as Thursday lead to a timetable that extends to Christmas just to report the bill off the Senate floor.
And then there's conference committee, with a House bill that is superior in many ways.
That's the one thing I want to emphasize tonight. This is not the time for the final evaluation of the bill, for taking a step back, for either giving up or going along. There's still work to do! The health reform fight isn't over..
There's lots of fights on very important provisions still left to be won or lost in Senate and in conference committee. We need to continue to advocate on the very crucial issue of affordability, and on issues like employer responsibility, insurer regulations and oversight, inclusivity, financing, as well as continuing to look for opportunities to include public health insurance options.
The fight isn't over to make it the best bill it can be--or to prevent it from getting worse. We still have work to do.
The other night on the PBS Newshour, our colleague Jacob Hacker, who was briefly at UC Berkeley and has now returned to Yale, said that the Senate compromise on the public option was a bit Dickensian, a tale of two public options, the best of times and the worst of times---that is a public option that was an expansion of Medicare to a new population, those aged 55 to 64 was the best of the public option while he was disappointed by the trigger on a public option available in the exchange. (He's also not impressed with another part of the deal, national nonprofit plans offered by the Office of Personnel Management.)
What would a Medicare buy-in mean for California? Courtesy of www.chis.ucla.edu, we took a look at how many Californians might benefit. Of the 3.7 million Californians ages 55-64, almost 12% are uninsured and another 7% buy their own insurance. That means that almost 20% of Californians aged 55-64 might benefit from a Medicare buy-in, especially if (or when) affordability credits are made available to help them afford that coverage.
This is a very big deal for those aged 55-64. In the current individual insurance market, these are exactly the people that are all too often uninsurable—precisely because by that age, most people have one chronic condition or another or have had an illness or surgery that made them uninsurable. And while 65% of those aged 55-64 have employment-based coverage, losing that coverage is a devastating life event at an age when most people expect to need health care. The Medicare buy-in would eliminate that fear.
We are somewhat bemused by the reaction of doctors and hospitals to the expansion of Medicare. The 4 million Californians who rely on Medicare today seem to have ready access to doctors and hospitals. Would an increase from 4.1 million Californians with Medicare coverage to 4.8 million undermine the ability of doctors and hospitals to provide care? The protests seem especially odd to us when a majority of those who might benefit from a Medicare buy-in are uninsured.
Health Access California congratulates John Perez on winning the unanimous support of the Democratic caucus to become the next Speaker of the California Assembly.
John Perez has been known to us for many years. While the many media accounts took note of his roots in the labor movement, we first met John when he was appointed by Senate President Pro Tem Bill Lockyer in 1997 to serve as a consumer representative on the Managed Care Advisory Task Force. Then-Governor Pete Wilson created the Managed Care task force as a means of thwarting the campaign for the HMO Patient Bill of Rights, sponsored by Health Access California.
John Perez was a forceful voice for consumers during the months of meetings of the managed care taskforce. We are pleased to note that when Governor Gray Davis signed the HMO Patient Bill of Rights in 1999, it was an even stronger package than the original proposal---in part because of the willingness of a broad range of consumer advocates to speak up for even stronger reforms of HMOs.
We also know John Perez because he led the Stonewall Democratic Club in Los Angeles along with Anne Marie Staas Niedorf. Health Access California was one of the many beneficiaries of Anne Marie’s long history of activism: she hosted more than one house party devoted to health care, including the HMO Patient Bill of Rights. We are saddened to report that Anne Marie finally lost her long battle with her various ailments last month. May she rest in peace.
John Perez has also served on the President’s Council on HIV and AIDS as well as on the board of AIDS Project Los Angeles, giving him insight into a key health issue that shows many of the flaws in our health care system.
And we would be remiss if we did not note that John was political director of UFCW during the very difficult grocery workers strike in Los Angeles in 2003, a strike over health benefits that helped to set the political context for the fight for an employer mandate in SB2(Burton)/Proposition 72 of 2003 and 2004--which in turn led to the passage of Healthy San Francisco and the employer reponsibility elements of proposed state and national health reforms. Health Access California is proud to have worked with the California Labor Federation and the California Medical Association on that pivotal campaign that restarted the health reform conversation in our state, and eventually nationally.
We greatly look forward to working with Speaker-elect Perez in his new role, which will include the massive amount of work to implement federal health reform at the California level.
There's lots of reporting about what the "deal" is in the Senate around the public health insurance option. But while there are lots of reports about what is in it, and reactions to it, the details matter--a lot. We'll be posting on Twitter any good information or analysis we see...
Speaking of Twitter, if you aren't on it, you should be! For why and how, read this piece in the California Pan-Ethnic Health Network's online newsletter, which I co-wrote with the prodigious Rachel Larson of CPEHN. It answers such burning questions as: * Why Tweet? * What Is Twitter? * How Do I Get Started? * How Do I Find People to Follow? * How Do I Get People to Follow Me? * What Are All of the Symbols I See in Other People's Tweets? * How Do I Keep Up with Twitter?
This technology enhances in-person communications, but doesn't replace it. We are happy to be having our holiday party at Max's in Oakland this evening with our colleagues at CPEHN and elsewhere. But if we don't see you there, we look forward to tweeting with you!
My colleague, Beth Capell, has already posted her impressions from the National Association of Insurance Commissioners (NAIC) meeting that we attended last week in San Francisco. It was so not what I expected that I thought I would add my reaction as well.
During my federal career at The Centers for Medicare and Medicaid Services and the Social Security Administration, I was responsible for holding public hearings on public policy issues according to federal requirements. The NAIC meeting had no resemblance to any official public hearing that I've ever attended. The entire premise is that a public hearing is designed to be a venue for informed expert testimony, but also a forum for probing follow-up questions of the policy experts by the Commisioners and an opportunity for public comment. A federal hearing must meet several criteria:
The hearing must be announced 3 weeks in advance in The Congressional Record and must be held in a public setting with access for persons with disabilities
There should be no admission charge whatsoever, offer free/reduced rate parking, and the location be accessible by public transportation
The sponsoring organization must transcribe the entire hearing and distribute it to all Commissioners and also take meticulous notes that are made available to the public
They must hold the hearing for a sufficient duration of time to allow for questions from the audience for the experts giving testimony and for the Commissioners
. . .And more
You get the picture. Although the NAIC "public hearing" met some of the above criteria, it was by no means free ($650 fee for each of us to attend just this one session, although they allowed how they would not charge us if we returned our badges.) I thought it had the closest resemblance to a "show hearing" (where they could say they held hearings outside of Washington, DC, but it did not provide any opportunity for new information or a dialogue between the panels of experts, the audience, and the Commissioners.
I was struck by the time constraints of the hearing. In a world where the health care dialogue occupies such a significant amount of time and includes many complicated policy issues, this felt very abbreviated. Out of a week-long conference, it allowed for 3 hours for panels to give testimony (and pretty much stuck to that.) I guess it is easier to shoehorn testimony into that block of time if you don't have to make allowances for pesky questions from the audience--or much engagement from the Commissioners themselves. Three hours for a fulsome discussion of the most significant changes to health care delivery in 45 years--since the enactment of Medicare and Medicaid--seems way not enough time. This is particularly true when by many versions of health care reform legislation under consideration, significant policy pieces will be developed by NAIC and or be delegated to them to enforce. And what about consideration of whether and how is it effective to delegate regulatory functions to a non-governmental entity like NAIC? This was not discussed at all.
Two consumer organizations gave testimony at the hearing and raised some significant issues for consideration, including AARP and Consumers Union, the publisher of Consumer Reports. (The third "consumer voice" at the table was represented by The Hemophilia Association, but their spokesperson was the former Insurance Commissioner from Indiana, so I'm not exactly sure that counts.) In addition, each of the consumer organizations were asked to truncate their testimony because of time constraints (although no similar request was made of other testifiers, such as the doctor speaking on behalf of the American Medical Association. He was able to expound at length about how underpaid doctors are.) I found it curious that although some of the consumer testimony ran counter to accepted orthodoxy at NAIC, it did not generate substantive questions of the consumer panel or an engagement by the Commissioners in any meaningful dialogue.
And, you may ask, how about the showing of California's contingent at this NAIC meeting on our home turf? What probing questions did our Insurance Commissioner ask? What leadership did he demonstrate among his peers after California's recent foray into enacting health care reform here? Mr. Poizner was not in attendance. Although he may have directed some of his staff to attend, they were in no way visible at this hearing. There were insurance commissioners from other states in attendance who raised issues from a protection-of-consumers perspective or discussed challenges they had faced in their states. Honorable mention goes to the insurance commissioners from PA, OK, and RI who added to the content of the hearing.
There was one distinct highlight of this hearing--that I would say could have taken the place of several so-called experts who were given equal time. That was Jon Kingsdale, who is the Director of the Massachusetts Connector and has the closest thing to real experience in what may be part of our new health care reality. He talked about the technology challenges he faced, how he staffed the health care exchange with real talent from public service and the private sector, how they rank on the report card from Bay Staters, and how he publicized the individual responsibility with the cooperation of the Boston Red Sox and CVS Pharmacy and got 98.9% compliance (and, as he acknowledged, that he "just didn't send all of the outlaws to New Hampshire!")
So, on balance, it was worth attending, and it was educational for us, but I have to admit it was a particularly mediocre cookie for my (hope I don't really have to pay) $650.
posted by Elizabeth C Abbott | Permalink | 10:12 AM
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Steps forward and back on the most contentious issues...
Tuesday, December 08, 2009
Earlier today, California Senators Diane Feinstein and Barbara Boxer joined the majority of their colleagues to table an anti-abortion Nelson/Hatch amendment, 54-45. They argued the amendment, which mirrored the Stupak amendment in the House bill, would go beyond the three decade-old Hyde amendment that prohibits federal funds to be used for abortions, which continues to be encoded in the main Senate bill. The amendment was opposed by most Democrats and the two female Republican Senators from Maine, Snowe and Collins.
They made the case that the amendment would prohibit women from using their own dollars to have private plans that cover abortion services. While Senator Boxer, who managed debate for the opposition, was successful, the issue continues. Senate Nelson of Nebraska, whose vote is crucial, may require other changes. And there remains a negotiation with the House bill, which does include the Stupak amendment.
In other news... ten Senators, five progressives and five moderates & conservatives, have come up with a potential deal on the "public option." What is it? No one knows for sure.
“This has been a long journey. We have confronted many hurdles, and tonight I believe we have overcome yet another one.
I asked Senators Schumer and Pryor to work with some of the most moderate and most progressive members of our diverse caucus, and tonight they have come to a consensus.
It is a consensus that includes a public option and will help ensure the American people win in two ways: one, insurance companies will face more competition, and two, the American people will have more choices.
I know not all 10 Senators in the room agree on every single detail of this, nor will all 60 members of my caucus. But I know we all appreciate the hard work that these progressives and moderates have done to move this historic debate forward.
I want to thank Senators Schumer, Pryor, Brown, Carper, Feingold, Harkin, Landrieu, Lincoln, Nelson and Rockefeller for working together for the greater good and never losing sight of our shared goal: making it possible for every American to afford to live a healthy life.
As is long-standing practice, we do not disclose details of any proposal before the Congressional Budget Office has a chance to evaluate it. We will wait for that to happen, but in the meantime, tonight we are confident.
Stinking badges: Pseudo-public meetings at the NAIC
Monday, December 07, 2009
On Friday, two intrepid Health Access staffers took a field trip to San Francisco to venture into the wilds of the National Association of Insurance Commissioners which was holding a “public” forum on health care reform, as part of their regular quarterly conference that moves around the country.
We thought this was important to do since the Senate version of federal reform gives the NAIC considerable responsibility in implementing health reform. We joined colleagues from AARP and Consumers Union, organizations that have worked closely with NAIC over the years on the regulation of Medi-Gap and Medicare Advantage policies.
So what did Health Access observe?
First, to get into the “public” forum, each of us was required to put $650 on our credit cards: the staff promised that this would be refunded if we dropped off our “official” badges. We put our badges in a drop box after 5pm on Friday. We will let you know if we get charged or not.
What kind of public meeting is that requires consumer advocates to present their credit cards to get in? Well, it’s not a public meeting. It's a private trade association advantaging the insurance industry it purports to regulate.
Second, we picked up the list of attendees: no surprise: page after page of insurance company representatives, at least one Pharma representative, lots of lawyers (presumably for insurers), and brokers.
Third, the attorney who presented an “impartial” analysis to the Insurance Commissioners called the Obama health care team the “Taliban”—and no one but no one challenged this characterization or even seemed to take it amiss—except of course for the Health Access team and our other consumer colleagues.
Fourth, our colleagues from AARP and Consumers Union, who were invited speakers, asked for “transparency” and public process. What was plain is that lots of the work of NAIC is done in conference calls in between quarterly face to face convenings that move around the country. Some of the commissioners or their staff said that they would try to provide notice so that there could be public input.
Good grief! In California, when important regulations are under development, there is plain statute requiring notice, the opportunity for the public to participate, an obligation for regulators to respond to comments, and a cop on the beat to enforce these requirements: the Office of Administrative Law. For instance, when the Department of Managed Health Care substantially rewrote the timely access regulations in late 2006 and gave only 15 days (over Christmas) for the public to respond, the Office of Administrative Law tossed out the regulations and forced DMHC to start over again.
But at NAIC, consumers are apparently at the mercy of whatever the Commissioners determine constitutes adequate notice and adequate public process.
When considering health reform, the NAIC should consider some reforms of itself.
SENATE FLOOR DEBATE STARTS ON HEALTH REFORM * Also: Giving Thanks for the Votes; * COBRA Subsidy Comes to a Close for Some; * Join Thursday's Health Reform Candlelight Procession in San Francisco; * Hang with Health Access & CPEHN at our Holiday Party: Wed, Dec 9th, in Oakland ...and other news for the week...
SENATORS TAKE FIRST FLOOR VOTE ON HEALTH REFORM: The U.S. Senate took a historic first floor vote on the health care reform bill, adopting a crucial amendment to help make health care more affordable for women. Last week, Sen. Dianne Feinstein gave the amendment needed momentum with her remarks about women unfairly having to bear extra cost burdens simply because of their reproductive roles. Speaking earlier today, Sen. Barbara Boxer rallied opposition to another amendment that is similar to the anti-abotion Stupak amendment. Emotion and optimism marked the first week of floor action on the legislation, with Sen. Harkin predicting swift passage: "This bill will pass the US Senate...we'll have it on the President's desk by early next year." Follow us on Twitter for real-time updates on Senate debate.
THANKS-GIVING CONTINUES INTO DECEMBER: Health care reform advocates throughout California continue to express thanks to the members of California's congressional delegation who've voted in support of health reform. Advocates are visiting the offices of each and every representative -- as well as the regional offices of Sen. Barbara Boxer and Sen. Dianne Feinstein -- to express gratitude. For more information, contact Patrick Romano, who leads the Health Care for America Now! campaign in California, at promano@health-access.org.
HOLD A CANDLE TO HEALTH REFORM: Some of the same folks will meet up in the Bay Area on Thursday, December 10, for a candlelight procession through the streets of San Francisco. Hundreds of people are expected to march from Yerba Buena Gardens to Union Square in a procession honoring the 45,000 Americans who died this year waiting for health care reform. For more info, visit our Facebook page.
COBRA SUBSIDY'S END STINGS: This week, Families USA released a report in conjunction with Health Access California calling attention to the approaching end of the COBRA subsidy for those who lost their job-based insurance along with their employment in the recession. Read about it on our blog. The nine-month subsidy, arranged through the ARRA stimulus package, made a huge difference in how many families and individuals were able to keep insurance after job loss, but now those who picked it up immediately are seeing it expire. It is yet another sign of the importance of reform, which would prevent many families from losing coverage when they lose employment.
STILL TIME TO JOIN THE PARTY: There's lots going on during December, but if you are in the Bay Area, take the time to join Health Access California and the California Pan-Ethnic Health Network for a holiday celebration. Health Access and CPEHN are hosting our annual holiday gathering in Oakland on Wednesday, December 9.
The location is Max's of Oakland, 500 12th Street, at the Oakland City Center. (12th Street BART). Here's a map. It'll be from 4 p.m. to 7 p.m. Please RSVP to Pam Flood at pflood@cpehn.org. Hope to see you there!
Any suggestions about the new update format, or questions about its content, should be directed to Cynthia Craft at Health Access, at ccraft@health-access.org.
Over the weekend and today, CA Senators Boxer and Feinstein voted with the majority when amendments came up for a vote: * for a Stabenow amendment to assure that Medicare Advantage plans continue to include core Medicare benefits; * for a Kerry amendment on home care; * against Johanns amendment to send the bill back to committee; * for a Lincoln amendment to limit tax break for insurance CEO compensation; * against an Ensign amendment to limit the lawyer fees of medical malpractice victims; * for a Pryor amendment to survey patients in the exchange about their satisfaction; and * against a Gregg amendment to prohibit program expansions funded by Medicare savings.
Only the Kerry and Pryor amendments got the needed 60 votes for passage; the rest failed.
Debates are continuing as we speak, including on an amendment by Senator Ben Nelson to include the anti-abortion language similar to the Stupak amendment in the House bill. The debate continues...
The U.S. Senate is in full debate on health reform, and they started voting on some amendments in the last few days, despite various efforts by the GOP opposition to slow the debate down even more.
I've been in DC this week, and so have not been posting as much. Despite all the negotiations about amendments, you do get a sense that we are nearing a major advance. Beyond my Hill visits, my hope is to go see a little of the Senate floor debate in person, to say I saw a piece of history.
California's two Senators are actively participating in the floor debate as well. Here's some clips to give you a sense of what they are saying. Here is Senator Barbara Boxer, on women's health issues, from just a few days ago:
Here's a longer clip from Senator Feinstein from about a month ago, about the history of health insurance in this country:
The report, by the consumer health organization Families USA and co-released by the statewide health consumer coalition Health Access California, states that the subsidies – which were started last March by the American Recovery and Reinvestment Act (ARRA), but were made available for only nine months – have enabled millions of laid-off workers and dependents to afford so-called “COBRA” premiums needed to continue health coverage from their previous employer.
Under the ARRA, the federal subsidies pay 65 percent of the cost of COBRA premiums. In California, the federal subsidies for COBRA family coverage average $720 per month.
Without subsidies, the report finds, COBRA premiums for family health coverage will cost laid-off California workers, on average, $1,107 per month – 82.1 percent of the average ($1,349) monthly Unemployment Insurance checks they receive.
For the first recipients, who began receiving subsidies in March, the subsidies will expire on November 30. For those who started receiving subsidies after March, the expiration will be nine months after their start-up date.
For millions of laid-off workers and their families, the federal COBRA subsidies have been described as a health-coverage lifeline. Health advocates are arguing that new jobs legislation extends those subsidies.
Health and consumer advocates noted that pending health reform legislation would provide a permanent source of help to laid off workers. The health reform bills pending in Congress would enable laid-off workers and their families to obtain health coverage through a newly created marketplace, called an “exchange,” and families with low incomes would receive tax-credit subsidies to help pay the premiums.
Health advocates are urging Congress to extend the COBRA subsidy as a much-needed measure in the present to protect recently laid-off workers and their families. But, they say, this issue shows the dire need for health reform moving forward, so nobody loses health coverage when he or she switches jobs or becomes unemployed looking for work.
The Congressional Budget Office and Joint Tax Committee estimated that approximately 7 million adults and dependent children would receive the COBRA subsidy in 2009. The Treasury Department is compiling data about how many workers received the subsidy, but a count of the people benefiting from the subsidy is not yet available.
The data for the Families USA report were derived from federal sources in the Departments of Labor and Health and Human Services. A more detailed description of the sources of the data is set forth in the report’s methodology section.
It's hard to make broad statements about whether premiums go up or down, because so many people are in such different circumstances, and people changes those circumstances frequently. The person getting great coverage heavily subsidized by their employer today may be unemployed tomorrow, paying 100% of a very high premium, if not denied for pre-existing conditions. A young person in the individual market could find his specific policy getting marked up significantly, even if the overall market is not a problem.
That said, it makes some key points: Even without taking into consideration a range of cost saving mechnisms (prevention, payment reforms, etc), premiums will go down for many people, especially low- and moderate-income folks who have the toughest time affording coverage, and who will get subsidies to help pay for coverage.
Even many of those who are not subsidized will have their coverage go down. For those who don't, it largely because they will be getting better, more comprehensive policies. These are folks who are largely underinsured, who now will be fully insured. So when opponents talk about some who may see an increase in premiums, they are not doing an apples-to-apples comparison. The minimum benefit standards are a feature, not a bug, in that people won't be suckered into "junk" coverage that leaves them in a lurch when they actually get sick.
For most people, the big takeaway is that for the vast majority of people, they will get a guarantee that health premiums for meaningful coverage won't be more than a certain percentage of their income. Because we will subsidize low-and-moderate income families based on their income, we will fundamentally change the regressive nature of health insurance. Under health reform, we will move toward a system where we pay premiums based on how much we can afford, rather than how sick we are--which is our current practice.
To provide the latest information about health policy and politics, from the California budget to the federal health reform debate, Health Access is piloting a new format to our regular Health Access Update, highlighting resources on our website, blog, Twitter feed, Facebook page, coalition partners, and elsewhere. Sign up by typing your E-mail address on the front page of our website. Please let us know what you think. Here's this week's update:
SENATE VOTES TO START FLOOR DEBATE ON HEALTH REFORM: The U.S. Senate will come back from Thanksgiving today and start floor debate on health reform, after a crucial vote before the break. If you follow us on Twitter, you'd have gotten the real-time updates as Senators voted affirmatively, 60-39, on a "motion to proceed" to debate health reform. The House of Representatives passed their own version of health reform three weeks ago.
Health advocates thanked California's Sen. Barbara Boxer and Sen. Dianne Feinstein for voting, with all Democrats and independents, to move health reform to the next stage.
The next day, on Sunday, Senator Feinstein went on to appear on NBC's Meet the Press, where she made strong points on the urgency of reform, the problem with our for-profit insurance industry, and the fabrication of opposition facts. Watch it and read about it on our blog.
Much more to come in the next few weeks, as Senate leadership hopes to finish debate and get the necessary 60 votes to stop debate before Christmas.
NEW BUDGET FIGURES SPARK SPECULATION ABOUT ADDITIONAL CUTS: Due to the economic downturn, things were decidedly less promising in California, where we were busy explaining, explaining, and explaining in the media that any additional budget cuts in health and human services would be beyond brutal in terms of their impact on individuals and families, on our economy, and on the health system on which we all rely. A fact sheet of the health budget cuts in the current budget is available on our website.
Governor Schwarzenegger is expected to release in January both a mid-year cuts package and a 2010-11 proposed budget. Many crucial health program are expected to be in jeopardy, as elected leaders seek to address another massive anticipated shortfall of upwards of $20 billion for the next year-and-a-half. Health Access will be actively organizing to prevent the worst of these cuts, and to advocate for the revenues that are needed prevent the cuts and sustain these programs.
MEDICAID WAIVER GETS LEGISLATIVE HEARING: Meanwhile, an administration proposal for a federal Medi-Cal waiver was given a hearing by the Senate Health Committee. This process would reshape for the next five years the Medi-Cal program, which provides coverage to seven million low-income Californians, largely children, parents, seniors and people with disabilities, and provides core funding to safety-net hospitals and other providers.
The Assembly Health Committee is expected to have its own informational hearing on Thursday, December 10th. Health Access' new paper discussed how the waiver may offer a bridge to health reform.
HOLIDAY PARTY: There's lots going on during December, but if you are in the Bay Area, take the time to join Health Access California and the California Pan-Ethnic Health Network for a holiday celebration in the Bay Area. Health Access and CPEHN are hosting our annual holiday celebration in Oakland on Wednesday, December 9.
The location is Max's of Oakland, 500 12th Street, at the Oakland City Center. (12th Street BART). Here's a map. It'll be from 4 p.m. to 7 p.m. Please RSVP to Pam Flood at pflood@cpehn.org. Hope to see you there!
Any suggestions about the new update format, or questions about its content, should be directed to Cynthia Craft at Health Access, at ccraft@health-access.org.
Even as reform makes its way through Congress, medical bankruptcies -- a term hardly known 20 years ago -- appear to be on the rise, says the New York Times.
Senator Joe Lieberman's latest argument against the public health insurance option struck me strange:
"This is a radical departure from the way we've responded to the market in America in the past," Lieberman said Sunday on NBC's "Meet The Press." "We rely first on competition in our market economy. When the competition fails, then what do we do? We regulate or we litigate. ... We have never before said, in a given business, we don't trust the companies in it, so we're going to have the government go into that business."
"What does he think Social Security is? Or Medicare? Or public fire departments?"
To be fair, his list includes responsibilities that the private industry largely shuns (there's no market for private fire protection), or which the government is the main provider and private industry is a structured alternative (Medicare Advantage) or a supplement (private retirement plans).
The model for the public health insurance option is one where the government isn't the sole provider, but is one among a range of options. One analogy used by Senator Schumer is public universities, UC-Berkeley being an excellent option alongside private colleges like Stanford. But even there, the public health insurance option is not going to be subsidized like the UC system (although less so, as the protests this week show), nor as dominant in terms of being the real and only option for so many Californians.
Maybe a better analogy for Senator Lieberman is public broadcasting, which he has strongly supported over his years (at least when he was a Democrat). Public radio and television stands alongside traditional private radio and television stations as one of several options. Yes, public broadcasting gets a small subsidy, but it's tiny compared to its overall budget. It has been structured with different incentives, and thus has been able to respond to market failures: for example, specializing in educational children's television programming and informational documentaries all of which were unique until the explosion of cable channels; even now, it is an important launching pad for programs. In radio, it has focused on in-depth news, and there's nothing like it on the dial.
There's been a lot of onlinecommentary about how the public health insurance option, given all the compromises to come and already made, may not be worth it. We need to still advocate for a public option that has strong negotiating power, that is national in scope, and begins on day one. But even if it is not available to everybody on day one, or doesn't save all the money that a stronger version does, I do think there are other reasons for it. With a different structure and accountability that the private insurers, it has the real potential to innovate in areas of market failures: Maybe it specializes in really doing the best possible treatment and management of asthma, diabetes, and obesity. Maybe it figures out new ways to provide access to rural populations. Maybe it is just a "safe harbor" for people against continued abuses by private insurers--much like PBS is a safe harbor for parents against TV commercials.
There are many other important issues as well in the health reform debate, from affordability to employer responsibility. But the public health insurance option continues to be a key concept worth fighting for, even with some of the compromises made.
Fresh from voting to begin debate on health reform, California Senator Dianne Feinstein was on NBC's Meet The Press this morning. (We tweeted her comments at @healthaccess on Twitter.)
Earlier this year, Senator Feinstein’s comments on health reform were noncommittal and even skeptical. She had a website post that indicated her “concerns” with health reform. But as she’s focused on the problem and the solution, she has become more convinced of the urgency of the need, as she stated the urgency of the problem: "The time has come to really see that people who have no insurance can get insurance."
She also seems to have more appreciation for the solution proposed. Always a moderate at heart, she described the bill as “incremental,” in a positive way. "The good part about this bill is that it is structured so it is phased in, so over time we can watch it, we can change it." She cited that some help comes early, like small business tax credits, and coverage for those denied for pre-existing condition,. Other changes, like setting up the exchange and the public option, come online in 2014, and she seemed comforted that it would give us time for adjustments if needed.
As she indicated in a new health reform statement on her website last month, Senator Feinstein was clearly influenced by the T.R. Reid book that compared health systems from around the world. A conclusion of the book is that while several countries have different systems, the U.S. stands out, and not in a good way. As Senator Feinstein said on Meet the Press, "America has serious problems with respect to health care. Virtually every other developed country has a better system than we do. Ours is costly, in places it is ineffective, it's deeply troubled."
But then Feinstein went further, showing that her centrism is not incompatible with a strong critique of insurance companies and our current for-profit system: "No developed country on Earth has a huge for-profit medical insurance industry that we have: 480% profit in 8 years. Premiums skyrocketing." She described that she had five California Daughters of Charity hospitals come to her, and talk about how they face a 17% in premium hike for their 6,000 workers, yet only got back 5% in rate reimbursement. The premium increase wiped out their operating capital for 2009. She argued strongly for a public health insurance option, and for a rate regulation authority.
She also pushed back against the wild falsehoods by the opposition. "I looked at the Republican talking points on the 2.5 trillion figure that is their cost [for health reform]. There's no substantiation for that... What [the CBO] does say: The deficit savings is $170 billion."
Senator Feinstein did Californians right with her vote to move health reform forward, and in her comments on health reform this morning.
Earlier tonight, the U.S. Senate voted on a "motion to proceed" to begin debate on a historic comprehensive health reform proposal, by a vote of 60-39. (All Democrats and Independents voting yes, all Republicans voting no, with GOP Senator George Voinovich not present.)
We thank California Senators Boxer and Feinstein for voting to move forward on the debate for desperately needed comprehensive health reform. Given the extent of California's health crisis, we need to move this bill, and work on the Senate floor to make it better.
The bill would provide stability and security for those who have coverage, and that would extend affordable coverage to those who don't. Californians are concerned that coverage won't be there for them when they need it, and this bill provides our families with much needed security from financial ruin.
Californians have a particular interest in this debate. Californians are more likely to be uninsured, face a higher cost-of-living, are at greater risk to be denied for coverage for pre-existing conditions, and are less likely to be offered on-the-job coverage.The Senate bill would provide crucial financial assistance to small businesses and low- and moderate-income families, expand our safety net, provide key consumer protections against insurance company abuses, and provide the choice of a public health insurance option.
There are areas where we will push to improve the bill, closer to where the House bill is in affordability, inclusivity, and employer responsibility. We need to do better to ensure affordable and meaningful coverage both in terms of what low- and moderate-income families pay in premiums, and in out-of-pocket costs. We need to do better secure on-the-job coverage for working families. We need to remove unnecessary paperwork and prohibitions for people to use the new health insurance exchange. But despite these details, this is a good framework for moving forward.
What we needed tonight was to move the bill foward. We are proud that California's Senators did the right thing for our state. We look forward to them taking quick action so that this legislation can become final law.
The U.S. Senate is currently debating health reform, and California Senator Barbara Boxer just announced on Twitter that she will be speaking on the floor at 6pm Eastern, 3pm Pacific.
We are leading up to a key vote Saturday night, 5pm Pacific. C-SPAN will be broadcasting it live.
In the arcane rules of the Senate, 60 votes are needed--given the united Republican opposition, that means all Democratic-caucusing Senators--just to begin the debate in the Senate.
For more information on the Senate bill, here's two central hubs of fact sheets, video clips, and information: dpc.senate.gov/reform
Our forecast of California’s General Fund revenues and expenditures shows that the state must address a General Fund budget problem of $20.7 billion between now and the time the Legislature enacts a 2010–11 state budget plan. The budget problem consists of a $6.3 billion projected deficit for 2009–10 and a $14.4 billion gap between projected revenues and spending in 2010–11. Addressing this large shortfall will require painful choices—on top of the difficult choices the Legislature made earlier this year.
It's hard to imagine the severity of the cuts that are left, a point I make in this Sacramento Bee article by Kevin Yamamura. Do we go back to eliminating the Healthy Families program that covers 900,000 children, a mere few weeks after a big-deal signing ceremony trumpeting the saving of the program? What else?
Jean Ross of the California Budget Project is right that we need to raise revenues, and start with repealing the corporate tax breaks that were granted in the last budget. The LAO agrees that the budget needs to include revenues, not just cuts.
Senate Majority Leader Harry Reid unveiled the new Senate health reform proposal today, a merger of the bills produced by the Senate HELP Committee and the Senate Finance Committee.
The immediate drama is whether Democrats will be able to get the 60 votes (requiring all Democratic-caucusing members) to start the debate on the measure later this week. Senator Baucus is in Montana with a family emergency; there's about 3-5 conservative Democrats whose vote is a question, both for the first vote to start the debate, and the vote to end the debate and allow the bill to be voted on.
Republican Senators have sought to delay the bill as much as possible. Senator Coburn is potentially going to force a full reading of the bill, a procedural stalling tactics. The best Twitter conversation was who could be made to do the reading, with suggestions including uninsured Americans to Christopher Walken to William Shatner.
As details come out about the bill, we'll continue to post more info here, and on our Twitter account, at www.twitter.com/healthaccess
The Senate Health Committee, chaired by Sen. Elaine Alquist, met Wednesday to hear panels of experts share ideas for how the state’s Medi-Cal program could be restructured through the development of a Medicaid waiver.
The waiver that California hopes to obtain from the federal government next year would allow the state to stretch the boundaries of Medicaid’s current rules. Administration officials, including David Maxwell-Jolly, Director of the CA Department of Health Care Services, argued that the proposed changes would help the state’s Medi-Cal program save money and improve coverage for California’s most vulnerable citizens. The focus of their talk, and a concept paper that was released a few weeks ago, was finding savings and in organizing and coordinating care of patients, especially those with chronic conditions.
The restructured health care delivery system would seek to do more with less, saving the state money in the long run. The informational hearing came as the Legislative Analyst’s Office predicted that California’s revenue shortfall will balloon to $20.7 billion in 2010.
Several advocates and health policy experts expressed hope that the state will pump any savings resulting from the waiver program back into health care services to prepare the state for a smooth transition into national health care reform, should federal legislation pass.
Proposed health care reform legislation in Congress would go into effect in 2013, midway into the five-year waiver period that the state hopes to begin in September of 2010.
Health Access California’s Beth Capell offered suggestions as to how the state could take advantage of the timing and dovetail into the rollout of federal reform by, for example, simplifying eligibility requirements before 2013.
“We’ll have to be ready to go from zero to sixty on January 1, 2013,” Capell told the committee, recommending that existing programs prepare auto-enrollment processes. That way, California would be poised to get as many Californians enrolled on day one, and take advantage of federal dollars for a reformed health care delivery system right from the start. These ideas were also explained in a Health Access Medi-Cal waiver paper released this week.
Several panel members fielded questions from the Health Committee members regarding the best methods of care in California.
Among those testifying about best practices and enhanced outcomes were a few administrators of a few spotlighted "medical home" and managed care systems already in place in 26 counties. They reported that their coordinated care systems led to fewer emergency room visits, greater attention to “whole body” wellness, better preventative care and more attention to co-occuring mental health and substance abuse cases. In addition, these counties were able to attract some uninsured Californians who had been putting off medical care, a practice that could lead to higher medical bills in the long run.
But Senator Alquist also raised questions to Administration officials, including whether all existing managed care plans actually did care coordination, and whether they were ready to take the responsibility to provide quality care and coordination in accordance with the special needs of seniors and people with disabilities in Medi-Cal.
Saying the hearing had proved informative, Senator Alquist said, “There’s no reason why we can’t produce a better product at a reduced cost.”
Western Center on Law and Poverty legislative advocate Elizabeth Landsberg expressed concerns about mandatory managed care, but supported a “medical home" model, as did several testifiers. The medical home model has a lot in common with managed care plans in that it serves as a hub of coordinated care for patients. Beneficiaries would have a practitioner who serve as their “medical home,” a source from which all medical and behavior care, diagnostic tests, medications -- and so on -- can be linked and coordinated.
There was some questions as to whether individual physicians would be prepared to serve as a medical home model, and if the Administration's proposal was simply to shift many seniors and people with disabilities into existing managed care plans.
Lots going on today. At 2pm Pacific, Senate Majority Leader Reid will unveil the new, combined version of a health reform proposal to his Democratic Senate colleagues, thus starting weeks of debate on the measure. The drama is whether all 60 Democratic-caucusing Senators will vote to allow such a debate to take place, in order to prevent a Republican filibuster. It's an important next step in getting health reform passed.
Back here in California, health reform will be front and center in its own way. At 1:30pm, the Senate Health Committee, chaired by Senator Elaine Alquist, will hold an informational hearing on "Redesigning California's Medi-Cal Program: Examining the Potential for Cost Savings and Program Improvements."
As we have reported before, California's Medi-Cal waiver agreement with the federal government is up for renewal next year. A new waiver would set the rules for the program, which now covers 7 million Californians, mostly low-income children, parents, seniors, and people with disabilities, for the next five years.
Those next five years would take us into the full implementation of health reform, should any of the pending proposals in Congress pass. The waiver process poses a challenge, since consumer advocates are always wary of changes that might undermine patients' rights or access to care. But it can be a significant opportunity to increase access to care and coverage and transition Medi-Cal to a newly reformed system.
I had to laugh out loud in my sedan while listening to the local NPR affiliate station recently. Think of it as an absurd, tragic-comic commentary on the present state of our health care delivery system. It was a blurb of no more than 5-10 seconds paid for by the underwriter of the local broadcast. A prominent managed health care plan touted its name, followed by a marketing slogan intended to attract more consumers:
". . . where doctors take extra time to get to know each patient."
In our current health care system, that's not standard, that's a selling point.
As we start the Senate debate on health reform, some key items about the health reform that passed the House of Representatives:
Politico's Jonathan Allen and Patrick O'Connor has the scoop on some of the behind-the-scenes back-and-forth around the House of Representatives, which highlights at least three California Representatives, starting with Representative Dennis Cardoza. The article points out an interesting footnote, that the last two Democratic votes for the bill were Californians, Rep. Maxine Waters (who waited to be the deciding vote #218) and afterwards, Rep. Loretta Sanchez.
Health Access supports H.R.3962, as we wrote in our letter supporting the health reform measure. Our letter does mention areas that we agree, and areas where it could improve. What it doesn't mention is the anti-abortion Stupak amendment, which was added on the day of the vote. It's an overreach, going beyond extending the current federal prohibition against federal funding of abortions, to impact any private health plans offered in the exchange.
The amendment is bad in its policy, but also in its politics. The House bill was a very good bill, in most cases better than in Senate counterpart. But the Stupak amendment is a major exception to that rule, and this makes it harder to rally aggressive support for the other House provisions.
There are other issues with the House bill that need to be worked out in a conference committee. Lisa Girion at the Los Angeles Times has an important story about how provisions in health reform might undermine state-based consumer protections. Health Access, which sponsored many of those HMO patients' rights in the past two decades, is working with Senators and members of Congress to point out the issues, so that national health reform serves as a floor, not a ceiling, for consumer protections. Luckily, as the article indicates, some of our members of Congress, from Susan Davis to Jackie Speier to John Garamendi, were heavily involved in the state passage or implementation of those protections, and so have a base of knowledge and passion on this issue.
Today, with Senate debate on health care reform gearing up for action, former Congressman Richard Lehman, of the Central Valley town of Sanger, had words of support for his House successors, U.S. Rep Dennis Cardoza and U.S. Rep Jim Costa.
"One can demonstrate true leadership and advocate for your district, as Costa and Cardoza have done, and try to address the difficult challenges facing us. Costa and Cardoza have demonstrated once again their choice to take the political hard road and advocate for one of the poorest regions of the country and try to improve our health care system."
Representatives Costa and Cardoza were the subject of major efforts to urge them to support health reform, as among the last to commit to vote for the reform. They did vote for the bill, and there were lots of reasons for them to do so. Health reform will be a major assist to the Central Valley, which needs the help.
We knew that the opponents of health reform will attempt to manufacture research findings against the pending proposals. Ken Jacobs at UC-Berkeley earlier offered here a point-by-point takedown about some citations made on the House floor about the supposed negative economic impacts of health reform--statistics that were not just inflated, but basically made up.
Now Michael Schear at the Washington Post has obvious evidence of this, as it has obtained an E-mail from the Chamber of Commerce's senior health policy manager soliciting funds from business lobbies for a study about the jobs impact of health reform. The E-mail states: "We are seeking 4-5 other groups to contribute $5k so that we can move forward as soon as possible, especially considering that Leader Reid has filed a rule 14 to begin debate as early as Tuesday.. The longer we wait, the less chance we have of influencing the debate... If you know of any other trade associations we should approach, please let me know."
They plan to use the money to hire a "respected economist" to produce a study. Then, "The economist will then circulate a sign-on letter to hundreds of other economists saying that the bill will kill jobs and hurt the economy. We will then be able to use this open letter to produce advertisements, and as a powerful lobbying and grass-roots document."
We suspected as much from the opposition, but never had the process of manufacturing data laid out before us so clearly.
Even with this evidence, the Post article tries to be even-handed: "The proposed economic study by the Chamber is the latest example of attempts by advocates and opponents of health-care reform to influence the debate with economic studies whose authenticity is later questioned by their adversaries." But what if one side is just much, much more willing to make stuff up?
Those who oppose an employer requirement, and health reform in general, have been making wild claims about the supposed negative impact. To fact-check these claims, here's a guest commentary by Ken Jacobs, Chair of the UC-Berkeley Center for Labor Research and Education:
Over the last few months, we have heard any number of outrageous claims about the potential impacts of the proposed health care bills (death panels, end to private insurance, etc.). Still, the claim made by Republican speaker after speaker during Saturdays House debate that the bill would result in a loss of 5.5 million jobs stands out. They even go so far as to say (see House Republican Leader John Boehner’s website), that the research was based on a methodology developed by Dr. Christina Romer, Chair of the Council of Economic Advisors, and Jared Bernstein, the Vice President’s Chief Economist. What’s going on here?
The Economic Policies Institute’s Josh Bevans pointed me to Politifact, which does a good job of debunking the claim. It turns out that the number comes from Republican staff of the House Weighs and Means Committee.
They started with an estimated tax increase on employers from the play or pay provision of $300 billion. It is not clear where this number comes from; the CBO estimate is $163 billion over ten years. They treat that number as though it is a direct reduction in GDP for a single year, thereby increasing the projected impact tenfold. To get the total impact on GDP they use a multiplier from a 2007 paper by Christina Romer which explicitly states that the analysis in the paper pertains to tax increases or cuts that change the total spending in the economy. This would be the case, for example, for a tax increase to fund the deficit where there is no corresponding increase in government spending, or for a tax cut to stimulate the economy that was not balanced by a reduction in spending. The paper is very clear that the analysis would not apply to a social insurance program where the increased tax is balanced by an equal increase in output—as with the healthcare act. Finally, the minority committee staff applied a ratio of changes in GDP to job losses or gains from the stimulus analysis by Romer and Bernstein to reach a number of lost jobs.
So to reiterate—they: * use a methodology that is clearly inappropriate for the case at hand * start with a cost to employers that is nearly double that of the CBO projections * inexplicably multiply the results by ten.
Then they claim that the analysis was done with a methodology from the Counsel of Economic Advisors—one Congressman actually directly attributed the estimates to the CEA—even as it directly contradicts what Romer wrote in the paper they cite. Amazing.
So, what does the academic literature tell us about pay or play provisions and job losses? Studies on Hawaii and San Francisco, which both have employer requirements, have found no measurable impacts on employment. Most economists believe that for workers above the minimum wage the costs of health insurance are passed on to workers over time in the form of lower compensation. The impact of a health requirement of the size under consideration would be equivalent to a modest increase in the minimum wage. Drawing on the minimum wage and health mandate literature, Philip Cryan found that the job impacts of an employer requirement of 8 percent of payroll, with no exemptions or subsidies for small businesses, would be in the range of 166,000 jobs lost to 55,000 jobs gained.
This is before taking into account the many positive impacts of health reform on jobs, small businesses and the economy as a whole. The biggest “job-killer” would be a failure to act.
Even as federal health care reform is inching forward, and change of some sort seems perched on the horizon, there's still plenty of opportunity to grasp the full context of its place in history.
The New England Journal of Medicine has an interactive timeline online that allows us to do just that -- with ease, and without a lot of online searching. The timeline starts with 1912 and the involvement of Theodore Roosevelt and the Progressive Party, and brings the health care reform movement all the way up to the present legislative process.
It's a clean, inviting informational graphic that depicts dozens of factors and events that helped shape the system of health care delivery in the United States. A simple rollover of the mouse gives greater detail to the events on the timeline -- and as a bonus, cites New England Journal of Medicine articles on the events as far back as 1916. We recommend it.
Health Access California, as part of Health Care for America Now (HCAN) – the nation’s largest health care campaign – launched a new television ad today to publicly thank Representative Jerry McNerney (CA-D) for his historic ‘yes’ vote on the House of Representatives’ health care bill – the Affordable Health Care for America Act (H.R. 3962).
The ad titled “About More” will air for a week on San Francisco Bay Area cable. The ad is one of more than twenty airing nationwide to show appreciation to Members of Congress who have done the right thing in voting ‘yes’ to pass health care legislation through the House and to emphasize the importance of Members continuing to hold strong as health insurance lobbyists and other opponents of meaningful reform are sure to ramp up their attacks in the coming weeks.
California HCAN partners visited Congressman McNerney’s office (and those of several other health reform-supporting Representatives) on Monday morning at 11am to deliver chocolates and a “health care hero” media to make sure Rep. McNerney knows how much his constituents appreciate his voting to make quality care affordable to families and businesses in Nevada and to let her know they will continue to stand with her until health care reform gets signed into law.
“We’re very proud of Congressman McNerney and all the Democrats in the California delegation for standing up to the health insurance industry and other special interests and doing what’s right for California. His historic vote to pass health care legislation through the House means we are one step closer to having good health care we can afford,” said Anthony Wright, executive director, Health Access California. “With his vote, Congressman McNerney has said yes to lower health care costs, yes to a guarantee of good, affordable coverage, yes to stopping health insurance companies from denying care, and yes to the real choice and competition we’ll get with a new national public health insurance option.”
Here's a television advertisement starting to run today by Health Care for America Now! in the district of Rep. Jerry McNerney, thanking him for voting for the historic health reform bill this weekend.
VIDEO DESCRIPTION:
Small floating SUPER: For Congressman Jerry McNerney, it’s about more than just health care.
Small business owners happily running their business. SUPER: Helping small businesses SUPER: Growing the economy
Skyscrapers. SUPER: Taking on insurance companies.
Middle class couple looking over bills at kitchen table. SUPER: Making health care affordable.
Patient in waiting room looking worried. SUPER: No more denying coverage
Middle aged woman speaking with doctor in a doctor’s office. SUPER: Medical decisions in the hands of you and your doctor.
Still of Congressman w/ SUPER: Thank You Congressman McNerney for fighting for us. 1-877-264-4226
AUDIO TRANSCRIPT and DOCUMENTATION:
For Congressman Jerry McNerney, it’s about more than just health care.
Now that the House has cast its vote for health care reform, it can be interesting to go back and see who voted for it, and who didn’t.
Of those who didn’t support reform, one might assume it may have been because few people in their districts were uninsured, and thus health care reform was not a priority.
Of course, it's not that simple.
Take U.S. Rep. Devin Nunes (R), whose district, including Visalia and Clovis, has an uninsured population rate of 23.8% -- nearly 1 in 4 people. He voted “no.”
Or U.S. Rep. Mary Bono Mack (R), with 24% of the population in her Palm Springs area district uninsured. She voted “no” as well.
The district with the highest rate of uninsured Californians – a whopping 42.4% -- is represented by U.S. Rep. Xavier Becerra (D). He voted “yes” for health care reform.
To see how all the California representatives have voted, the uninsured rate in their districts, and an accounting of health industry contributions to the Congress members, visit this graphic on the Washington Post site.
You'll also note that newly sworn-in U.S. Rep John Garamendi (D) managed his transition swiftly enough to have his say on the historic reform proposal -- voting "yes," as promised during the campaign.
Feel like you’re ready to buckle down and review the basics of the process here on out regarding health care reform in the comfort of your own home or office?
Like you ought to be taking this policy shift seriously, because everyone, including the President, describes it as history in the making? Something you’ll want to tell the grandkids about some day? There are plenty of blogs and news stories and informal conversations online, where you can pick up bits and pieces of the process of health care reform.
But if you want to feel like you’ve attended a real, buttoned-down, online university mini-course, try this one at Kaiser.edu.org, a project of the Kaiser Family Foundation. It’s got to be in the Ivy League of online overview slideshow/seminars.
Earlier tonight, the U.S. House of Representatives passed H.R.3962, a historic comprehensive health reform proposal, by a vote of 220-215.
We thank ALL of California's Democratic Congressional Representatives for voting for this desperately needed comprehensive health reform. Given California's health crisis, it's appropriate that the House of Representatives, led by Californians like Speaker Pelosi, Chairmen Miller, Waxman, and Stark, and many others, took the lead in crafting this historic bill.
The bill would provide stability and security for those who have coverage, and that would extend affordable coverage to those who don't. Californians are concerned that coverage won't be there for them when they need it, and this bill provides our families with much needed security from financial ruin.
Californians have a particular interest in this vote. California has more uninsured, a higher cost-of-living, more denials of coverage for pre-existing conditions, and fewer workers offered on-the-job coverage.The House bill would help people keep their on-the-job coverage and expand our safety net. It would provide consumer protections against insurance company abuses, and provide the choice of a public health insurance option.
This is the equivalent of passing Social Security or the minimum wage in the 1930s, or the passage of Medicare or civil rights legislation in the 1960s.
This is not the end of the process, but it moves the process forward. The Senate should take quick action the conference committee to meld the two bills can start its work can begin as soon as possible.
We will look to conference committee to change the one unfortunate development from today's debate, which was the adoption of the Stupak anti-abortion amendment. The main bill had already prohibited federal funds to be used for abortion. The amendment provides for an unwarranted extension that would place anti-abortion restrictions on private plans offered in the new health insurance exchange. While over 190 Democrats voted against the amendment, it's unfortunate that over 60 Democrats--including California Representatives Joe Baca, Dennis Cardoza, and Jim Costa--joined all Republicans in voting for this amendment. This issue needs to be fixed in conference.
Aside from the abortion issue, the House bill is a very good bill--and superior to the Senate versions, especially on key issues like affordability, employer responsibility, the public health insurance option, inclusivity, the bargaining power of the exchange, limits on out-of-pocket costs, financing, and several other issues.
So there's a lot of work to do, but let's remember the importance of this vote. It moves the process forward. And this process has now moved farther than any other previous effort in over 100 years of effort, with an entire body of Congress endorsing a proposal. Let's keep the focus on passing reform, while working to make the reform better.
As I write this, Speaker Nancy Pelosi spoke on the House floor. "This is an historic moment," and said, in a strong voice, "Today we will pass" health reform. "Today, we answer the call" of history. She talked of three pillars: Innovation, Competition, and Prevention. She talked about the benefits of reform for consumers, including that "there's a cap on what you pay in, but there's no cap on what you receive." She gave a long series of bullet points of what "no longer" will happen under the bill, with the biggest applause when she said, "No longer will being a woman be a pre-exisiting condition." At the end,Speaker Pelosi invokes Rep. John Dingell's long fight the health reform, as well as the quote from the late Senator Kennedy: "What is at stake is the character of our country."
There's been other poignant speeches by Californians, including Education and Labor Chairman George Miller's statement focusing on preventing financial insecurity for families. "We cannot ask American families to continue to live on the edge of insecurity..today, we deliver security... A small event, because of lack of healthcare, can explode into the life of a family, the life of a community. That's not going to happen again" under this bill.
Progressive Caucus Chair Rep. Lynn Woolsey explained how she worried about her three children's health when they were uninsured, and no mother will have to now.
The debate is expected to go into this evening.
There will be tough amendments on abortion and immigration before the day is done. * An amendment by Bart Stupak would limit abortion coverage for even *private* health coverage offered through the health insurance exchange. * A Republican amendment would limit undocument immigrants from *using their own money* to buy coverage in the health insurance exchange.
So if you can, keep calling your Congressmembers TODAY (Saturday) 1-877-264-4226.
Health Access California is opposed to the amendments, but strongly for the main bill, H.R. 3962.
with a background as a consumer advocate and community organizer on many issues, including health issues for the last ten years in California and New Jersey.
