The “Year of Health Reform” in California: Take Two–Lessons for the Next Attempt

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It’s been over a year since Governor Schwarzenegger decided to join the decades-long debate on health reform, and I’m actually quite pleased that he’s indicated he will continue to focus on health reform in the years remaining in his administration. It may not have been clear to the Governor, but we always knew that the sheer magnitude of the needed reforms would take more than just one year to achieve. Any success to be gained on his “second try,” however, will require a very different approach, both in terms of policy and in terms of politics.

Predictably, a number of interests in Sacramento have attempted to characterize the failure of the Governor’s and the Speaker’s bill as the victim of uncompromising single payer proponents on the left and powerful insurance companies on the right, as though the Governor’s plan was “just right” in a three-bears, middle of two-extremes, spin. In fact, the Governor’s plan appropriately fell because of the Governor’s own reluctance to make the difficult policy decisions necessary for the plan to be in any way affordable to the state as well as to businesses and individuals, but which would have stirred up strong opposition from insurance companies.

Simply put, insurance companies will not support any plan that would prevent them from continuing to raise premiums 2-3 times faster than wages, limits that must be imposed in order for any long term financing to work. In the positive column, the Governor’s plan included a number of reforms needed, if insurance companies were to be retained, that would have regulated (read wrestled) them into good behavior. It required insurers to accept all patients, to spend a minimum amount on actual care, and to refrain from singling out sick patients for unaffordably high premiums.

Unfortunately, it contained nothing that would have made premiums affordable for the vast majority of Californians, all of whom would have been required by the law to buy health insurance. The “subsidies” contained in the plan were only for very low income families (not a bad thing) and, except for those at the very poor end of the scale, would have partially subsidized premiums but left families to pay whatever co-pays and deductibles were set by the companies.

It’s also worthwhile to refresh everyone’s memory that labor unions and health care advocates who ostensibly “supported” the Governor’s compromise plan did not register a support position with the Senate Health Committee, but rather indicated they supported the bill only if it were amended. The requested amendments, which were lengthy and substantive, were rejected by the Governor and the vaunted “support” was actually no support at all.

(If you are interested in seeing the support if amended section of the health committee analysis, click here. It’s a very long analysis, and the support if amended section begins on page 94).

If there is any clear lesson to be gained, it’s that any large reform (single payer or other) must directly take on the insurance companies and must protect consumers against skyrocketing premiums and out of pocket expenses. Anything short of that is fatally doomed, both politically and in practice.

On the Recent Field Poll

A recent Field Poll has been characterized, by the sound-bite pundits, as concluding that a majority of Californians would have supported the “major provisions of his proposal”. This is a mistaken conclusion. First, it assumes that the field poll questions presented the major provisions of the plan, both pro and con, which it did not. The poll did not ask, for example, whether respondents favored mandating individuals to purchase private health insurance without limiting how much premiums could grow each year. This means that the poll results regarding the Governor’s plan are of limited use in assessing how respondents would have voted had the proposal been brought to the voters in a statewide election.

Interestingly the same Field poll showed that the California Nurses Association have the highest favorable rating for their role in the debate, a great deal higher than any other person or organization involved. The nurses are rightly seen by the public as fighting to protect the interests of patients, which, in this debate, involved opposing the Governor’s plan and explaining why single payer meets the needs of consumers and the state without the problems raised by the Governor’s plan.

Even as the Governor tiptoes around offending insurance companies, the Field poll reveals just how much the public is fed up with them–no surprise considering their recent legal troubles for rescinding coverage when patients get sick as well as systematically improperly denying needed care. Couple these transgressions with the steady gutting of benefits and increasing of cost sharing, all the while grossly inflating premiums, and it’s easy to understand the public outrage. While insurers pretend they are taking these actions in order to contain costs, they have been painfully slow to take those steps that have been proven to improve health outcomes and save money, like chronic disease management, preventive medicine, and investing in health information technologies.

What has not been widely reported is that the Field poll actually found significantly diminished support for employer sponsored health insurance, and lower support for “individual responsibility” since the last poll in 2006. In contrast, the poll documented a surge of 9 full percentage points in support of “Government Provided Health Care”, which is one of the more unfavorable descriptions of single payer, and which does not even present the fact that, under single-payer, health care would continue to be privately delivered, while being funded publicly through premiums shared by government, employers and individuals.

Most importantly for us, the Field poll shows that the investment by single payer advocates in steady community organizing and education is paying off big time. Since 2002, universal health care advocates have rallied around Senate Bill 840 (Kuehl) the California Universal Health Care Act. These advocates have formed the OneCareNow coalition, made up of hundreds of supporting organizations around the state. The coalition has prioritized community education about universal health care and sponsored hundreds of public educational events throughout the year, and they are just getting started.

The unmistakable trend toward single payer is documented by other polls, including a recent survey of U.S. physicians that found a 10 percentage point jump since 2002 in support for government legislation to establish national health insurance.

There you have it. Two years of health reform with the Governor in the spotlight has resulted in a 9 percentage point jump in favor of single payer and diminished support for other policy options. Single payer supporters have always known that the more people think about health reform, the more they support single payer. We are winning.

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