U.S. CONGRESS PASSES CHILDREN'S COVERAGE; SCHIP HEADS TOWARD VETO * Senate passes SCHIP/Healthy Families expansion with veto-proof 69-30 vote * Follows House passage of SCHIP, 265-159, a majority but not enough to override veto * ACTION ITEM: Write your Representative about their SCHIP vote
New on the Health Access WeBlog: Much More on SCHIP; Health Premium Increases; Special Session Gossip.
The U.S. Senate on Thursday sent to President Bush a bipartisan $60 billion package that would extend the State Children’s Health Insurance Program (SCHIP) for another five years. Healthy Families, California's version of SCHIP, currently covers 850,000 children. Both California Sens. Barbara Boxer and Dianne Feinstein voted in favor of the measure.
Even though SCHIP is set to expire on Sunday, September 30th, President Bush has already vowed to veto the measure, which achieved a veto-proof majority in the Senate, but not in the House.
Thirty-four of 53 California Representatives supported the measure in the House of Representatives vote on Tuesday, including Representative Mary Bono, who was the only one of the 19 California Republicans to cross party lines to vote in favor of children’s coverage. HR976 ultimately passed with a 265-159 vote majority on Tuesday evening, but not the 290 votes needed to withstand a veto. See the full list of how California ’s delegation voted here.
The State Children’s Health Insurance Program expires on Sunday after 10 years. It covers 6.6 million children nationally, including about 850,000 children in California through our Healthy Families Program. HR976 (the SCHIP reauthorization bill) would extend coverage to an additional 4 million children – halving the number of uninsured children in the nation.
THE BILL
HR976 would provide an increase to SCHIP of $35 billion over five years. State would receive a 2:1 federal match that dollars states spend in covering eligible children.
The bill would provide federal funds for children in families up to 300 percent of poverty -- $61,950 for a family of four. While many states only allow children under 200 percent of poverty, some states with high costs-of-living have higher eligibility levels: California ’s Healthy Families program goes up to 250 percent, and has pending proposals to extend that coverage to 300 percent. New Jersey has had 350 percent, and New York has proposed 400 percent, although their request has recently been rejected by the Bush Administration.
Allowing more middle-income families to join the program has been a point of contention with the President and other Republican members of Congress who view expanding SCHIP into middle-income territory as leverage toward “socialized medicine.’’ But supporters of the expansion argue that private health coverage has become too expensive for families to buy on their own – especially as employers scale back benefits offerings or decline to offer coverage altogether.
In California, some estimate the increase would help the state achieve near-universal coverage for children: about 650,000 children. Gov. Arnold Schwarzenegger and Democratic leaders have all advocated for increasing eligibility for children under the SCHIP/Healthy Families program, and such expansions are part of their overall health expansion proposals.
The expansion of eligibility at the federal level would be covered by a 61-cent increase in the tobacco tax, which was decried by Republican opponents, even though a new poll shows that 67 percent of Republicans favor an even larger tobacco tax to fund children’s health care. The same poll even shows that smokers don’t mind (by a 51-47 margin) paying more to keep children healthy.
THE DEBATE
Many senators, both Democrat and Republican pointed to the hypocrisy of those who planned to oppose the extension and expansion of children’s health insurance.
Sen. Edward Kennedy, D-Mass., for instance, pointed out that senators who planned to vote against expanding SCHIP earned $160,000 annually, “well above 300 and 400 percent of poverty’’ yet still receive a generous health package paid for by taxpayers. “You’d think if they (the opposing senators) are so offended by federal government spending, they wouldn’t use it themselves. But no, they’ll take it. …This is extraordinary hypocrisy. How can they be complaining all afternoon about a federal government program, and then have the federal government paying for their own,” he said.
Sen. Chuck Grassley, R-Iowa, also spoke in favor of the measure, accusing some of his Republican colleagues of distorting information and correcting the inaccurate assertions his friends made. Grassley also reminded lawmakers that President Bush declared at the 2004 Republican Convention that low-income children should receive the health care they need when they need it.
Republican senators who opposed the bill denounced the expansion as leading to “government health insurance,’’ an argument that President Bush has been rolling out the previous weeks in laying out reasons he will veto the bill.
Others, like Sen. Jim Bunning, R-KY, opined that his state, which does not allow anyone earning more than 200 percent of poverty ($41,300 for a family of four), was subsidizing other states, like California and New York, which had higher thresholds for eligibility. But there’s a reason some states have higher thresholds – it’s far more expensive to live in California than it is to live in Kentucky.
While the Senate voted with over two-thirds of the chamber voting for the SCHIP reauthorization. the House also had a broad bipartisan vote, with 45 Republican votes in favor.
Republicans Congressmen in those states with higher eligibility thresholds (and thus more to gain for their states) generally voted for the program, including 4 of the 6 New York Republican Representatives, and 3 of the 6 New Jersey Republican Representatives. This was not the case for California's delegation. Despite the support from Republican Governor Arnold Schwarzenegger, only 1 of 19 California Republican Representatives--Mary Bono--voted in favor of SCHIP. Another, Wally Herger, did not vote.
THE CONSEQUENCES FOR KIDS
If Bush keeps his promise to veto the SCHIP re-authorization bill, a California HealthCare Foundation analysis by Peter Harbage, found here, shows that California could run out of money to run Healthy Families by mid-November. That means our Healthy Families program may have to disenroll 850,000 children, who would suddenly be unable to go to the doctor, the dentist, fill prescriptions and other medical needs.
Bush has urged Congress to extend the program at current funding levels, but that would also be a detriment to California . Our Healthy Families program has been partially running on money that was saved up from previous years when fewer children were enrolled. With more children enrolled now, California would not have enough money to keep the currently enrolled children covered, let alone accept new children into the program. According to the CHCF analyses, that would mean California would run out of money by summer 2008, leaving all children without coverage, or dis-enrolling about 250,000 immediately in October to keep the program going for slightly longer period.
WHAT’S NEXT
The children’s coverage reauthorization debate has unfolded this year in tandem with the larger debate about expanded health coverage. In California , and many other states, the expansion of children’s coverage is a first step and an important building block toward a larger coverage expansion for the uninsured.
Seeing this, advocates this year have worked hard and remained unified in advocating for coverage expansions for both children and adults. The work was enough to convince a majority of California ’s congressional delegation to vote in favor of the SCHIP re-authorization. Advocates are encouraged to write THANK YOU notes, to members of Congress, particularly Rep. Mary Bono, who was the only California Republican who crossed party lines to support the measure.
Advocates should also write and follow up with other delegation members, such as and others who voted against the measure, to express their disappointment. Their “no’’ votes have put hundreds of thousands of California children at risk.
Again, to see how the delegation voted, click here. To find your Representative, click here. To find their addresses, click here.
For more information, you can contact Health Access, including Hanh Kim Quach, policy coordinator, at hquach@health-access.org, or Elizabeth Abbott, project director, at eabbott@health-access.org.
The U.S. Senate just voted for SCHIP 67-29 on a concurrence vote--a margin that could override a veto, if the House went along. Boxer and Feinstein voted in the affirmative.
"America's children must also have a healthy start in life. In a new term, we will lead an aggressive effort to enroll millions of poor children who are eligible but not signed up for the government's health insurance programs. We will not allow a lack of attention, or information, to stand between these children and the health care they need. (Applause.)"
It's disappointing SCHIP didn't get a veto proof majority. It's even more disappointing how little California was able to get there, compared to other similar states.
In the SCHIP battle, a few states have been targeted, namely New York, New Jersey, and California, as states that expanded their state child health insurance programs above the norm of twice the poverty level. All three started their programs under Republican Governors (Pataki, Whitman, and Wilson, respectively). And all three have lots of children on the program now, have a high cost-of-living and are thus justified in a higher eligibility level, and recognize that SCHIP reauthorization is a big deal for the state to draw down federal funds--not to mention the benefit of providing health coverage to the children of the state.
So how did we do compared to the other states that are particularly targeted? In comparison, California did poorly in getting our House Representatives to vote for the interests of their state.
Of our 19 California House Republicans, only one--Mary Bono--voted for the measure. (Another did not vote.)
In comparison, New Jersey had 3 out of 6 Republicans in a 13-member delegation vote for SCHIP. New York both had 4 out of 6 House Republicans in a 29-member delegation vote the interest of their state over their President. (To complete the tri-state area, Connecticut also meets the criteria above, and has only one Republican Congressman out of a 5-member delegation, and yes, he voted for SCHIP.)
For whatever reason, our counterparts in the Mid-Atlantic did a much better job in getting their Representatives to represent them, in bringing in federal funds and extending coverage to children. As a result of California's inability to produce the votes, we may have to have hundreds of thousands of children disenrolled from California's Healthy Families program shortly.
One would have hoped that the broad support of Republican Governors--including Governor Schwarzenegger--would have made more of an impact on the Republican Congressional Representatives. New York and New Jersey actually have Democratic Governors now, but they still were able to have some sway with their Representatives. So what's wrong with our delegation?
Here's the full vote list on SCHIP for California Representatives.
Again, of the 53 members of the California delegation, all Democrats voted "Yes" except for Rep. Diane Watson, who voted "Present." All Republican voted "No" except for Rep. Mary Bono, who voted "Yes" and Rep. Wally Herger, who did not vote.
The SCHIP Reauthorization Bill, H.R. 976, passed in a broad bipartisan vote of 265-159, with 1 Representative saying "present" and 9 not voting.
The problem is that the two-thirds vote needed to override a veto is 290 votes. So while the bill has a veto-proof majority in the Senate, and even though SCHIP got more House Republican votes than expected, we are 25 votes shy in the House.
President Bush can veto the bill, as he has promised, and it will stick.
All but 12 Democrats voted for the bill. Of the Republicans, 45 voted for it. From the California Republican delegation, it seems only Rep. Mary Bono saw fit to vote with Governor Schwarzenegger and the interest of California children.
As workers prepare for the open enrollment period in a few months, they'll notice a bigger chunk missing from their paychecks. In 2008, workers will pay about 10.1 percent MORE (that includes premiums and out-of-pocket costs. Ouch) than they have in previous years. The Wall Street Journal today reports on a trend that we've been watching closely, which is the gradual and heavy shift of health care costs from businesses to consumers.
Health premiums, many are aware, have been increasing at a rate two to three times inflation. But the increase has slowed a bit, due to the fact that "employers have been....passing a significant percentage of costs to employees,'' the article says. This creates even bigger costs later, as employees/workers are getting sicker because they're skipping preventative care and their meds.
"They're essentially trading preventative care now for "rescue care'' later, which will lead to unhealthy employee populations, a decrease in employee productivity and ultimately -- higher health-care costs,'' said the expert from Hewitt's Health Management Consulting business.
So even though workers aren't taking up the high-deductible plans, which more blatantly shiftsmore costs onto them, workers are seeing more of a crunch in their pocketbooks through traditional plans -- an average of $3,597 a year, which includes premiums, co-pays, deductibles and co-insurance. That's a lot.
That's why, this year consumer groups adamantly insisted that health costs be "affordable'' for consumers -- meaning the cost of premiums and deductibles and other out-of-pocket costs be no more than 5 percent of a person's annual income -- as was ultimately passed in AB8 (Nunez/Perata), which Gov. Schwarzenegger has threatened to veto.
Whatever happens with AB8, it's why the health reform conversation is so important to have this year. Without it -- this shift would be happening whether consumers had a voice or not.
CONGRESSIONAL VOTE TODAY TO DECIDE DIRECTION OF CHILDREN'S COVERAGE * State Child Health Insurance Program (SCHIP) expires in five days * President Bush has vowed to veto legislation to extend the program * California's Healthy Families may have to disenroll hundreds of thousands of children * Compromise $35 billion bill would cover one-half of remaining uninsured children * ACTION ITEM: Contact your member of Congress today, to support SCHIP expansion
New on the Health Access WeBlog: SCHIP Deal; New Language Access to Care Standards at the Department of Insurance; How Close to a Deal on Health Care? Special Session Gossip.
The U.S. House of Representatives is set to vote TODAY, Tuesday, September 25th, on the extension and expansion of the popular State Child Health Insurance Program. The vote will determine the future of the federal program, and of children's health coverage in general.
California's version of the program, Healthy Families, now covers 850,000 children. With extended federal funding, the program has the potential to meet its promise to cover the rest of California's uninsured children.
Unfortunately, the big vote today could send also signal of the reverse, and force the program to consider disenrolling hundreds of thousands of Californians children.
To avoid this, CALL YOUR CONGRESSIONAL REPRESENTATIVE TODAY, and urge them to support of SCHIP expansion, and to support an override of President Bush. To call the Capitol swtichboard using a toll-free number, call: 1-800-828-0498.
THE PROMISE: COVERING ALL KIDS; THE THREAT: KICKING KIDS OFF COVERAGE
Hundreds of thousands of children enrolled in Healthy Families could be abruptly dropped from health coverage as early as mid-November, unable to see a doctor, go to the hospitals and get medical treatments they need, if Congress does not vote to continue the State Children’s Health Insurance Program today with large margins.
Sen. Sherrod Brown, D-Ohio, spoke eloquently on the Senate Floor about the importance of extending SCHIP on Monday, pointing out that private insurance is prohibitively expensive for many Americans, “These families are uninsured because they have no choice and their children have no choice.’’ Extending the SCHIP program, he said, could give those families necessary health coverage.
BUSH'S VETO THREAT AND IMPACT: Yet President George W. Bush has threatened to veto the proposal, suggesting such an expansion would lead to a federal system of "government-run health care." If there is no extension is granted by the start of the federal fiscal year, federal money will run out for the program by mid-November, according to independent estimates.
Mindful of the deadline, he suggested that Congress extend the program at current funding levels. Because California is using federal dollars saved from earlier years of low enrollment, an extension on current levels would not be enough to even keep the children covered who are currently enrolled, much less accept new enrollment. Such a proposal, as proposed by Rep. Barton, would force California to have to dis-enroll hundreds of thousands of children from the Healthy Families program, according to estimated commissioned by The California HealthCare Foundation. The choice for California would be cruel: either to continue to cover all the children in the program until the money runs out in summer 2007, potentially leaving all the children without coverage; or to immediately disenroll around 250,000 children in October.
VOTES FOR AN OVERRIDE? The Senate has already voted for this extension with a veto-proof 2/3 majority. In order to show President Bush that they can override his veto, the U.S. House of Representatives would need 290 votes in support of the SCHIP reauthorization bill--including all Democrats, and 57 Republicans in Congress.
California has 53 Congressional representatives that could make the difference, especially the Republican ones, who have the choice between loyalty to the President, or representation the best interest of their state and its children.
CONTACT YOUR CONGRESSIONAL REPRESENTATIVE TODAY.Click here for a list of California Congressional offices and contact information, including phone numbers.
BACKGROUND: SCHIP's SUCCESS: The SCHIP program has been largely successfully since it passed 10 years ago with bipartisan support, enrolling 6.6 million children nationwide at a time when private health coverage through employers has been declining. In California, 850,000 children receive benefits from the Healthy Families Program.
STATES SEEK TO EXPAND: Coinciding with efforts to re-authorize SCHIP, many states, including California are looking to expand the number of children who are eligible for SCHIP/Healthy Families. Gov. Arnold Schwarzenegger, in his January health reform proposal, suggested that families earning up to 300 percent of poverty ($61,950 for a family of four), should be able to obtain coverage through this program.
Currently, in California, families earning up to 250 percent of poverty ($51,000 for a family of four) qualify. A few other states have more more generous expansions for families earning 300 or 350 percent of poverty. New York recently sought to expand coverage to 400%, but was rejected by the Bush Administration a few weeks ago.
AN EXTENSION TO MEET THE NEED: Ironically, in the same year that health reform and reducing the number of uninsured has come into national focus, President Bush has taken a stand to do the opposite.
As SCHIP ticks toward its September 30th expiration, the president has declared he would veto legislation that would allow it to continue and expand coverage to about 4 million more children, halving the number of uninsured children. Estimates are that the bill Congress is considering now could help as many as 650,000 additional children in California.
BUSH'S PROPOSALS: Bush favors funding the program at only $5 billion more over the current level over the next five years – rather than the additional $35 billion proposed. Such a proposal would force California to create a waiting list for children wanting to get coverage, and probably disenroll some already on the program.
Additionally, Bush proposes to scale back eligibility – only allowing those who earn 200 percent of poverty ($41,300 for a family of four) or less to qualify. That would reverse gains made in 18 states, including California, who have eligibility limits higher than the 200 percent of poverty threshold. In California, that would mean 190,000 children would lose coverage. Failure to extend and expand the SCHIP program could also endanger California's efforts to pass a health reform and provide near universal coverage this year.
ACTION ITEM: Please call your Representatives and urge them to support the compromise measure allocating an additional $35 billion for children and families over the next five years. To find your representatives, visit www.house.gov.
There's been a spate of articles in the San Francisco Chronicle and the Washington Post about an apparent deal between the Governor and the Legislative leaders. The Governor's press aide is quoted that they are "inches" apart.
Inches? I've always said that the plans were more alike than they were different, and that previous obituaries were way premature. I do think there's a place for agreement. But inches?
It seems there are substantive issues still left to decide. And once those issues are sorted out, there's the details that make the plan work. Rather than inches, I'd say we're miles apart, but with a roapmap on how to make the connection. It's still driving distance: no getting on a plane or a boat, but there's still some travel time.
We were just informed that the Health Interpreter regulations at the Department of Insurance issued under SB 853 were approved by Office of Administrative Law on 9/19/07 and will be effective 10/19/07.
With the Department of Managed Health Care adopting regulations earlier in the year, we now have an appropriate framework to ensure that insurance subscribers have the ability to communicate with a medical provider.
There's more work to do, to ensure that insured patients not proficient in English receive the translated documents and individual interpreter services the law and regulations require. Part of that is increasing the provider pool that comes from communities of color; part of it is using Video Medical Interpretation technology that Health Access has worked on. As always, there's more to do... posted by Anthony Wright | Permalink | 3:05 PM
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Resources!
Just a reminder to look at the home page of the Health Access website as a reference during special session, which features various new documents and resource pages, including:
You'll also notice other good stuff, including archives of the ballot and legislative fights on expanding employer-based coverage, prescription drugs, and other issues. We also have the archive of the state's Health Care Options Project, which re-started this conversation over six years ago, providing studies of ways to expand coverage.
HEALTH CONSUMER BILLS ON THE GOVERNOR'S DESK * Legislature passes a dozen health-related bills of interest to advocates * ACTION ALERT: Submit letters to Governor’s office to support key bills
New on the Health Access WeBlog: SCHIP Deal in Congress; Timely Access to Care Standards Pending at the DMHC; Jon Stewart on HillaryCare and Health Care; President Bush on Kicking Kids Off Coverage; Will the Governor Release Legislative Language? Special Session Gossip.
Even though most of the focus in the 2007 legislative session focused the prospects of major health reform, health advocates dutifully worked on other bills as well.
In addition to AB8 (Nunez/Perata), several other bills on health issues made it to Gov. Arnold Schwarzenegger’s desk. He has until October 12th to sign or veto the legislation.
While Schwarzenegger has announced he will be vetoing AB8 and working with lawmakers to craft a package in an extraordinary session this fall, many consumer advocacy organizations are still writing the Governor to support the foundation that AB8 sets for negotiations.
Read the Health Access fact sheet on AB8 here. See Health Access' full list of bills tracked in 2007 here.
Advocates supporting AB8 and other measures should submit letters to: Gov. Arnold Schwarzenegger State Capitol Building Sacramento , CA 95814 FAX: 916.445.2841
Following is the list of bills that health advocates followed this year and their status:
To the Governor’s desk:
* AB8 (Nunez/Perata): Would make coverage more available and affordable through employer benefits, public programs, and the individual market. Creates a statewide purchasing pool for employers purchase health insurance. Sets a minimum employer contribution for health care. Expands Medi-Cal/Healthy Families for children and parents up to 300% federal poverty level. Brings in federal dollars through Medicaid matching funds and Section 125 tax breaks. Reforms the individual insurance market to restrict pre-existing coverage exclusions and require at least 85 cents of each premium dollar be used for patient care. Would lead to coverage of 95% of Californians. SUPPORT * SB275 (Cedillo): Would prevent patient dumping by requiring hospitals to have a written policy on discharging patients, and requiring hospitals to appropriately plan post-discharge care with patients. Also prevents hospitals from moving patients to locations, other than their residence, without the consent of the patient. SUPPORT * AB423 (Beall): Would expand Knox-Keene to include diagnosis and treatment of mental illnesses. SUPPORT * SB474 (Kuehl): Would clarify that hospitals would continue to get paid the same amount under the federal hospital financing waiver and extends the sunset date to the 2007-08 fiscal year. Would also protect patients who live in Los Angeles and will be impacted by the closure of the Martin Luther King Jr.-Drew Medical Center . SB474 would create a special fund that would pay for services that would have otherwise been provided by King-Drew Medical Center . Los Angeles County would contract with other providers in the area to assure that patients could continue to receive care. SUPPORT * SB472 (Corbett): which would require state Board of Pharmacy to come up with standardized drug labeling for prescription medications. SUPPORT * AB343 (Solorio): Would require the state to disclose names of employers who, rather than providing health coverage, have many of their workers and their families on Medi-Cal and Healthy Families. (Gov. Schwarzenegger vetoed a similar bill – AB1840 (Horton) -- last year.) SUPPORT * AB910 (Karnette): Would ensure that privately-purchased health coverage for children with mental or physical disabilities would not end at a certain age. SUPPORT * AB1113 (Brownley): Would extend and increase eligibility for the Medi-Cal California Working Disabled Program. SUPPORT * AB1324 (De La Torre): Would require health plans to justify to DOI or DMHC why they are rescinding health coverage to enrollees. Health plans may not recover costs of care provided to enrollees unless they can prove consumers purposely deceived them. SUPPORT
A bill to expand children's coverage, AB1 (Laird/Dymally), passed both the Assembly and the Senate, but was held in the Legislature by the author, at the request of the Schwarzenegger Administration. AB1 would allow children in families up to 300% of poverty to enroll in Healthy Families. This is a repeat of the last version of AB772 (Chan), which was vetoed by Gov. Schwarzenegger in 2005. The Governor has stated he wants children's coverage as part of a broader reform package.
Also of note is SB350 (Runner), which makes technical changes to California' s landmark legislation last year, AB774(Chan) to prevent the practice of hospital overcharging. Health Access California, the sponsor of AB774, is neutral after working with the authors and sponsor. Also of interest to some health advocates is AB12 (Beall), which would create the Adult Health Coverage Expansion Program in Santa Clara County, which would be administered by a county or local initiative.
Bills of interest to health advocates that were not sent to the Governor and will be pending for next year include:
* SB840 (Kuehl): Would establish a universal, single-payer health care system in California that would enable all Californians to have available, affordable, and automatic health coverage. This bill passed the full Legislature for the first time in 2006, but was vetoed by Gov. Schwarzenegger. * SB1014 (Kuehl): The financing piece of SB840, which would impose an income tax of 3.78 percent for workers earning less than $200,000 annually. Employers would pay 8.14 percent of payroll toward system. Would impose an additional personal income tax for those earning more than $200,000 to fund SB840's single payer system, in lieu of premiums and cost-sharing. * SB32 (Steinberg): Expands children’s coverage, including the Healthy Families program, to all children in families up to 300% of poverty ($49,800 for a family of 3). Identical to AB1(Laird) * AB2 (Dymally): Would reform and restructure the Managed Risk Medical Insurance Program, for the medically uninsurable, who are denied coverage elsewhere because of “pre-existing conditions.’’ Also restructures the individual insurance market to assure any Californian who wants coverage can get it. This bill has been reintroduced in special session as ABX1-3 . * AB51 (Dymally): Would have created a consumer report card for Medicare Part D plans. * AB52 (Dymally): Would have required the state to operate a 24-hour, toll-free number for patients to register complaints about hospital facilities. * SB606 (Scott): Would have required pharmaceutical companies to disclose clinical trial results for drugs sold in the state. * AB1554 (Jones): Would have regulated insurance premium rates by requiring DMHC/DOI approval before copayments, premiums, coinsurance, deductibles or other out-of-pocket costs could be increased.
The two houses of the U.S. Congress came together on a proposal to extend and re-authorize SCHIP, the State Child Health Insurance Program, called Healthy Families in California.
The compromise attempts to bridge the differences between the House and Senate versions, maintain the bipartisan support, including that of Republican Senators, in the hope of getting a veto-proof majority. The proposal also attempts to address the issues--however specious--raised by President Bush.
That said, the deal in uncertain to give California all the resources it need to continue its gradual increase in children's enrollment... that depends on how the formula works out. Also, the deal does make harder California's efforts to further expand coverage to middle-income children, and to parents.
Yet it is likely, even expected, that Bush will veto. That's why we need the full California delegation--Republicans and Democrats--in support, since the alternative is to start kicking kids off coverage.
Here's the press release from the Congress:
SENATE, HOUSE ANNOUNCE AGREEMENT TO RENEW, IMPROVE CHILDREN’S HEALTH INSURANCE PROGRAM NOW
Bipartisan, bicameral coalition ready to move on full reauthorization of vital program
Washington, D.C. – A bipartisan coalition of Senate and House leaders today announced a bicameral agreement to reauthorize the Children’s Health Insurance Program (CHIP) for an additional five years. CHIP provides health coverage to American children whose parents do not qualify for Medicaid, but can’t afford private insurance. The $35 billion agreement struck by House and Senate negotiators will bring health coverage to approximately ten million children in need – preserving coverage for all 6.6 million children currently covered by CHIP, and reaching millions more low-income, uninsured American children in the next five years.
Below is an outline of the agreement, which is designed to target specifically the lowest-income uninsured American children for outreach and enrollment. The agreement does not call for CHIP coverage for children in families at higher income levels. Instead, it reduces Federal matching funds for future coverage of children at higher income levels, and provides incentives to cover the lowest-income children instead. CHIP coverage of childless adults and parents will be phased out to maintain the program’s focus on kids.
Investing $35 Billion in New Funding for CHIP. The agreement reauthorizes the Children’s Health Insurance Program, investing an additional $35 billion over five years to strengthen CHIP’s financing, increase health insurance coverage for low-income children, and improve the quality of health care children receive.
Lowering the rate of uninsured low-income children. The agreement will provide health coverage to millions of low-income children who are currently uninsured. The bill also ensures that the 6.6 million children who currently participate in CHIP continue to receive health coverage. Pending final Congressional Budget Office estimates, the reduction in the number of uninsured children will approach four million children.
Improving Access to Benefits for Children (Dental Coverage/Mental Health Parity/EPSDT). Under the agreement, quality dental coverage will be provided to all children enrolled in CHIP. The agreement also ensures states will offer mental health services on par with medical and surgical benefits covered under CHIP, and protects medically necessary benefits (EPSDT) for low-income children.
Prioritizing children’s coverage. The agreement makes several modifications as it relates to populations eligible for CHIP.
Pregnant Women: The agreement provides coverage to pregnant women as a new state option as well as preserving the options to cover them through a state waiver or through regulation.
Parents: The agreement prohibits any new waivers to cover parents in the CHIP program. States that have received waivers to cover low-income parents under CHIP will be allowed to transition parents into a separate block grant. The federal match for services to parents covered through CHIP will be reduced.
Childless Adults: The agreement retains the current law prohibition of waivers to allow coverage of childless adults. Currently covered childless adults will transition off CHIP. For states that have received CHIP waivers to cover childless adults, the agreement terminates those waivers after a one-year period, provides temporary Medicaid funding for already-enrolled adults, and allows states to apply for a Medicaid waiver for coverage.
Providing states with incentives to lower the rate of uninsured low income children. Under the financing structure, states will receive state-based allotments that are responsive to state demographic and national spending trends and allow additional up-front funding for states planning improvements. States that face a funding shortfall and meet enrollment goals will receive an adjustment payment to ensure that no child who is eligible for Medicaid or CHIP is denied coverage or placed on a waiting list. The formula also sets in place new overall caps on federal funding to ensure the program’s expenditures do not exceed the amounts authorized. The agreement provides incentives for states to lower the rate uninsured children by enrolling eligible children in CHIP or Medicaid.
Agreement Replaces CMS August 17th Letter to States. The Congress agrees with the President on the importance of covering low-income children have health coverage while taking steps to address crowd-out and prioritize coverage of lower income children. The agreement replaces the flawed CMS August 17th letter to states with a more thoughtful and appropriate approach. In place of the CMS letter, the agreement gives states time and assistance in developing and implementing best practices to address crowd out. The agreement also puts the lowest income children first in line by phasing in a new requirement for coverage of low-income children as a condition of receiving CHIP funding for coverage of children above 300 percent of the poverty level.
Improving Outreach Tools to Simplify and Streamline Enrollment of Eligible Children. The agreement provides $100 million in grants for new outreach activities to states, local governments, schools, community-based organizations, safety-net providers and others.
Improving the Quality of Health Care for Low-Income Children. The agreement establishes a new quality child health initiative to develop and implement quality measures and improve state reporting of quality data.
Improving Access to Private Coverage Options. The agreement expands on current premium assistance options for states. The agreement allows states to offer a premium assistance subsidy for qualified, cost-effective employer-sponsored coverage to children eligible for CHIP and who have access to such coverage. It also changes the federal rules governing employer-sponsored insurance to make it easier for states and employers to offer premium assistance programs.
Legislative language is currently being finalized, and will be available Monday. The House of Representatives will likely vote on legislation implementing this agreement on Tuesday of next week. The Senate will take up the measure shortly thereafter, to deliver a full renewal of the Children’s Health Insurance Program to the President for signature into law before CHIP’s current authorization expires on September 30.
After his well-deserved Emmy, Jon Stewart of The Daily Show has taken brief breaks from their war coverage for some short commentary on health care.
On Wednesday, he spotlighted the coverage of Hillary Clinton's health plan, and the howls of "HilliaryCare," "socialized medicine," and "big government" from the right-wing pundits. He corrected a clip of Newt Gingrich, who suggested to call the plan "Daughter of HillaryCare"; Stewart responded, "Wouldn't that be ChelseaCare?"
He spotlighted CNN's chiron, which really did state, remarkably, "Clinton on Health Care: Why is she trying again?"
On Thursday, Stewart mocked the President's attack of the SCHIP program as a "government-run" program: "Oh my god, there's gonna put communism in our kids' drinking water! And inject them with the gay and load them onto Micheal Moore and float them to Cuba! Wake up America!"
In responding to Bush's statement that he instead wanted "to empower people and their doctors...," Stewart said, "I figured out the disconnect. You see, he thinks the uninsured have doctors."
It would be funny if it wasn't sad. Back to the war.
TIMELY ACCESS TO CARE STANDARDS DEBATED * Tuesday DMHC Hearing Brings Insurer and Provider Opposition to Consumer Protections * Consumer Groups Say Delayed Care is Denied Care; Seek Stronger Regulations * ACTION ALERT: Deadline for Consumer Comments is Friday, September 21st!
New on the Health Access WeBlog: SPECIAL SESSION SPECIAL! What's Next in the Special Session?; Negotiation Next Steps; California and the National Debate; How Many Experience Uninsurance?; Rising Health Care Costs; Governor, Read the Bill!; Lessons from Healthy San Francisco; Assembly Workgroups for the Special Session; More Fallout from the Budget Cuts
The Department of Managed Health Care (DMHC) held another hearing this Tuesday, September 18, 2007 in Sacramento to seek public comment on their second proposed revision to the new regulation governing timely access to care.
This long-delayed regulation is based on AB2179(Cohn) sponsored by Health Access California and passed in 2002. The inability of *insured* patients to get in to see a doctor or specialist is one of the most common complaints that consumer groups get. The lack of ability to get a medical appointment also leads people to unnecessarily go to the emergency room, leading to ER overcrowding and increased medical expenses. The law and regulation are intended to remedy these problems, and protect the value of the coverage for which people are paying.
DMHC wrote these regulations to require that consumers must be able to see a physician within certain prescribed time frames. Some examples specified in the regulation require that consumers see a primary care physician for urgent care within 24 hours, get an appointment for routine care with a primary care physician within 8 business days, or be referred to a specialist for urgent care within 72 hours. DMHC also outlined procedures for measuring performance, tracking compliance, and potential enforcement mechanisms.
INDUSTRY OPPOSITION: Health plans, providers, and their associations spoke against the Department’s regulation as written. They emphatically expressed their clear dislike for any time-elapsed standards. Some in provider community emphasized that this would result in “chaos in the delivery of health care in California ” and would be “very burdensome to administer.” Many medical groups said this regulation would continue to drive doctors to retire or move to other states to practice. Many plan representatives asserted that the implementation of this regulation would be extremely costly and would actually make timely access to care less available. Many providers objected to any tracking or monitoring of whether they actually met even the plan’s own internal standards for timely access and they objected to the imposition of any administrative sanctions or penalties for repeated failure to achieve this minimal performance standard.
There was testimony given that DMHC should drop this regulation entirely, after five years of work, and form a work group of plans, providers, and DMHC staff to formulate alternative standards. Despite the Department’s repeated specific requests, neither plans or providers presented any proposals which included outlines of meaningful alternative standards in place of the Department’s specific time elapsed standards.
CONSUMER RESPONSE: Consumer advocates, including Health Access California, Western Center on Law and Poverty, Health Care Rights Hotline, several mental health advocates, countered these claims at the hearing. They emphasized that this law was passed five years ago and, because of the delay in drafting the regulation, plans and providers had plenty of time to prepare for their implementation.
They argued that the best way to ensure that consumers were afforded timely access to care was to measure how long it took to get a necessary health care appointment. Often the requirement to provide timely access to care uncovers the inadequacy of the provider network, or even so-called “phantom networks” which list more providers as available for appointments than actually are.
Advocates emphasized how the failure to receive timely access to care affects consumers by describing several actual experiences. For example, one patient who had a medical emergency, had to make 19 calls before being able to secure an appointment. Although the plan insisted their network was sufficient, this consumer found many problems. The obstacles she encountered included the listed providers were on vacation, they no longer belonged to the plan, they were no longer taking new patients, they did not have any appointments available for at least 30 days, they had their telephone number disconnected, their voicemail was full, or they did not return phone call messages.
Advocates urged that it was now time to move forward and were generally supportive of the regulation as written. They have asked for some changes, including wanting to close gaps that would have allowed insurers to get out from timely access standards if they declared there was a provider shortage.
The issue was raised again regarding whether it would be acceptable for consumers if they had to forego any entitlement to timely access to care if they required language assistance. This is especially troublesome since the Department finalized their Cultural and Linguistic Access to Care regulation earlier this year, on February 23. This landmark regulation guaranteed low English proficient consumers the right to have health care delivered in a language they understood and written documents provided in multiple languages. Consumer advocates stated unequivocally at the hearing that consumers should not be required to make a “choice” between receiving health care in a language they understood and receiving health care on a timely basis (nor should providers be permitted to make that choice for their patients.) The impact of being forced to make such a decision would be clearly discriminatory.
Action: Consumer advocates are awaiting the Department’s decision whether to make the regulation final as written, to revise the regulation, to invite another round of comments, or to begin the process all over again.
All interested parties should immediately indicate their support of time-elapsed standards by sending comments on Timely Access to Health Care Services (Control No. 2005-0203) by 5:00 pm on Friday, September 21, 2007.
For more information, contact Health Access Project Director Elizabeth Abbott, the author of this report, at 916-497-0923, or eabbott@health-access.org.
"What I'm describing here is a philosophical divide that exists in Washington over the best approach for health care. Democratic leaders in Congress want to put more power in the hands of government by expanding federal health care programs. Their S-CHIP plan is an incremental step toward the goal of government-run health care for every American."
Instead, President Bush is seeking to disenroll children and leave them uninsured.
"Congress must pass a clean, temporary extension of the current S-CHIP program that I can sign by September the 30th. And that's the date when the program expires."
If there's a flat extension, without any increase in funding, California will have to disenroll children in Healthy Families, our SCHIP program. In recent years, we've been using SCHIP funds that we had saved during the earlier years, when we had low enrollments.
If we just got the federal allotment we got last year, it doesn't just mean that Healthy Families has to install a waiting list. It means actively kicking kids off coverage. If this impass lasts the entire year, we are talking of hundreds of thousands of children.
Because of 2/3 vote requirement for taxes in the California legislature, the Republican legislative caucuses have effectively blockaded several efforts to raise the funds for health coverage expansions. George Skelton of the LA Times appropriately puts some spotlight on their position.
The Governor is unwilling to just do the revenues that can be passed by majority vote (all the ones in AB8, which is on his desk: the "fees" on employers and insurers, the worker contributions, and the resulting matching federal funds and tax credits).
Instead, he is insisting that health reform go on the ballot.
Any attempt to go to the ballot will need eyes wide open. According to the Secretary of State's history of initiatives, from Hiram Johnson's days in 1912 to 2002, only 99 of 286 of the ballot measures that made it onto the ballot were approved--about one-third.
Every ballot measure is different, given the proposal, the coalition support, the opposition, the funding, the timing, and the general public mood. Is health reform winnable on the ballot? Depends on what it is.
How many people are uninsured? The answer depends on the question. Typically, the established Census number for California is around 6.5 million. That's what came a few weeks ago
There's also the California Health Interview Survey from UCLA: they have a similar number for those who are uninsured at some point in a given year. The modelers, however, use a different number from that data: 5 million, or the number who are uninsured at any given time.
But how many people experience uninsurance over the course of two years? In fact, it's a much bigger number. As my colleague Hanh indicates, Families USA and the Lewin Group put out a report today, using Census data, that shows that nearly 13 million Californians had a gap in coverage over the past two years.
The highlights: * 40.5% of Non-Elderly Californians Were Uninsured During 2006-2007 * 12,987,000 Californians Were Uninsured At Some Point Over the Past Two Years * Two-Thirds (65%)-8,557,000--Were Uninsured for Six Months or More
This study is unique in that it quantifies the people who experience uninsurance over two years, rather than one year, or at a single point in time. In this way, it shows how our current health system leaves many more people at risk than is commonly assumed--and that there is potentially a bigger base for reform.
This study shows why even people with coverage are concerned it is not going to be there for them when they need it. That's why expanding health coverage is so important: Many of the reforms on the table here in California would reduce these gaps, and provide more security, by expanding group coverage, and reforming the individual market.
Specifically, in the 2006-07 time frame, 13 million Californians are likely to be uninsured at some point in time. This jives with the 6.5 million uninsured at some point annually.
That means 40.5 percent of Californians under 65 find themselves without health coverage at some point during a two-year period. Could be a month. Could be three months. Or, for 8.6 million, it's longer than 6 months, the study finds.
This number has grown since the beginning of the decade, when 11 million were uninsured over a two-year period (or 35 percent of the population).
Why is this happening? Why are the ranks of uninsured growing? Simple.
* Health insurance is more expensive. * Fewer employers are offering coverage. * There's less money for public programs to cover the poor or near-poor.
That's why it's a good thing that we're all still ready *i hope* to keep talking about health care this year. At least 13 million are ready.
So now we are in special session. What's the next step?
When the special session was announced, both the Speaker and the Senate President made the case that the Governor needed to produce language to negotiate about.
As an advocate, it's been frustrating that the Governor's proposal has not evolved, in detail or in policy, from the 10-page concept paper introduced in January. Health Access' preliminary analysis still applies, ten months later. The lack of movement also stops the conversation: a policy change in one area has implications in other areas, that then need to be explored in a new light.
It's also part of negotiations. For years, the Legislature has passed (and Health Access and other consumer groups have supported) reform measures, including an employer mandate, children's coverage, and single-payer, but the Governor said "no." In January, the Governor put forward his proposal, of what he would say "yes" to. It borrowed a lot from the previous proposals, but he combined them together with his own details.
So it was the Legislature's turn. The legislature advanced a single-payer proposal again, not giving up on that framework and keeping the momentum for that alive... but if that was the only thing that they placed on his desk, the Governor would say, with reason, that the legislative leaders were not working in good faith, since he already rejected that proposal.
The legislative leaders also advanced and placed on his desk a comprehensive bill, AB8, that was similar to the Governor's proposal, but made changes that fixed objectionable parts and made improvements, especially on affordability and cost containment. In fact, the major differences between AB8 and the Governor's plan were due not to ideology, but to the practicality of needing to pass a financed bill on a majority-vote basis. (The need for a 2/3 vote to raise revenues--and the resulting need to get recalcitrant Republicans--remains a roadblock for both single-payer and the Governor's plan.)
The Governor says he'll veto AB8. So now it's his turn. The Governor needs to show his language of what he wants, that he thinks will pass. Then we'll see if he and his team listened to the concerns about affordability, about the need for the consumer protections that come with expanding group coverage, rather than relying on the individual market.
The rumour mill has that the Governor will introduce legislative language soon, for the special session. It'll be good to see the details, and if there's been any movement. Then we can have a real--special--discussion.
Carla Marinucci at the San Francisco Chronicle takes a step back to look at the health reform scene, and the importance of California's health reform in the national context.
In the article, I mention how the conversation we've been having here in California is fully ripe, after five years, while the national debate is just getting started. The debate in Washington is very narrow right now: whether to expand or even maintain enrollment in the State Child Health Insurance Program. A program to cover children that was created by the Gingrich Congress and supported by Republican Governors is now being attacked by the President Bush as the path to "socialized medicine."
Our debate in California is significantly broader: the ideas on the table span the ideological spectrum, from tax credits to a single-payer solution, and everything in between. As of last week, the California Legislature has passsed *four* major health expansions in the past five years, through an employer mandate (SB2), an expansion of children's health programs (AB772), the creation of a single-payer system (SB840), and a multi-pronged "shared responsibility" approach (AB8). Health Access California has actively supported each of these proposals, since they reform the health system by expanding *group* coverage--where the risk and cost of health care is shared, and the power of bulk purchasing can ensure value for consumers.
Will the presidential campaign allow us to have the full debate we are having in California? We'll see. It won't be happening under the current White House.
Lots of press last week made a big deal of the fact that health care premiums were inching up 6.1 percent, rather than the usual gazillion percent of years past. Some even gave passing mention to how consumers were paying more out-of-pocket.
Many, rightly, fixate on deductibles. For instance, in 2000, only 1 percent of workers had deductibles higher than $1,000; now 10% of workers have deductibles at that level.
Deductibles are part of the picture, but not the whole thing.
This year, for instance, the survey started tracking separate "hospital'' deductibles that consumers would have to pay, on TOP of their regular deductibles. More than half of plans are now imposing those fees. Some plans have also started imposing separate prescription drug deductibles, but that's not reflected in this year's survey -- yet.
Another interesting finding -- we're getting nickled and dimed to death by co-pays. Just three short years ago (2004), 68% of patients had copays of less than $15; now 45% have copays at that level. Meanwhile, in the same period, the number of people paying between $20-$25 per visit nearly doubled.
As we head into Round two of health reform in California, let's not forget about these pesky out-of-pocket costs. Assembly Speaker Fabian Nunez and Senate Leader Don Perata wisely added -- at the last minute -- language in their AB8 that would limit consumers' out-of-pocket costs. Let's make sure it stays that way.
(And 'Hi.' I've been neglecting this for a bit, but now I'm back on.)
The Assembly Republican Caucus picked the members that are part of their "workgroup" for the health care special session:
Assemblyman Greg Aghazarian, R-Stockton Assemblyman John J. Benoit, R-Palm Desert Assemblyman Sam Blakeslee, R-San Luis Obispo Assemblyman Bill Emmerson, R-Redlands Assemblyman Ted Gaines, R-Roseville Assemblyman Martin Garrick, R-Carlsbad Assemblyman Bob Huff, R-Diamond Bar Assemblyman Alan Nakanishi, R-Lodi Assemblyman Roger Niello, R-Fair Oaks Assemblywoman Audra Strickland, R-Westlake Village Assemblyman Cameron Smyth, R-Santa Clarita
That's a lots folks for a caucus that has yet to put up a vote for a major health reform proposal.
They are blocking any tax revenue to fund health care--even the Governor's hospital fee, which the hospitals now support, which would draw down much-needed federal matching funds to California, and which would go to raising Medi-Cal reimbursement rates--something they say they support.
It seems that's a place they should begin when they start meeting in their workgroup.
Does San Francisco offer lessons for the special session? The article goes into all the ways that San Francisco is advantaged, including a relatively small uninsured population, and an already heavy investment in caring for them through a robust safety-net of clinics and hospitals. In other words, the opposite of California as a whole.
Yet even with this program--which is not coverage and does not offer access to coverage outside of San Francisco, they needed to take a second step--place a minimum spending requirement for employers, to prevent certain employers from abandoning their contribution to their workers' health care. The issue is called "crowd out."
Most employers provide health care, to attract and retain workers, and because it is expected. But if workers would get benefits anyway, why would employers spend the money to provide it? That means some employers would drop or scale back coverage. The issue is that the public program gets more expensive, since it is now covering more folks. It's not an issue if you can get enough money from the employer to actually pay for the care provided to his/her workers.
So when we hear of proposals to "replace" the employer fee in AB8 or the Governor's plan with another revenue source, the main issue is not some attachment to employer-based coverage; it's that you have to raise a lot more money to make up for it. There's also an equity issue, between those employers who provide coverage, and those who don't.
Speaker Nunez announced today the legislative working group on health care issues, to help him in negotiations with the Governor. Here's the list... Assembly health care reform working group:
* Majority Leader Karen Bass (D-Los Angeles) * Assemblymember Hector De La Torre (D-South Gate) * Assemblymember Mervyn Dymally (D-Los Angeles), Chair of Assembly Health Committee * Assemblymember Patty Berg (D-Eureka) * Assemblymember Mark DeSaulnier (D-Martinez) * Assemblymember Ed Hernandez (D-Baldwin Park) * Assemblymember Mary Hayashi (D-Hayward)
It drives me nuts that the Governor's team is allowed to get away with saying that their plan "covers everybody." It is simply not true.
Their own modeling leaves out 800,000 Californians.
More than that, there is another 1,000,000 Californians are not "covered." They are simply required to buy coverage in the individual market. These are folks that are not getting any assistance whatsoever, including from their employer, or from a public program. They are being forced to buy coverage, and will probably can't afford anything--and if they can, it would be a high-deductible plan. That requirement, without any subsidy or even the power of group purchasing--that's not a benefit, that's a burden.
So there's nearly 2 million people who are not provided "coverage" under his plan. AB8 actually covers more--through group coverage. So if the Governor's plan does not provide coverage, he better move away from his own plan, and come up with additional revenues to build on top of AB8.
As to health, Nunez indicated there was not the same deadline, but he did not want to give himself and others too much time. He made the comment that if it was up to him and the Governor, they could have a deal put together in 20 minutes.
The idea for health care that emerges from what both the Speaker and the Governor said is for there to be legislation passed by the legislature but with the financing to be placed on an election ballot for the voters to approve.
Speaker Nunez said “bingo” when a reporter asked him if the idea was to have legislation that would stand on its own, even if the funding mechanism on the ballot did not pass. He also said that AB 8 would be the “baseline” from which negotiations would take place and at one point said he did not want to see too much deviation from it, but at another time said “everything is on the table.”
As I write this at 6:45pm, Speaker Nunez is establishing the 1st Extraordinary Session for the purpose of considering comprehensive health reform.
It's interesting that they are quickly going through the motions of re-electing the Speaker, re-establishing the rules of the Assembly, etc. They are also establishing a 2nd Extraordinary Session on water issues.
It's the Governor's job to call a special session, and the Legislature's to schedule and run the session. Here's the Governor's proclamation:
Special Health Care Session Proclamation PROCLAMATION
by the Governor of the State of California
WHEREAS, an extraordinary occasion has arisen and now exists requiring that the Legislature of the State of California be convened in extraordinary session;
now therefore, I, ARNOLD SCHWARZENEGGER, Governor of the State of California, by virtue of the power and authority vested in me by Section 3(b) Article IV of the Constitution of the State of California, do hereby convene the Legislature of the State of California to meet in extraordinary session at Sacramento, California on the 11th day of September 2007, at a time to be determined, for the following purpose and to legislate upon the following subjects:
1. To consider and act upon legislation to comprehensively reform California’s health care system that relies on shared financing and contributions from individuals, employers, health providers, federal, state and local government, and others. 2. To consider and act upon legislation that will provide for health care coverage for all Californians and access to health insurance without regard to medical history. 3. To consider and act upon legislation to make health care more affordable by: (a) reducing the cost to employers and insured individuals associated with uncompensated health care services delivered to the uninsured and low Medi-Cal reimbursement rates, (b) preventing chronic diseases, and (c) promoting more cost effective health care delivery. 4. To consider and act upon legislation to modify or extend existing programs to provide for a transition to comprehensive health care reform.
IN WITNESS WHEREOF I have hereunto set my hand and caused the Great Seal of the State of California to be affixed this 11th day of September, 2007.
This morning, I presented in front of a group of children's advocates and others who have been active in the outreach and enrollment of children into health coverage--and who had the rug pulled out from them with the recent budget cuts.
I stayed to hear the representative from the Department of Health Services listen to their concerns, and while people recognized that he was just the messenger, they had strong words to take back to the Governor.
The anger and disappointment was palpable. They challenged the Governor's sincerity and his commitment to both children's coverage and overall health reform. Even with the budget stalemate and the pressure from Senate Republicans to make cuts, how could he make cuts to enrolling children in coverage?
It was worse that I imagined. I knew that several counties and community groups had to lay off people. I knew that several projects had just started up, coalitions builts, relationships made, and they were now being disbanded. I knew that advertisments and leaflets had been published to offer health coverage, and not those 800 numbers will go unanswered. I knew (personally) that these enrollment efforts had been zeroed out once before during the budget crisis, and how the second time was unexpected and will cause many folks to give up all together.
But I didn't know that as the counties and community organizations try to get reimbursed for past work, they are being stuck with the bill, for the two months since the beginning of the fiscal year of July 1st. The Governor didn't even leave a little funds to meet existing obligations.
These cuts don't make the task for health care reform any easier. In a special session, the Governor has a lot of pressure to produce something this year... the only thing so far we have to show for the year of health reform is a bunch of budget cuts to health care. posted by Anthony Wright | Permalink | 4:51 PM
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Inside baseball...
It's official. Around 3:30pm, the Governor announced he would call a special session on health care. We're in extra innings. Or maybe the right analogy is a double header? Maybe a rain delay, recognizing the budget stalemate as the factor?
AB8 still is making its way to the Governor's desk. The Governor says he intends to veto it, but as we've posted below, his stated reasons don't actually jibe with the actual bill, or his own proposal.
LEGISLATURE PASSES GROUNDBREAKING HEALTH CARE REFORM * AB8 (Nunez/Perata) passes on largely party-line votes in both houses * Governor vows to veto, urges lawmakers to “keep working’’ in special session
New on the Health Access WeBlog: Fact Checking the AB8 Debate; Truth Squad on the Governor's Veto Statement; SCHIP Updates; Snake-Bite in a Gurney; Hospital Disclosure
The California Senate and Assembly passed historic health care reform legislation Monday. If enacted, AB8 (Nunez/Perata), which would mark the most significant health care expansion since the passage of Medicare and Medicaid in the 1960s. For the fourth time in five years, the California legislature has distinguished itself from those of most other states by passing major health reform.
Yet even before the debate on AB8 (Nunez/Perata) was finished in the Assembly, however, Gov. Arnold Schwarzenegger announced -- though not unexpectedly -- that he would veto the bill and call the Legislature back to work in a “special session’’ to “keep working until we achieve the kind of historic solution that all of us and the people of California want.’’
Speaker Nunez referred to the Governor's statement in the Assembly bill, disputing the Governor's characterization of . "I need to ask the Administration to read the bill....Folks need to read the bill." For the text of the Governor's statement, and a fact check, visit the Health Access WeBlog, at: http://www.health-access.org/blogger.html
Sen. Don Perata, in his speech presenting AB8 on the Senate Floor, criticized the lack of specificity in the Governor’s health plan, which has remained the same – a 10-page concept paper -- since January.
As part of a special session, Perata insisted that the Governor provide actual legislative language. "We would continue where we left off, not that we would necessarily begin anew... We also recognize that incumbent upon the Governor would be for him to provide us with his legislation... We have been arguing with specific goals and specific legislation with written language, while the Governor have been dealing mainly in concepts. The special session will end the conceptual portion of the debate, and we’ll have real words and real pages to look at. We want to acknowledge that we’ll continue to work with him. While the Governor is within his right...to veto this bill... no one should see this as a failure, but it is really an opportunity for us to dispatch the obligation we have as legislators,’’ Perata said. "We are trying to recapture the seven weeks what we lost" during the budget stalemate."
Perata stated that the bill was worthy of support without additional chances, stating the the bill was "the best work product available at this time, and without question, this would be the best step forward, and the finest state health care reform package anywhere in the Union."
AB8 OVERVIEW
AB8 would provide coverage to about 3.4 million Californians who currently do not have health insurance – over two-thirds of the uninsured.
Speaker Fabian Nunez said that while AB8 did not yet cover everyone, as SB840 (Kuehl) the universal single-payer bill would have, it provided real help to more than 3 million Californians and could be passed this year.
Specifically, AB8 includes:
* The biggest public program coverage expansion since the creation of Medicare and Medicaid 40 years ago. The bill expands Medi-Cal and Healthy Families to include children and parents up to 300%FPL, which is around $60,000 for a family of four, and streamlines the programs so that are easier to get on and stay on.
* The establishment of a minimum employer contribution for health care, of the similar import to the creation of a minimum wage 70 years ago. Providing more security the majority of Californians who get employer-based coverage but who are concerned about losing it, the bill sets a standard for a minimum employer contribution to spend 7.5% of payroll on health benefits, either by paying into the purchasing pool or by expending the funds on health insurance or other health benefits. * This statewide purchasing pool would create a new affordable option for employers to cover their workers, initially for employees and dependents of employers that choose to use the purchasing pool. Employers could use the pool to cover their entire workforce, or at least their part-timers. The pool would offer affordable coverage, including an assurance that workers under 300%FPL would get coverage at less than 5% of their income.
* New oversight over the insurance industry would especially help individuals and small businesses who don't have the market power of large group purchasers of coverage. The bill has: * Reform of the individual insurance market so that coverage is available to anyone who wishes to purchases, by limiting insurers ability to deny people based on “pre-existing conditions,” and providing better funding for coverage for those that are denied, through an assessment on insurers. * A requirement that premium dollars go to patient care, and a 15% limit on the percentage of premium dollars that go to administration, marketing, and profit. * Expanded small group insurance reforms, making coverage more accessible and affordable for employers of 2-100 workers.
* A better and more fairly financed health system would be bolstered through shared responsibility from six different funding streams, including required employer and worker contributions, reinvested state savings for public program expansion, an assessment on insurers, and two strategies for brining in California's fair share from the federal government, to: * Bring in over a billion in new federal matching funds to California ’s health system, by getting matching Medi-Cal funds for these expansions of public programs and employer contributions. * Offer workers new tax savings, by providing the ability to pay premiums, or share-of-premiums, with pre-tax dollars through Section 125 plans, for a savings of 15-40%.
* Several cost containment strategies, which, working together, can credibly slow the rate of growth in health costs. The coverage expansions and fair financing provisions could help in reducing the "hidden tax" that results from not having all employer provide coverage to their workers, and for having the uninsured go without cost-saving preventative care. Other stategies include: * Preventing Californians from getting sicker by helping patients to affordably control chronic diseases such as asthma and diabetes. * Requiring public reporting on health care costs, and the quality of services, which would enable health purchasers and consumers to make wiser decisions about their care and the best way to spend their money. * Requiring the adoption of health information technology, which could help avoid duplication and costly errors. * Bulk purchasing of prescription drugs, which would enable the state to use its leverage to drive down prices. * Helping foster the creation of a statewide public insurer from county efforts, allowing this low-overhead, not-for-profit agency to compete for business.
SUPPORT AND OPPOSITION
Sen. Sam Aanestad, R-Grass Valley , started the debate by mistakenly stating that there was no organizations in full support of AB8. While that may have been true in earlier hearings, many groups came on in strong support after amendments were taking adding cost containment and key affordability protections for consumers. As a result, supporters included consumer groups like Health Access California, CALPIRG, and Consumers Union, grassroots groups like ACORN, children's and senior groups like AARP, the Congress of California Seniors, and the 100% Campaign, and unions including the California Labor Federation, SEIU, AFSCME, CTA and others. Several of these groups appeared with Speaker Nunez and Senate President Perata at a press conference Monday morning.
Aanestad did quote one opponent, the California Nurses Association. The CNA, whose nurses were in town for a conference, had hundreds of red-shirted nurses in the hallway chanting slogans against AB8, and in support of a single-payer plan. They, and other organizations focused on SB840(Kuehl), called AB8 a "sell-out bill" and a "bad healthcare deal." They shared opposition to AB8 with much of the insurance industry, including Blue Cross of California, which has also been running full-page ads against AB8. Other organizational opponents of AB8 include some business groups such as the Chamber of Commerce.
Aanestad and other Republican legislators attempted to disaparage AB8 by comparing it with the Massachusetts plan, pointing out that Governor Romney in "running from it." While AB8 certainly shares certain features with the Massachusetts plan, one missing provision is glaringly obvious: the absence of any mandate to buy coveage in the individual market. Even for group coverage, AB8 does not require anyone to have coverage if they can't afford it. Affordability is explicitly defined in the bill – unlike in Massachusetts . No worker would have to take up coverage if their health care costs – premiums and out-of-pocket costs --would exceed 5 percent of a person’s wages.
Assembly Republican Leader Mike Villines, whose daughter has a “pre-existing condition’’ that would make her uninsurable, complained that AB8 would not fix that problem. In fact, AB8 attempts to provide assistance to his daughter. AB8 limits insurers ability to deny because of their health status, developing a standardized questionaire to prevent insurers from rejecting more than 5% of the market. Otherwise, It requires health plans to write a policy for anyone that applies – called “guaranteed issue." Those still denied coverage would be eligible for subsidized coverage, with more expansive benefits that currently provided in the current high-risk pool, that would be better funded by an assessment on insurers.
Senators speaking in the debate on both sides included Senate President Pro Tem Perata, and Senators Aanestad, Runner, Cox, Kuehl, Machado, and Steinberg. Members of the Assembly include Speaker Nunez, and Assemblymembers Dymally, Huff, Davis , DeVore, Berg, Gaines, Hernandez, Nakanishi, Karnette, Swanson, Garcia, Niello, Mullin, Adams, Arambula, Emerson, De La Torre, Keene , and Villines.
LEGISLATIVE DEBATE AND OPPONENTS
In speaking against AB8, many Republicans, again, brought up the spectre of health care rationing – an argument that is typically paraded during SB840 single-payer debates. AB8 (and SB840) assure that more people have access to care. Whether critics choose to admit it, health care rationing occurs now based on ability to pay, stated responding Democratic legislators.
Opposing legislators also charged that the employer mandate amounted to a “tax’’ on businesses that would drive small employers out of businesses and, according to Assemblyman Rick Keene, cause “one million’’ Californians to be without a job. A recent study, however, by the UC Berkeley Labor Center showed the bill to have minimal, if not positive impact on jobs. Additionally, as Republican Assemblyman Mike Duvall admitted – many businesses that provide coverage spend far more on health coverage. Duvall spends 12.8 percent – about the same as experts have estimated. Sen. Runner admitted that some business people have suggested that, "well, 7.5%, I actually pay more than that, that's not such a bad deal," and having to convince them that "once the door opens, it is 10, 15, 18%."
Senator Cox downplayed the issue, arguing the many of the uninsured don't want coverage, are undocumented, or are already eligible for public programs but don't enroll.
Assemblyman Roger Niello and Sen. Runner also pointed out that the uncertainty surrounding the reauthorization of the State Children’s Health Insurance Program (SCHIP) – called Healthy Families in California – could also create holes in the plan as AB8 seeks to expand Healthy Families eligibility while President George Bush is attempting to restrict eligibility.
Assemblyman DeVore argued that health care is *not* a right, which he argued would mean every Californian had an "infinite draw on the state Treasury," crowding out all other priorities.
Sen. Sheila Kuehl was one of the two Demoocratic lawmakers who voted against AB8 in the Senate. Kuehl, who has championed and authored single-payer health care reform in SB840 for the past five years, said "our failing health care system has often been compared to the Titanic, and I have said in the past that attempts at reform are only attempts to rearrange the deck chairs. Well, AB8, I admit, is trying to turn the boat... but the Titanic should have faced the iceberg head on. Had it done so, it would have survived, at least long enough to save more of the passengers..." as she then launched into a critique of insurance industry practices.
“I see a number of real flaws in this much-improved bill. I continue to believe that the movement that is building for single-payer will continue to build in 2008, 2009, and 2010, and then, with a new Governor, a perhaps a chance to get a signature for the best solution..., said Kuehl. "I praise those who have been working on [AB8], they are trying..." she said of her Democratic colleagues who would vote for AB8, "I understand... we need to have a Democratic plan this year... I understand your vote, but I would like to ask you to stay with me on SB840, next year... it is not going down to the Governor for a veto, we are continuing to use it as a kind of flag, as an organizing tool, until the day we understand that facing the iceberg head on is the only way we are going to save everybody on the ship."
Sen. Lou Correa, D-Anaheim, was the other Democratic lawmaker to vote against AB8 in the Senate, where the bill passed on a 22-17 vote. Correa is the only Democrat who has opposed both major health reform measures this year – AB8 and SB840 (Kuehl).
On the Assembly side, the vote was a completely party-line vote, 46-31, with only Democrat Loni Hancock of Berkeley not voting.
DEMOCRATIC LAWMAKERS DEFEND AB8
Many lawmakers, however, hailed AB8 as a crucial step in fixing the health care system.
“If some reforms were implemented, we could start to stabilize the system,’’ said Sen. Denise Ducheny, of San Diego . “It doesn’t cover everybody, but if we get more and more folks in, and many businesses are paying more than 7.5 percent [of payroll], maybe we can get more people covered.’’
Senator Steinberg also spoke in favor, as a supporter of single-payer: "Let's be honest here, it's the only majority-vote option available to move forward the issue of comprehensive health coverage for uninsured Californians... If you believe that it actually costs money to provide coverage for millions of people who currently don't have insurance, then together we must find a way to provide the subsidies necessary to make sure everyone has preventative health care." He hinted at the need to go to the ballot for broader funding.
Assemblyman Dymally also mentioned the obstacle of the 2/3 vote to pass a single-payer system or even the Governor's plan, and "this is the only ballgame before us today." He talked about the 10 town halls he visited, and the strong support he saw for AB8, and for the "historic opportunity" he saw in his years. Assemblyman Mike Davis from Los Angeles said he was moved by his constituents, who spoke to him at a Town Hall meeting. “I know this is an important …in South Los Angeles and they [constituents] understand the impact, of corporations… making multimillions and not paying one red cent for people. They deserve to be accountable.’’
Assemblywomen Berg argued that "this would not impede the drive for single-payer" while providing immediate assistance. Assemblyman Hernandez argued that this "would move the ball forward." He countered that small businesses would want such remark, because today they are "locked out of the market." Assemblywoman Karnette said in all her travels, in all the diversity of her district, "everyone cares about health care. They want something done." Assemblyman Swanson talked about his days working in Congress, and seeing debate but no action. "We must move this forward."
Assemblyman Arambula agreed. “Without good health, it’s hard to enjoy anything else in life. AB8 meets general principles of prevention and early intervention’’ that are the precursors to being healthy, he said.
Assemblyman De La Torre described the problem of a large rate of uninsurance, rising health costs, and closing emergency rooms, and slammed "half-measures" that are often discussed--"Let's look at the tried and true Washington DC policies of tax breaks...that doesn't get you where you need to be. We need to get more people covered, we need to protect the people who already have coverage, and we need to strengthen a system that is on the ropes."
Many lawmakers, including Assembly Speaker Fabian Nunez, said AB8 was California ’s opportunity to provide a model for the federal government to implement health care reform. “We have a broken health care system in California and we must do something to fix it now….This health care package will deliver what the federal government has failed to do: to provide all Americans with affordable health care coverage,’’ Nunez said.
RECOGNIZED NEED TO GET SOMETHING DONE
In spite of the rhetorical disagreements in both chambers, most lawmakers seemed resolved to get some legislation passed this year in special session. As early as Tuesday, Schwarzenegger could veto AB8 and call a special session, which lawmakers agree is a necessary step.
House leaders said AB8 should be the basis for negotiations with the governor. Republicans said they wanted a second look at some of the ideas they had introduced, such as Health Savings Accounts, private clinic expansions and tax breaks to encourage reform.
Assemblywoman Bonnie Garcia, while voting “no’’ on AB8, said health care reform should transcend party lines. “You don’t go into the Emergency Room with a broken Democrat leg or a broken Republican nose. It’s up to all of us to sit down and have a dialog,’’ she said.
Perata said lawmakers are in a unique position, in that they have health insurance – unlike 18 percent of Californians who live day to day, afraid to see a doctor or get sick. “Everybody here’s got health insurance paid for by the taxpayers of this state. This, for us, is a theoretical debate. We are not hurting at all. We are benefiting because of the largesse of our constituents. Let's not be too high and mighty, that if we just did this, this would fix the system. We are in a very luxirious position. Forty of us in this state have had the honor bestowed by our constituents to represent them today. This is about the common good and the commonwealth. It’s not ideology. Not party."
Speaker Nunez highlighted both the need for health care reform, and also indicated that California can take the lead again on a major issue, like it did last year with global warming. "I believe that today is a historic day for California , to put itself on the map once again, and send a loud and clear message to Washington , DC , that the inaction on the part of the federal government to deliver on health care reform is landing on the shoulders of California ."
For more information, contact Hanh Kim Quach, the author of this report, at hquach@health-access.org.
Just took a gander at the Health Affairs blog, which is chock full of reports and analyses on the SCHIP debate in Washington, DC.
While we debate historic expansions at the state level, we are facing the possibility of a remarkable contraction at the federal level. If SCHIP is not reauthorized, or even reauthorized at current levels, the state's Healthy Families program will at some point in the near future stop enrolling children (and create waiting lists), or start kicking them off. It's not a pretty picture.
President George W. Bush want to cutback on SCHIP and Healthy Families, because he sees such programs as leading toward a system of "government-run health care." As if that's a bad thing. Or a relevant thing, given the needs of children to have health coverage.
What does this mean for state health reform? * Bush's directives are a direct attack at California and health reform here, and could reduce the lucrative 2-to-1 reimbursements our state would get from SCHIP, making health reform harder to finance. * In a perverse way, the efforts to restrict SCHIP makes the need for health reform even greater. If children are going to lose SCHIP/Healthy Families coverage, then we need to ensure children get coverage through Medicaid, which is an entitlement program, and for which the Bush Administration hass less ablity to deny funds. While we wouldn't get a 2-1 return, California would still get needed federal matching funds--but only if reform is in place. posted by Anthony Wright | Permalink | 11:44 PM
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Assembly passes the bill. On to the Governor!
After an extensive debate, the Assembly passed the bill 45-31, a party line vote.
“First and foremost, AB 8 does not cover everyone. Any reform that leaves millions without health insurance and fails to address our dangerously overcrowded emergency rooms simply maintains a broken system. I have said from the beginning of this debate that coverage for all Californians is critical to reducing health care costs for everyone.
The Governor's plan does not cover everyone. * By his own modeling by MIT Professor Gruber, his plan leaves out over 800,000 of the 4.9 million uninsured at any given time. * In addition, while his plan does extend public program coverage to some, it simply requires over a million people to go get coverage in the individual market, without any assistance from employers or public programs. Hundreds of thousands of people will likely not abide by the mandate--or be in a high-deductible plan that really doesn't "cover" them.
If you exclude those people who are forced to buy an unaffordable product without any assistance from group coverage, AB8 would actually provide more coverage than the Governor's plan.
“AB 8 does not protect consumers because insurers would still be allowed to deny coverage, leaving Californians vulnerable to loss or denial of coverage when they need it most.
AB8 limits the insurers ability to deny coverage, and provides subsidized coverage to those who are denied, so they are not left without coverage.
“I also believe that AB 8 is financially unsustainable. I have always said that I would not sign a health care bill that puts the vast majority of the financial burden for reform on any one segment of our economy. AB 8 unfortunately does that by requiring businesses to pay at least 7.5 percent of their payroll into a state fund or on health care services for employees.
AB8 has six different funding streams, with not a single one forming a majority. Based off the Gruber modeling, the employer contributions would be less than half of the total funding.
AB8 is a majority vote bill that can get to the Governor's desk, and so does not have some proposed funding sources, including the hospital tax. However, it does include: * a minimum employer contribution; * required worker contributions; * reinvested state savings; * new federal Medicaid matching dollars, * new use of Section 125 federal and state tax breaks, and * an assessment on insurers.
The Assembly is still debating AB8, and the Governor has already sent his de facto veto message.
The real news is that he has announced his intention to call a special session. Here's the statement, from his website.
Gov. Schwarzenegger Issues Statement Regarding Health Care Legislation
Gov. Arnold Schwarzenegger today issued the following statement regarding Assembly Bill 8, by Assembly Speaker Fabian Núñez and Senate President Pro Tem Don Perata.
“I applaud all the hard work that has gone into efforts to reform California’s health care system, but I cannot sign AB 8 because it would only put more pressure on an already broken health care system.
“First and foremost, AB 8 does not cover everyone. Any reform that leaves millions without health insurance and fails to address our dangerously overcrowded emergency rooms simply maintains a broken system. I have said from the beginning of this debate that coverage for all Californians is critical to reducing health care costs for everyone.
“AB 8 does not protect consumers because insurers would still be allowed to deny coverage, leaving Californians vulnerable to loss or denial of coverage when they need it most.
“I also believe that AB 8 is financially unsustainable. I have always said that I would not sign a health care bill that puts the vast majority of the financial burden for reform on any one segment of our economy. AB 8 unfortunately does that by requiring businesses to pay at least 7.5 percent of their payroll into a state fund or on health care services for employees.
“I believe we can find agreement on a financially sustainable reform plan that shares responsibility, covers all Californians and keeps our emergency rooms open and operating. The historic agreement reached this past week on the use of hospital contributions for coverage demonstrates that a more balanced approach is achievable.
“We have made tremendous progress on this issue during the past session and have found considerable common ground.
“That is why I intend to call a special session of the Legislature so that we can finish the job of truly reforming our health care system. I know that legislative leaders are willing to get the job done.
“We must keep working until we achieve the kind of historic solution that all of us and the people of California want.”
The state Senate just concluded debate on AB8, which passed 22-17.
(Aside: All Republicans and Sens. Lou Correa, D-Anaheim, and Sheila Kuehl, D-Santa Monica voted against the bill. Correa is the only Democratic lawmaker to oppose any health reform measures this year.)
The bill now heads to the Assembly, where I'm sure all 80 lawmakers will want to get up and speak. Lest they planned to crib from Senators, I wanted to set the record straight on some of the erroneous statements made by their colleagues in the red-wing of the Capitol.
Myth: "I cannot remember a bill -- either minor or major -- that comes before the Legislature without any organization in complete support,'' (Sen. Sam Aanestad, R-Grass Valley)
Fact: Last week, AB8 underwent substantial amendments that dealt with controlling the rapidly increasing health care costs, and affordability of health coverage for consumers. After amendments on both those issues surfaced, a number of strong consumer voices -- such as Consumers' Union, Health Access, CalPIRG, AARP, Congress of California Seniors, Service Employees International Union, California Labor Federation, AAFSME and ACORN and other groups moved to support the bill.
Myth: "This plan does nothing to contain costs.'' (Aanestad). Sen. Dave Cox, R-Fair Oaks, also alluded to this.
Fact: Amendments added to the bill last Wednesday directly address the issue of cost containment -- something that the It's OUR Healthcare coalition has been asking for all year. We recognize that without without controlling costs, any health reform efforts would collapse under the weight of increasing health care expenses. Cost containment provisions include:
Preventing Californians from getting sicker by helping patients to affordably control chronic diseases. Asthma, diabetes and heart disease are among the biggest cost drivers in health care. Preventing and maintaining these diseases keep patients from getting sicker, and costing more money to treat. This means reducing co-pays and cost-sharing for doctor’s visits, lab tests and medications. High cost-sharing deters patients from seeking the necessary treatment and care for their diseases, causing their conditions to worsen.
Requiring public reporting on health care costs, and the quality of services. By publicly reporting how well – or poorly – doctors, hospitals and other providers perform health care procedures, providers would be driven to improve quality, thereby saving lives and saving health system dollars. Better information on quality and cost can allow purchasers and consumers effectively purchase care that gives them value for each dollar they spend.
Requiring the adoption of health information technology. Electronic records could help reduce costly errors due to poor handwriting, unclear instructions and other human errors. Technology could also help cut down on administrative costs.
Reining in prescription drug costs. Prescription drug costs climbed an average three times higher than the rate of inflation from 1994 to 2006. AB8 allows the state to combine with other public entities and trust funds to create a purchasing program for prescription drugs, using the power of a larger group to help leverage lower prices for prescription drugs.
Creating a public insurer that would compete for business with private insurers to help drive down costs. The public insurer, built on the foundations of California’s existing local initiatives, county-organized health systems, public hospitals and community clinics, would give Californians the option to obtain coverage from a publicly owned entity, such as a municipal utility.
Myth: Sen. Aanestad, in his speech on the Senate floor opposing AB8, also said the bill was "modeled on the Massachusetts plan.''
Fact: While AB8 certainly share certain features with the Massachusetts plan, one missing provision is glaringly obvious: the absence of an individual mandate. AB8 does not require anyone to have coverage if they can't afford it. Here's how it would work: workers would be required to take up health coverage IF their employer pays for it and IF -- BIG IF, HERE -- the cost of health care (that includes premiums and out-of-pockets costs) does NOT exceed five percent of a worker's wages. That means a worker earning $41,000 a year would not have to pay more than $2,050 in premiums, co-pays, co-insurance and deductibles.
Assembly Speaker Fabian Nunez and Senate President Don Perata announced at a news conference today that they planned to take up the newly amended AB8 -- which Health Access supports -- on both floors today.
Stay tuned for a long session. My colleague Anthony posted details of the new amendments on Friday and attempts to dispel some of the misinformation that is floating around out there about the new AB8. ..
By a poll of the board, Health Access California, the statewide health care consumer advocacy coalition, is in strong support of AB8(Nunez/Perata).
Passage of AB8 would be historic, it's hard to imagine the appropriate analogy. * It would be the biggest expansion of public health coverage, since the creation of Medicare and Medicaid 40 years ago. * Setting a minimum level of employer contribution to health care is as big a deal as the first time the country set a minimum wage. * The new oversight on insurers are among the several provisions that, by themselves, would be the biggest reform in health care in any other year, and yet this year get little attention.
Very few bills have the promise to dramatically improve the lives of millions of Californians; AB8 would extend coverage to millions of Californians, and make coverage more available and accessible for millions more who have coverage, but are concerned that it's not going to be there when they need it.
It deserves to be passed, and is worthy of the Governor's signature.
For some, including a handful that are considering opposing the bill, there has been some mis-information circulating: * Some folks didn't realize that the affordability amendments were in fact included, but they are official as of Friday. * Some think the bill includes a mandate to buy in the individual market--which there is not. * Some think the insurance companies are in support--when in fact they are opposed, with Blue Cross running full-page ads against the bill. * Some are concerned about potential last-minute changes to AB8--but the deadline is now past to make any changes. (If they go into special session, they'll have to start with a new bill number--even if they use the language of AB8 as the basis for further negotiation with the Governor.)
The bill in print is what to consider, against the unacceptable status quo. And there's a lot to recommend it: it would make coverage more available, affordable, and automatic for the vast number of Californians. It would dramatically expand public program and group coverage for millions of uninsured Californians.
If signed, it would be major advance, on par with the passage of Medicare and Medicaid 40 years ago. It's not perfect, nor accomplish all the reforms that are needed; but passing and enacting the bill would create momentum for additional efforts. This isn't the first year of the health reform debate, and it won't be the last, regardless of what happens this year. posted by Anthony Wright | Permalink | 10:50 PM
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Health plans boring? Really?
Saturday, September 08, 2007
My erstwhile Sacramento friend Megan at From The Archives usually blogs on boys, bureaucracy, and water policy, but she's entered the world of health reform, with her two recent posts (here and here).
She opines that health policy differences center on folks having a different "theory of the individual." One of her main points, given her theory of individuals, namely herself: the notion that people should go and have to develop expertise to make choices about health care is not just unreasonable, "it's BORING". At some point, don't we want to be part of a large group to help us make these decisions, rather than have that burden placed on us?
She gets "best thing to have read today" linkage from both the libertarians at Marginal Revolution and the progressives at Ezra Klein, so the resulting discussion is interesting. posted by Anthony Wright | Permalink | 11:25 PM
That's a different type of hospital infection than what we have here in California, but it's a good reminder: hospital infections not only impact the patient, but they also are significant contributor to health costs.
My colleagues at Consumers Union, as well as others like the Pacific Business Group on Health, are particularly excited about the new section of AB8(Nunez) to facilitate the transparency of health care costs and quality, such as hospital infection rates.
Performance information is an essential foundation for quality improvement and cost containment. What gets measured and publicly reported gets improved. While there is some voluntary reporting of health care quality and costs, the data are inconsistent, incomplete, hard to compare, and often kept secret.
The ability of a single state entity to collect this data, and provide reliable, consistent, and comparable reports, would do wonders, for both improving the quality and addressing the cost of health care. posted by Anthony Wright | Permalink | 11:02 PM
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The lay of the land... and affordability amendments!
HEALTH ACCESS UPDATE Friday, September 7th, 2007
HEALTH REFORM HEATS UP IN FINAL DAYS OF LEGISLATURE * AB8 (Nunez/Perata) Amended with Additional Affordability & Cost Containment Measures * As Deadline Approaches, Options Include Special Session, Ballot Initiative
New on the Health Access WeBlog: More on Health Reform Negotiations; Blue Cross Opposition; Health Wonk Review; Supreme Sacrifice; Cartoons; Tony Snow’s 401K; Health Wonk Review; Hospital Billing; New Endowment Ads; New Census Data Released; Policy vs. Politics; Governor’s Budget Cut Impacts;
With a legislative deadline looming in the next week, negotiations are reportedly still continuing on major health reform this year.
Legislative leaders have continued to amend AB8(Nunez/Perata) in the last two days, including making changes supported by consumer and health advocates on affordability and cost containment. There are reported to be talks between the legislative leaders and the Governor, who offered his own concepts in the beginning of the year, but no word has been given on where those negotiations are.
The legislative session is officially scheduled to end on September 15th, although there has been talk of ending earlier, on September 11th, in deference to the Jewish holidays. Given the shortness of time, two other options have emerged regarding the process of passing health reform. * Press reports have indicated a willingness by legislative leaders to go into special session, this year. This could be concurrent with the ongoing legislative session, or be called anytime in the fall. * There has also been consideration to placing some or all of the health reforms in a ballot measure next year, one which would be supported by the Governor and legislative leadership. An initiative, while risky, has some appeal to the policymakers because of the ability to raise revenues to fund coverage expansions, especially given the prohibitive bar of raising taxes in the legislature because of the 2/3 vote requirement and Republican legislative opposition. Placing a ballot measure on the February 2008 ballot would require 2/3 vote of the legislature; the other option would be to submit signatures to qualify for the November 2008 ballot.
THE LEGISLATION
AB8(Nunez/Perata) is the main vehicle for the Legislative leadership. It seeks to make health coverage more available, affordable, and administratively simple in each of the three ways that consumer now get coverage: through employers, public programs, and the individual market.
Also in the legislative consideration is SB840 (Kuehl), to create a statewide single-payer, universal health care system, which is pending in the Assembly Appropriations Committee. Senator Kuehl intends to move the bill next year, so that it may continue to be the focus of organizing and education efforts by health and consumer advocates.
The framework of AB8(Nunez) bill would:
· Create a statewide purchasing pool initially for employees and dependents of employers that choose to use the purchasing pool. A new, affordable option for employers to cover their entire workforce, the purchasing pool would cover an estimated three to four million people. · Establish a standard for a minimum employer contribution to spend 7.5% of payroll on health benefits, either by paying into the purchasing pool or by expending the funds on health insurance or other health benefits. · Expand Medi-Cal and Healthy Families to expand coverage for children and parents up to 300%FPL, which is around $60,000 for a family of four. · Reform the individual insurance market so that coverage is available to anyone who wishes to purchases, by limiting insurers ability to deny people based on “pre-existing conditions,” and providing better funding for coverage for those that are denied, through an assessment on insurers. · Bring in billions in new federal dollars to California ’s health system, by getting matching funds for these expansions of public programs and employer contributions. · Offer workers tax savings, by providing the ability to pay premiums, or share-of-premiums, with pre-tax dollars, for a savings of 15-40%. · Place other rules and oversight on insurers, including limiting the percentage of premium dollars that go to administration and profit, rather than patient care. · Expands small group insurance reforms, to make getting more accessible and affordable for small and medium-size employers with 2-100 workers. · Encourage use of health information technology and disease management.
Recent amendments include additional cost containment provisions to foster better transparency and data on cost and quality of health care, to allow for prescription drug bulk purchasing, and to facilitate a public insurer option in addition to the purchasing pool. It would allow ventures to build on the various county-based “Local Initiatives” that currently offer Medi-Cal and Healthy Families and that have pioneered universal kids coverage.
RESPONSIBILITY AND AFFORDABILITY:
AB8 is a majority vote bill, but with multiple funding sources, including the minimum employer contribution; required worker contributions; reinvested state savings; new federal Medicaid matching dollars, use of Section 125 federal and state tax breaks, and an assessment on insurers.
INDIVIDUALS: AB8 includes individual responsibility, for those who have their risk of health costs shared by an employer or the statewide purchasing pool. Unlike the Governor’s plan, AB8 does not have a mandate to go into the individual market, for those that lack access to group coverage from a public program or an employer.
Other amendments were made today to ensure affordability,(in print and on-line Monday September 10). These amendments have been long sought by health, labor and consumer advocates. While AB8 requires workers to take up coverage offered at work or in the purchasing pool, there are exemptions for those with other group coverage (for example, through a spouse).
With the amendments, the bill now would also exempt anybody from having to take-up employer-based coverage that would cost them more than 5% of their income.
In the purchasing pool, those under 300% of the federal poverty level (around $30,000 for an individual, $60,000 for a family of four) would be guaranteed coverage at a maximum premium of 5% of their income; they would not have to take up coverage if the plan had a maximum of more than $1500 for total out-of-pocket costs, including deductible.
EMPLOYERS: While most employers already provide coverage to their workers, all employers would have to contribute 7.5% of payroll to health care under AB8. For those that don’t provide coverage or provide minimal benefits, they would also have a new purchasing pool option to only pay 7.5% of payroll, and get the benefit of having all their workers covered. This is a significant, especially for low-wage and small employers, that would have to pay a much larger percentage of payroll to cover their workers, and is a reason they are more likely not to. Right now, most employers pay more than 7.5%. Like the minimum wage does for pay, this minimum employer contribution would set a standard that employers can’t go below, but that many do above, in order to attract and retain workers in the job market.
GOVERNMENT: In the biggest expansion of public program coverage in 40 years since the creation of Medicare and Medicaid, children and parents under 300% of the poverty level would be eligible for Medi-Cal or Healthy Families-type coverage. This is partially funded from the reinvested state savings from having employers contribute to the health care of worker that have been on existing public programs. The rest comes from federal matching funds, which California has been leaving behind every year. Expanding the use of “Section 125” plans uses federal tax breaks to also finance coverage.
INSURERS: Insurance companies would be required to spend 85% of premiums collected on patient care, rather than administration, marketing, and profit. They would be limited in their ability to deny coverage because of “pre-existing conditions,” and they would pay an assessment per covered life to help fund coverage for those Californians in the individual insurance market that were denied coverage.
PROVIDERS: AB8(Nunez) does not include the provider taxes proposed by Governor Schwarzenegger in his proposal, largely because of the 2/3 vote requirement. The hospitals yesterday came out in support of the hospital fee, which would be used to bring down federal matching funds, that would be used to increase the Medi-Cal reimbursement rates, as well as expand coverage. (See below.) This component will need either significant Republican votes to pass, or need to be passed by a ballot measure.
UNINSURED IMPACT
Earlier estimates indicate that AB8 would cover 70% of the uninsured, 3.2 million of the 4.9 million Californians that are uninsured at any point in time, through expansions of group coverage, through employers and public programs. (About 6.5 million Californians are uninsured at some in the year: about 4.9 million at any point in time, according to the California Health Interview Survey.)
If the bill is accompanied by a hospital provider fee, AB8 can cover 80% of the uninsured, four million of the 4.9 million uninsured, by expanding Medi-Cal to cover 600,000 very poor adults without children at home (“childless adults below 100% of the federal poverty level"). If the bill includes the hospital provider fee and such an additional Medi-Cal expansion, such reforms can cover 97% of Californians.
NEXT: THE NEGOTIATIONS WITH THE GOVERNOR
The next Health Access Update will detail the similarities and differences with Governor Schwarzenegger’s proposal, as they continue to negotiate.
New York City's public hospitals will begin releasing data about rates of hospital-acquired infections and deaths at their facilities.
This kind of disclosure is key if we want to start controlling the underlying expenses associated with health care -- saving billions in avoidable health care expenses to fix mistakes.
In California, advocates have been fighting for such information as part of the larger health care reform effort. AB8 (Nunez/Perata) was just amended earlier this week to include such provisions, which would help control California's own health care costs.
Today, there's a full-page ad in the Sacramento Bee by Blue Cross against AB8 and, frankly, any health reform. They also sent out letters to all their subscribers attacking reform, and just sent out an E-mail blast.
In order to make sure that Californians realize the self-serving nature of Blue Cross' anti-reform position, here's a fun video just released today that spotlights Blue Cross' practices, on the website, www.sickofbluecross.org...
Due to a mis-directed link, there are *two* versions on Health Wonk Review up!
Our post about the results of the California small business survey is cited by Dr. Bob at The Doctor Is In. There's also other posts of interest, including a 8-part series by the host about the maze of medical billing and coding! While he wasn't supposed to be the host this wek, he clearly is a member of the tribe.
Brian Klepper at the similarly named The Doctor Weighs In has the "official" review up, with links about presidential politics, retail clinics, physician oversight, and the prospects for reform in general.
Both are worthy... posted by Anthony Wright | Permalink | 10:29 PM
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Solidarity....
Wednesday, September 05, 2007
The brief vignette in this Boston Globe Op Ed crystallizes why we need health reform now:
[S]he lives in constant fear of major uninsured health bills. Not her own -- those of her son. He can't afford insurance because his son -- her grandchild -- has a preexisting condition.
The "she'' the writer refers to is former Supreme Court Justice Sandra Day O'Connor. The anecdote illustrates that the health care system, as it is now, does not care who you are. It does not care who you know. It does not care what post you hold. And in some cases, it won't care how much money you have.
It is not working for anyone, which is why it baffles me that after the Governor and Legislative leaders made a big toodoo about health care reform this year -- knowing that stories such as O'Connor's are more common than not -- they may leave empty handed in less than a week.
So Tony Snow left the White House because he couldn't afford to live on his six-figure salary. I guess Fox News pays better.
Yet his job was to defend the White House's position that families of four over $41,300 should not get help with health coverage for their children. Hmmph.
The New York Times defends states--including New York, New Jersey, and California--that want to provide subsidized coverage to families, even $82,000 for a family of four.
Daniel Gross at Slate makes another point about Snow's situation. The spokesperson for Bush's "ownership society" apparently didn't take advantage of the 401K plans offered by Fox. As a cancer patient, the expensive health care treatments he gets are covered from his group coverage--government-provided, no less. If he had a "consumer-directed" plan (a HSA, or otherwise) that the President advocates for, he'd be in a world of hurt. posted by Anthony Wright | Permalink | 6:16 PM
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The biggest bill you'll ever get...
Sandy Kleffman of The Contra Costa Times had an in-depth story over the Labor Day weekend on hospital billing and "charity care" practices. It's an important reminder about what hospitals' responsibilities should be to respond to the needs of their communities.
A companion story couples these issues with the plague of underinsurance. A double whammy. posted by Anthony Wright | Permalink | 11:55 AM
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More, not fewer, things on the table...
Usually, when a negotiation gets down to the final days, the focus narrows to a few key elements of disagreement that need to get sorted out.
For this week's health care reform negotiations, the options are seemingly broader, rather than narrower. The notion that there might be part or all of health reform done at the ballot does open up new possibilities, especially for financing a plan--given the 2/3 vote obstacle in the Legislature for passing taxes.
But going to the ballot comes with a price, including a greater possibility of failure. For consumer advocates, it's a mixed blessing: it does mean that big industries can raise lots of money to defeat it; at the same time, the voters will insist that any proposal deal with issues of affordability and cost containment.
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.
