(Cross-posted from The Courage Campaign)

This year if we do nothing else, we've got to make sure that we provide heatlhcare coverage to all Californians independent of their income status or their legal status in this country. And we're comitted to making that happen.

       – Speaker of the Assembly, Fabian Nunez

I assure you we will have something out of the Assembly this year…Especially for the children.

        – Assemblyman Mervin Dymally, Chair of the Assembly Health Sub-Committee

This past Saturday, the Speaker of the CA Assembly, Fabian Nunez, held a townhall meeting in downtown L.A. to discuss his "Fair Share Healthcare" Plan. As the term "townhall" implies, the meeting was very much about getting our thoughts and answering our questions. As the Speaker and his gathered panel of experts spoke, it became clear to me just how committed they are to passing healthcare reform this year. Unfortunately, Nunez’s plan as it exists now is quite short on details, as it is still very much a work in progress. To quote the Speaker:

We're gonna look at Sen Perata's plan and look at the good things in that plan…Look at the governor's plan…We got to take the best pieces of every one of these plans and put them together.

Yes, Nunez seems to be embarking on a copy and paste method of healthcare legislation; he will try to devise a plan to be all things to all people…well, everything, it would seem, except single payer.

More…

Despite the lovefest about how great everyone's plan is, Sen. Kuehl was conspicuously absent from the discussion. Until the Q&A that is. To Nunez's credit, the very first question he took was about Sen. Kuehl's single payer bill that the governor vetoed last year. His response:

Yes I do support Sen. Kuehl's bill but it's not a bill that is going to get the support of both sides. So in the meantime we have 6.5 million people without healthcare insurance. We've got to do something to solve the problem now.

Which pretty much sums up the primary dynamic at play in the healthcare debate in California this year: pragmatism vs. idealism. What are we prepared to sacrifice to make sure that we get the uninsured covered sooner rather than later?

Not surprisingly, uniting divergent interests was a theme of the townhall. It was a post-partisan fest with Nunez even calling the governor's plan "more progressive than mine"  (oy, say it isn't so, Fabian…) It's clear than Nunez desperately wants to be the author of the bill to pass not only the Assembly but also to be signed by the governor and to that end, he is echoing some of the governor's messaging, including calling for bipartisanship and citing the 'hidden tax.' But the realilty is, from what I can tell, Nunez's plan is far better than the governor's, a sentiment which Sal Roselli affirmed when he told us on our recent conference call that SEIU's United Healthcare West is working with Nunez to shape the bill as a potential legislative compromise.

Nunez's plan does have some solid guiding principles, the most overarching of which is that everyone must pay their "fair share," hence the name of the plan; employers bear a burden, so do individuals and so does the state. From a messaging perspective, I think it works because it merges conservatives' concerns for individual responsibility and liberals' concerns for fairness. But it's also inherently non-committal, which perhaps is appropriate for a plan designed to be clay yet to be molded rather than a fully formed bill.

In addition:

– this plan rejects the individual mandate; rather there is an employer mandate under a pay or play model (if employer chooses "pay," they pay a fee as % of payroll (unspecified) into a state-level purchasing cooperative)

– underwriting reform is key; no insurance provider would be allowed to reject someone for a pre-existing condition

– while the ultimate goal is to make sure everyone in the state is covered, the "priority first step" is to cover all California children in households with incomes up to 300% of poverty

Other key issues the townhall addressed, although it's unclear how these would be built into the final bill, included:

– the need for more efficient record sharing; access to electronic medical records will save time, money and lives

– the tragic closing of trauma centers throughout Los Angeles (10 in the last 5 years) as a result of millions of dollars in uncompensated care ($60 million in 2006 alone,) has lead to overcrowding (his hospital was built to handle 38,000 patients a year, it's now seeing 55,000 a year,) which reduces the effectiveness and timeliness of care

– high cost and lack of access to care lead many people to wait to deal with an ailment until it's an emergency, thus necessitating going to the ER; increasing access to preventive care inherently reduces overall costs

– wording can be divisive; small business hates the term "mandate" and labor hates the term "health savings accounts," we have to find a way to unite despte these divides

Throughout the townhall, it was clear that Nunez and Dymally were using the meeting as an opportunity to sort of try out some of their messaging. Here's a rundown of some catchphrases we can expect to hear from the Speaker in the coming months:

"healthcare is a right, not a privilege"

regarding the children of the undocumented: "the only document that concerns us is the one that says they have a clean bill of health"

"everyone must pay their fair share"

"healthcare for all Californians especially for California's children"

And finally, I'll share with you the question I asked and Nunez's response:

Me: Will this bill require 2/3 majority? If so how do you intend to get Republicans on board. If not, how do you intend to accomplish this without raising taxes?

Him: As of this moment we think that this ultimately is going to be revenue neutral legislation which does not require 2/3 majority but we wait to see what the legislative analysts in Sacramento, they might tell us no, it is a 2/3 majority in which case we're going to need Republicans to get this passed. We have got to make sure that we work all of the legislators, Republicans and Democrats, to get them to understand how important it is. And the question about taxes, there is already a hidden tax and this is $1200 that everybody who already has healthcare insurance is paying. How do we reduce that hidden tax or eliminate it altogether and make sure that we cover more people and improve the quality of healthcare for everyone?

Overall, the townhall was extremely educational, both from a fact-gathering perspective as well as sort of seeing close up the politics of the debate. But it was also quite emotional at times as members of the community went up to microphones to tell the Speaker and his panel their stories. We talk theoretically about the uninsured and the fact that the poor don't go to the doctor for fear of cost until finally their ailments reach emergency status, but it is rare to actually see them in person and hear their stories. Watching Nunez's reactions to them, I have no doubt of his sincerity. I did, however, leave the meeting wishing I was more convinced that he was the leader our state requires to tackle this problem. In Nunez I didn't see a progressive leader taking the offense on one of the top issues of our day but rather an adept politician who is approaching the debate in a defensive position, using the governor's frames hoping the governor's popularity and reputation as 'post-partisan' will rub off on this legislation.

As I wrote here, there are benefits to embracing the governor as Nunez is doing and certainly, the governor's pledge to work with Democrats to pass healthcare reform this year is a bit of leverage we can use in our favor. But is Nunez being too passive with this plan? Perhaps it's too early to tell. I certainly look forward to seeing how the legislation progresses as it forms and comes to fruition. Hopefully Nunez will ultimately embrace the substance of progressive reformers' plans even as he embraces the rhetoric of the governor's.

I know others here disagree with my position that individual mandate is a step in the wrong direction, but, well, it’s how I feel.  And sure, I know there is something positive about a Republican governor addressing the health care issue.  However, for me, there are just too many negative effects of the individual mandate.  It takes a market based system (the regular insurance model) and tries to graft a non-market solution upon it by requiring everybody to buy in.  It denies people the right to opt-out of the insurance system in the country.  For all we know, it’s more affordable for that person to just put aside the premiums that he/she would have been paying in a nice investment account and use that for the rainy day that will eventually come.  In many ways, self-insurance would really make a lot of sense for most people, especially for those who are pretty healthy.

Of course, the people for whom self-insurance makes the most sense are the same people that the insurance companies really want.  Their basic model is to make lots of money off of healthy people to pay for the sick people.  Now, I really don’t have a problem with that as long as everybody knows about, and agrees to, this deal.  That’s just the nature of insurance.

The individual mandate doesn’t allow people to disagree with this bargain.  They are forced into the insurance world and are denied the option of self-insuring.  And, in many cases, the only insurance they can afford has outrageous premiums and/or ridiculously high deductibles.  So, your healthy 25 year old who might have considered self-insuring or just considering “going naked” because they cannot afford the cost of insurance will no longer have a choice.  “Going naked” really just spreads the cost of insurance to the state and to the creditors who you won’t be able to pay, but that’s for a different essay.  If you go ask any “true” conservative (read: not a corporatist), they will tell you what the individual mandate really is: a tax on being healthy.  Who gets the windfall? Insurance companies, who currently take up to 25% of every health care dollar, get rich off of the individual mandate plan. (Source: Health Affairs (Vol 24, No. 6)

In Massachusetts, which now has an individual mandate, it is becoming painfully clear that the individual mandate program is only really helping the insurance companies.  Sure, you can buy a cheap insurance plan, but individuals buying their own insurance might still quickly end up $20K in the hole pretty quickly.  From Progressive States:

The Massachusetts Health Care Plan, negotiated by former Governor Mitt Romney and the legislature, is proving to be expensive, just as critics warned, with the lowest cost plan costing state residents as much as $9,560 per year in out-of-pocket expenses if they suffer a serious illness. While the Mass plan has been pointed to as a model for other states, these new numbers make clear that the Romney model of individual mandates is not a reasonable approach.
{snip}
“We’re talking about a plan that will take almost 1/6 of people’s income in premiums alone. People could pay as much as 1/3 of their income into medical expenses. That simply is not affordable,” said Thompson. “To penalize individuals who reject this expensive proposal by levying $1,000 fines borders on cruel.”(Progressive States 1/22/07)

The individual mandate is a giveaway to the insurance companies.  It legislates the ceding of health care discretion to for-profit industry.  And as we can see from the example of Massachusetts, the insurance companies have given us no reason to trust them.  Gov. Shwarzenegger, if you’re looking for a model, look right past Massachusetts.  There’s nothing to see there.

Unbelievable! He doesn’t get it. This is what the C student from Yale doesn’t get:

Health Insurance DOES NOT EQUAL Health Care

His Plan make some “generous” employer provided plans taxable and allow those who have to pay for their own insurance tax deductible.

(I cross posted this diary on the Daily Kos, OrangClouds115 asked me to join your site here and cross post). I’m glad to help…if it helps.
  I’m new to your community, but not to kos, please forgive me, if my language is a little more direct than you are used to.

I don’t know how his plan is going to decrease the number of uninsured from 46 million to what – 33 million? Most people need the cash now to pay their bills. Giving a tax break of 15 cents on the dollar isn’t going to get these people enrolled in health insurance programs. Why do I say that?

The uninsured (73%) are largely people who are in the 15% tax bracket. This is according to an HHS report – this is a department under George Bush’s authority. Can’t the boy can’t read! Here’s a snippet from the report:

That the uninsured are concentrated among lower-income individuals is not surprising, given that low-income individuals are less likely to:
• be working, and if they do work they are less likely to be working full time,
• receive an offer of insurance, and
• be able to afford an offer of coverage.

This means their pay check is a maximum of about $580 per week. If they are a single parent with a child, their health insurance costs are about $800 per month. I don’t see where making the cost tax deductible is going to help one iota.

So who is Bush targeting? The remaining 27%.  The same report continues:

While the income distribution of the uninsured is skewed toward those with lower incomes, Figure 2 shows 27% of the uninsured have incomes above 300% of poverty, with one-in-ten (11%) uninsured above 500% FPL.(4) That the uninsured comprise non-trivial percentages of middle and upper income individuals is surprising.

Here’s the poverty thresholds for 2004.

These are actual dollars. A family of four all under 65 years of age has an average weighted poverty threshold of $19,307 annual income (I used the first column on the chart, the average, they used a less expensive state). Make more than that and you aren’t living in poverty (according to the government anyway). 300% of this figure is $57,921 (again, 3 x the average); which will leave the family in the 15% tax bracket after deductions, exemptions and child tax credits. The cost of insurance (medical, dental and vision care forget about nursing home care rider) is over $1,100 per month for a family of four, if you can get it*. This will leave the family a little over $44,000 to pay their federal taxes, social security and Medicare taxes….Here’s the math

  $ 19,307 x 3 =  2004 poverty threshold family of 4: 
  $ 57,921  300% of the 2004 poverty threshold for family of 4 
  – $8,109  taxes, Social Security, Medicare
  – $13,200  Health Insurance (for a year)
  _________
  $36,612  What’s left to pay mortgage/rent, transportation,
  food, car and home insurance =

*This plan will still require the mother to pay a $100 copay for a mammogram, the HPV vaccine is likely to be a non-covered item for their teenage daughter ($500) and the drug co-pay for name brand drugs is likely to be $50. The Dad and son are more likely to seek care in an ED for a multitude of reasons and that co-pay will be $100-$150 plus drugs.

Even if his plan is successful, the most he can do is reduce the rolls of the uninsured by 27%. That still leaves 33.5 million uninsured people.

Even if he is successful and gets these people into insurance plans, how is he going to get them to be able to use them? If you are paying for insurance, then you might not be able to pay the co-pay to see a physician or go to the ED! “Uh, I just paid the $1,100 monthly insurance bill. I don’t have the $30 copay to see the cardiologist or the $50 to get the prescription filled.”

Health Insurance DOES NOT EQUAL Health Care

I think this is another government sponsored/attempt at “feel good” legislation. It will look like he’s doing something, but the plan is faulty. It will still leave over 33.5 million without health insurance and no way for those pushed into the plans to use them.

What is George Bush thinking!?!

(While we’ve been busy crashing the gates of the party, health care and budget issues are rolling along. This is a good little update. – promoted by bolson)

(I composed this for the broader orange audience – let me know if this is too redundant here)

Sen. Sheila Kuehl, the author of the state’s most popular universal health care proposal, nicely waltzes through the Schwarzenegger plan, and leaves no doubt that it’s a patchwork that won’t, in the end, fix a thing.

Kuehl’s key points after the jump.

1. An individual mandate guaranteed to leave millions without insurance.

The central basis of the Governor’s plan is simply to mandate that every Californian must, by law, carry health insurance. There is no requirement that it be affordable and no minimum coverage. This means that the requirement can be met by a bare-bones policy covering only catastrophic events, with a $5,000 deductible and up to $7500 in out of pocket expenses for all the things that aren’t covered by the policy.

This is not universal health insurance. Think for a moment about automobile insurance. Even before Prop 103 passed, limiting the amounts by which insurance companies could raise your auto insurance premiums to those approved by the Insurance Commissioner, we all had to have auto insurance. Would you call it Universal Auto Insurance? 25% of Californians don’t comply […]

Healthcare wonks immediately notice that those uninsured people will just get paid for, expensively and inefficiently, by the rest of the system, by you and me.

2. The employee mandate is nonsense. It only covers 20% of businesses – those with 10 or more employees – and only asks business who opt out to pay for less that half of the cost of insurance. This ham-handed version of a mandate contains the worst of worlds, it continues to let bad bosses skate, and it encourages small employers to reduce payroll. Worse still, this mandate caps employer expenses but shifts 100% of cost increases to employees.

3. Scope. Unbelievably, the plan does not set a floor for minimum benefits.

4. The cost containment farce. Who needs cost containment when you let insurers cut coverage?

5. Screw the poor. The plan costs many families more than the current MediCal cost sharing system does. Parenthetically, this is just one more body blow to a system that structurally unsound. Now reimbursements are so  low, most pediatricians refuse to see MediCal kids – they can’t, since reimbursements are around half of actual office expenses.

These are the high points, but go read the rest. It’s the template we’ll be using to fend off another Schwarzenegger big budget disaster.

(Can we please do this right? – promoted by blogswarm)

In today’s single-payer update, writer Paul Krugman ponders single-payer, Cape Cod plans plans for it, and California nurses advocate for it.  Schwarzenegger’s proposal sets the terms for the nation’s healthcare debates, which will be conducted in a state whose voters support government healthcare-and a nation not getting enough preventative care.

Brought to you by the National Nurses Organizing Committee as we organize to make 2007 the Year of Single-Payer Healthcare.

In today’s New York Times (reg. req’d), Paul Krugman is of the same mind(s), as many other supporters of single-payer healthcare: it’s nice that Arnold is trying…but his plan is bad.  Krugman writes:

As a result, the plan requires a much more intrusive government role than a single-payer system. Instead of reducing paperwork, the plan adds three new bureaucracies: one to police individuals to make sure they buy insurance, one to determine if they’re poor enough to receive aid, and one to police insurers to make sure they don’t discriminate against the unwell.

And so…

Maybe those flaws could be fixed once the principle of universal coverage was established – but there’s also the chance that we would end up stuck with those flaws, the way we ended up stuck with a dysfunctional system of insurance tied to employment.

What’s ironic about all this: blogger nyceve points out that the insurance companies, despite making out like bandits under Schwarzencare, don’t like it because they’re greedy. 
And unnecessary.

Heading east, Cape Cod is looking to join San Francisco in offering LOCAL single-payer, and looking even farther east, the President of the California Nurses Association makes a point in the LA Daily News about what the US will gain once we have a rational, universal health care plan:

Taiwan adopted a single-payer system in 1995, boosting health coverage from 57 percent to 97 percent with little if any increase in overall health care spending. The public system sets fair reimbursements applied equally to all providers, and uses its clout to negotiate volume discounts for prescription drugs and medical equipment. The public sets the policies and administers the system, not high-priced CEOs making decisions based on what inflates their compensation packages or stock wealth.

Elsewhere, Stratfor, a business consultancy, makes the case that California’s debate is setting the terms for our national fight over healthcare, while a new San Jose State poll shows that a solid majority of California voters support a government guarantee of coverage, though far fewer favor treating undocumented immigrants equally

A new report by the Agency for Healthcare Research and Quality
should lay to rest any doubts you might have about how our current, broken health care system is a moral tragedy.  Americans are not receiving the preventative care they need to live long, healthy lives-especially poor and ethnic minority Americans. 

Americans as a whole largely are not getting the tests, exams and advice from doctors that can lessen the burden from asthma, cancer, diabetes and obesity, according to the fourth annual national health care quality and disparities reports.
“It’s encouraging to learn that overall quality continues to improve,” said Dr. Carolyn Clancy, director of the federal Agency for Healthcare Research and Quality, which issued the two reports. “At the same time, the message is clear: Much more can be done to prevent illness from occurring or progressing.”
There also continues to be a wide split in access to health care, with poor and minority patients generally receiving poorer care, according to the reports.

(I missed Todd’s post, but I’ll leave this one up. I have a somewhat different take. – promoted by SFBrianCL)

Today, the first part of a new Field poll came out on health care (here-PDF), and what it says will likely not come as a great surprise to anybody in Sacramento. The poll of registered voters shows that 81% of the state’s voters support  the statement that “It should be public policy that government guarantee that all Californians have access to affordable health care insurance or other health care coverage.”

Much of the poll goes on to give reasons why the voters think that health care is too expensive.  Many of the reasons are accurate, others…well, not so much.  Follow me over the flip for the reasons and some more analysis.

So, here’s a quick rundown of the “reasons” why health care is expensive, according to our voters:

• High profits made by drug and insurance companies, (65%)
• Waste, fraud, and inefficiencies in the current system, (60%)
• Paying for the health care costs of the uninsured (57%)
• People not doing enough to keep healthy, like exercising and eating right (54%)
• The increasing number of older age residents and the higher costs associated with providing them care (47%)
• Too many malpractice lawsuits against doctors, hospitals, and health plans (46%).
• People getting too many unnecessary treatments and medications (38%)
• The use of new and expensive medical technologies, procedures and treatments (36%)
• Little incentive or ability for insured residents to comparison shop for health services (31%)
• Doctors and hospitals making too much money (28%)

A consensus is slowly building around the concept that PhARMA is too powerful, too profitable, and doing more harm than good.  Of course, the problem with that consensus is where does it really leave us?  We can either have state-sponsored health care research, or we can have for-profit companies.  There’s very little in between the two poles, and for-profit companies will always act in the way that does the most benefit for their stockholders, not their customers.  And furthermore, at the state level, we only have limited leverage overPhARMA .  Sure, we can force them into drug discount programs and the like, but only the federal government can truly address the underlying faults in our health care delivery system from top to bottom.

Of course, a full overhaul would also draw in reason #2, waste & inefficiencies.  The ultimate inefficiency in the system, is really the system, isn’t it?  At least 15% of every healthcare dollar ends up in the pockets of insurers.  Is that efficiency?  Hardly.  Conservatives have often argued that government couldn’t possibly be responsible for making these kinds of life/death decisions.  That these decisions of what is covered must be left in private hands.  And in the end, these private hands are insurance companies.  Blue Cross, Kaiser, etc.  Now come on, is it really any better to have Kaiser in charge of what health care you receive than the government?  Is a bureaucrat at Blue Cross really any more compassionate than a bureaucrat in the government?

At the state level, we have several options, including one which passed both houses of the legislature last year.  Single payer, which was embodied in Sen. Kuehl’s bill that was vetoed by Arnold Schwarzenegger, is still on the table.  The Massachusetts program of mandatory insurance seems flawed as applied to California, due primarily to the size of the state.  And socialized medicine seems unlikely at the state level.  The question ultimately will be whether the state is willing to cough up the dollars to pay for a program that can guarantee affordable health coverage for everybody in the state.  Given Arnold’s rigid anti-tax stance, is that a real possibility this year?

(Cross-posted from The Courage Campaign)

George Skelton has an interesting piece in yesterday's LA Times that suggests that those of us who seek expanded access to healthcare in California should actually be optimistic about Arnold's claims to want to fix the current healthcare crisis (6.5 million Californians are uninsured.)

Conventional wisdom among Arnold skeptics is that he's a pretend progressive who has no core principles other than his own ambition and maintaining power. Well, healthcare may be that rare exception. Remember where he comes from, after all.

Arnold Schwarzenegger says one of his first purchases after coming to America 38 years ago was health insurance.

"It's a cultural thing, maybe," he says. 

"I come from Austria, where everyone's insured. It was a totally normal thing to me. Like eating and sleeping and finding an apartment. It was like, 'Now you've got to get the insurance.' One of the things I wanted to do the first month."

More…

Austria has a generous social insurance program that has only been cut back recently as more conservative leaders have taken power. Essentially, health insurance is a part of social security and is handled through a combination of contributions from citizens, employers and the government. So Arnold is a product of a society that values government as a means to level the playing field; a society that gets that the socio-economic status one is lucky or unlucky enough to be born into should not dictate the level of healthcare one receives.

Is that to say Arnold will sign the most liberal of health insurance plans that come across his desk? Of course not, we've already seen him veto single payer. He is a Republican after all who is beholden to interests who traditionally oppose such programs. But this might make him just the advocate we need to gain consensus on this issue, which, while it may not be needed politically, is in the longterm interest of any program that is implemented in the state. Gavin Newsom stood up to his liberal city council to pass a compromise health care program that, because it is somewhat business-friendly, has a chance to get replicated in other less liberal cities across the country.

As an example of Schwarzenegger's ability to bring conservatives around to the progressive view on certain issues, look at how he framed Prop 90 back in November when he finally came out against it. He used conservative language touching on their fears of "trial lawyers," "frivolous lawsuits" and wasted "taxpayer dollars" to make his case against 90. He does the same thing here by framing the healthcare of his homeland not as socialized medicine or the triumph of big government but rather in terms of personal responsibillity (he says "everyone's insured" and "you've got to get the insurance"), which of course is another favorite buzzword of conservatives. 

If Schwarzenegger is as committed to expanding health insurance to the 6.5 million uninsured Californians as Skelton seems to genuinely think he is, he could really serve as a great tool by which to frame the healthcare debate nationally and to normalize the idea for those whose kneejerk reaction would be to oppose it. As Senator-elect Bernie Sanders said on Air America this morning, the way the US is going to adopt a national plan is only once states start implementing them at the local level. We have a unique opportunity to lead the nation on this issue, here's hoping the governor doesn't squander it.