How do we get all Californians access to affordable health care? ‘Bold action’

Note to readers: Each week through November 2019, a selection of our 101 California Influencers answers a question that is critical to California’s future. Topics include education, healthcare, environment, housing and economic growth.

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California Influencers this week answered the question: Should California make it its mission to ensure that every resident has health care coverage? What’s the best way to achieve that goal? Below are the Influencers’ answers in their entirety.

Mark Ghaly Secretary, California Health and Human Services Agency

Health coverage for all just makes sense. It lifts all boats. It is a win-win, and we are relatively close to achieving it. Coverage for all provides individuals and communities with access to the prevention and early intervention services that curb disease and allow everyone to be productive members of our communities. Similarly, it allows emergency rooms to focus on the acute care services they are intended for rather than becoming defacto primary care providers. Coverage for all focuses our money on high value services, helping our resources go farther.

The good news is that stakeholders seem ready to move from “should we?” towards “how do we?”. So let’s stop debating the worthiness of the goal and start discussing how to make care affordable and how the mechanics work. Governor Newsom’s first days in office highlighted some strategies: cover low-income undocumented Californians from 19-26 years old, lower prescription drug costs, and establish an individual mandate. In the months ahead, we can move even closer to coverage for all through meaningful progress on issues such as cost sharing, network design, and single-payer. So, let’s get to work. Achieving coverage for all will help make California for All a reality.

Dustin Corcoran – CEO, California Medical Association

Yes. But coverage has to translate to affordable and accessible health care. Health care is a primary driver of economic insecurity in our state – even for those who have coverage. Premiums are too high, and many forgo or delay necessary medical care because they cannot afford deductibles and copays.

We can control costs and expand access by building on the successes of the Affordable Care Act. That means extending coverage to the remaining uninsured and continuing to address issues of cost and affordability. Increasing subsidies for coverage will help, but we can also make changes within our health care system to improve delivery of care and lower costs. Gov. Newsom’s plan to leverage the state’s bulk purchasing power to lower the cost of prescription drugs is one important way to drive down costs for millions of Californians. We can also increase access through expanding telehealth and removing administrative burdens for physicians to give them more time to spend with their patients.

Our focus should be on access to care for all Californians. Expansion of coverage is meaningless unless those who are covered can get the affordable, quality care they need when they need it.

Anthony Rendon – Speaker, California State Assembly

I absolutely believe California, and our nation as a whole, should make certain that every person has access to quality health care. It is one of the defining challenges of today. We have the building blocks to transform our healthcare system and a path to take on a thoughtful approach towards that goal. An Assembly select committee held hours of hearings last year just to lay the groundwork. The new Council on Healthcare Delivery Systems can develop the necessary critical details. Suffice it to say, providing universal coverage will require adequate attention to preventative care, reducing health disparities, quality-driven outcomes, and putting the brakes on rapid rises in what it costs to deliver that care.

Bonnie Castillo – Executive Director, National Nurses United

Nurses every day care for people denied care due to cost, insurance restrictions, and disparities created by a system premised on profits and ability to pay, not patient need. It’s inhumane, and it must end. If our elected leaders believe, as many profess, that health care is a right, not a privilege, there’s only one solution, guaranteed care for everyone through real reform, single payer/Medicare for all, as the California Nurses Association has long proposed and campaigned for.

A mandate to criminalize people without insurance is not care, it’s a taxpayer handout for wealthy private insurance corporations. Twenty years ago, Gov. Gray Davis signed legislation establishing a state committee to develop a universal health care plan that led to single payer legislation ultimately vetoed by his successor Gov. Schwarzenegger. A study then showed it would save the state billions and ensure care for all. We don’t need to recreate the wheel. We could act now to enact a state version of two bills currently in Congress, H.R. 1384 and S. 1129. Let’s not lose one more patient to a broken profit-focused system.

Le Ondra Clark Harvey – Director of Policy and Legislative Affairs, California Council of Community Behavioral Health Agencies

Health care should be a basic right for Californians. Adequate coverage translates to greater focus on preventative care and can in turn lessen the use of emergency room services for routine health concerns. Ensuring coverage began with the implementation of the ACA. However, what is missing is active bolstering of the health care workforce to accommodate the influx of the newly insured population. California should invest in the health care workforce pipeline by educating individuals, beginning in high school, about the range of careers in the health care workforce. Our state should invest in training for non-licensed and certificated health care providers within community colleges, and add additional slots in training programs and residencies for licensed health care providers. California should also create incentives to address burnout for all health care providers.

Anthony Wright – Executive Director, Health Access California

California has already taken big steps towards universal coverage, leading the nation in implementing and improving on the Affordable Care Act. Californians should be proud we reduced the uninsured from 7 million to 3 million—the largest drop of all 50 states. California must keep taking bold action to achieve an affordable, accountable, equitable health care system that works for all Californians.

Governor Newsom was right to begin the planning to get to a more efficient, effective, and universal Medicare for All-type system, even despite the obstacles, especially those from the current federal government. But his proposals also recognize Californians can’t wait for the feds for help.

California should take aspirational and achievable steps now to increase health coverage, such as expanding Medi-Cal to all income-eligible Californians regardless of age, disability, or immigration status. The Legislature should also support Governor Newsom’s proposal to continue the ACA’s individual mandate in California, while supplementing it with greater affordability assistance for low- and middle-income Californians.

These complementary short- and long-term steps to a universal system will provide health and economic benefits for not just the uninsured, but their families and the community as a whole. Everyone benefits when everyone is covered.

Robert Ross – President and CEO, The California Endowment

Should California make it its mission to ensure every resident has health coverage? This one is easy, and the answer is a resounding, without-a-doubt, two-handed slam dunk “YES!” We know our entire nation must do this – but that’s another column for another day.

The best way to achieve that goal, from my perspective, is a two-part answer. The first part is “The Prize”, and the second part is about “The Roadmap”. The Prize represents the longer game, the final policy answer. At the health foundation I lead, we are growing increasingly agnostic about allegiance to a single right approach. I would be fine with Single Payer; I would be fine with Medicare-for-All or some variant of that; and, I would be fine with putting the ACA/ Obamacare on policy steroids and just building from that platform. Let’s just get everybody in the boat.

The Roadmap represents the more immediate three-year timeframe in front of us – and lets call it bold pragmatism. This to-do list is as follows: 1) Extending health coverage for our undocumented residents, 2) Improving affordability by enhancing subsidies through Covered California, 3) Re-assert the individual mandate for coverage in California through tax penalties, and 4) Governor Newsom is one the right track with a frontal assault on drug-pricing as a measure of cost control.

See? It’s easy….

Richard Pan – California State Senator (D-Sacramento)

Health care is a right, and California should strive to achieve universal access to quality, affordable health care for every Californian. Ensuring every resident has health coverage is important to reach this goal. With full ACA implementation including Medi-Cal expansion, California reduced the number of uninsured by over half with further gains by covering undocumented children under 18.

To achieve the goal of universal coverage, first strengthen the ACA from assaults by the Trump administration that destabilize coverage markets and increase premiums. Require coverage while providing subsidies to increase affordability for middle and low income families in Covered California. Align incentives across public and commercial plans to promote continuous improvement in the management of chronic conditions, which account for 70-80% of health care spending. Health plans should be competing on value, not on which plan has the most favorable case mix.

Reductions in the growth in health care costs from improvements in chronic diseases management including mental health care will help fund coverage expansions. In fact, expanding coverage may prove to be more cost effective than leaving people uninsured. And we must increase investments in public health to address social determinants of health affecting all Californians and their need for health care.

Marie Waldron – California State Assemblywoman (R-Escondido)

California should make it a goal to ensure that everybody in our state is able to get health coverage. But access to insurance does not mean access to care. It doesn’t matter if you have an insurance card if you can’t get in to see a doctor or your co-pay is prohibitively expensive. The better goal is actual universal access to affordable, quality care. In the worst-case scenario, Californians are stuck paying hundreds of dollars each month for coverage they’re not able to use because they can’t get in to see a doctor.

Fortunately, there are opportunities to tackle both issues at the same time. Reforms to bring down costs and improve quality and access to care will reduce out-of-pocket expenses and encourage providers to operate in underserved areas to ensure that consumers can actually receive the care they need.

Reforms should include cutting bureaucracy, allowing free market competition, expanding choice in coverage, raising Medi-Cal provider rates, incentivizing more providers to work in rural and underserved areas and simplifying patient navigation while encouraging community-based teams of healthcare professionals.

Jeannine English – National President (retired), AARP

As we look at California’s population today it’s obvious that a large number of our residents are fighting to make ends meet. A recent study by United Way found that one in three households in the state are “struggling to stay afloat”. The lack of affordable comprehensive healthcare is one of the key impediments to many families achieving household security. The Affordable Care Act significantly reduced the number of people without coverage in California to about 3 million. However the recent attack by the Trump administration eliminating the federal mandate and reducing the open enrollment period has jeopardized the goal of expanding coverage to all and may erode recent achievements.

That’s why Governor Newsom’s proposal to expand healthcare coverage to hundreds of thousands of people that are uninsured by establishing a state mandate to replace the now defunct Federal mandate and to extend Medi-Cal to low income undocumented immigrants ages 18-26 is an important next step for California. But we can’t stop there. We now have technology that can allow us to transform health care by aligning financial incentives to improve performance and quality care that doesn’t just extend life span but extends health span and reduces the overall health care costs.

Kassy Perry – President and CEO, Perry Communications Group

Nine out of ten Californians has health coverage, they see a primary care physician and receive the medicines they need and are admitted to hospitals if necessary. For them, the current health care system is working well.

But for California’s older adults, the picture is not as rosy. By 2030, the number of older Californians will increase 90 percent, or four million people. California is heading for a crisis in caring for its’ older adults. Medicare covers acute hospital care, but it doesn’t cover long term care and support services, nor does it cover primary care, dental services and medicine without a supplemental benefit. Medi-Cal provides coverage to the most vulnerable of seniors, but finding providers is nearly impossible.

In his State of the State, Governor Newsom called for a Master Plan for Aging to make successful aging a reality for seniors throughout the state, and lawmakers have introduced legislation to create that framework. If we look to local programs that are working well and fund additional health care and support services we can empty the homeless tent cities, increase the number of available beds in clean and safe long-term care facilities, and provide the health care services our seniors deserve.

We can close the gaps of the uninsured without disrupting the high quality care provided to 36 million Californians, by providing services at the local level to those most in need.

Bruce Chernof – President and CEO, The SCAN Foundation

Having worked for years in a major health plan and served as the Director of the LAC Department of Health Services it is clear to me that all Californians will need healthcare at some point in their lives. And ultimately, the purpose of healthcare should be to improve the overall health and lives of individuals and communities. As a result, California should have a basic benefits package that is available to all residents of the state. As a condition of licensure to do business in the state, all health plans ought to offer at least one basic benefits product. Ultimately every Californian needs basic coverage. If this sounds expensive and a difficult goal to achieve, we should remember that we already currently spend more per-capita on healthcare than all other industrialized countries yet produce substandard outcomes. The money is already in the system but wasted through convoluted billing, redundant levels of administration, lack of meaningful care coordination, and outrageous drug costs.

Lanhee Chen – David and Diane Steffy Research Fellow, Hoover Institution

California shouldn’t put the cart before the horse. Above all, the mission of state government policy should be to lower health care costs as a way of further expanding coverage to more Californians. The state has expanded coverage over the last several years, but these gains will be unsustainable or rendered ineffective if additional changes aren’t made in a fiscally prudent manner. That means policymakers should first focus on ways to bring down costs and create a more competitive marketplace for the provision of health care services in our state. That means expanding access to health plan choices for Californians, not restricting them; looking carefully at ways the state can reform payment systems in government programs to reward the quality and value of care first; and ensuring that state policies and regulations are doing less, not more, to encourage consolidation amongst health care providers. The answer is not, as some have suggested, more government intrusion into the health care space--that will only drive costs higher and make it harder for us to expand access to coverage for those who may need it.

Chet Hewitt – President and CEO, Sierra Health Foundation

California should continue to demonstrate national leadership by working to ensure every resident has health care coverage regardless of immigration status or income. But a system that provides coverage for all is not enough. The state also needs to ensure every resident has timely access to quality care, including preventative, urgent, and specialty care. Single payer is likely the best strategy for making this happen, and while financing remains a challenge, the idea should be pursued, not abandoned. In the interim, we should continue along the promising path set forth by Governor Newsom, whose budget calls for expanding coverage for the undocumented up to age 26. Important next steps could include state subsidies for those ineligible for federal subsidies due to its income limits but who cannot afford rising premiums, simplifying enrollment for residents that are eligible for state programs but remain unenrolled, and implementing a state mandate for coverage to promote a stable health care marketplace. While I’m not a fan of chipping away at the problem, I’ll rally behind any thoughtful advance to make coverage for all a reality.

Carmela Coyle – President and CEO, California Hospital Association

Health care is as basic a human need as food, water and air. Everyone – regardless of circumstance or where they come from – deserves the medical care they need, when they need it.

In emergency rooms, hospitals have always provided around-the-clock life-saving care for people with serious medical needs, but the reason everyone needs health care coverage is so they can get the right care at the right time and in the right setting. Coverage helps people stay well in the first place, get the preventive care they need and see a primary care doctor before conditions worsen. And that makes care more affordable for us all.

We should celebrate that California leads the nation in expanding coverage – building on the Affordable Care Act, 93 percent of residents have health care coverage. It’s time to finish the job. Next steps: expand insurance premium subsidies for low-income families, establish a state-level individual coverage mandate and make coverage available to undocumented individuals.

Universal coverage is within our reach. It is up to our state’s leaders to make sure we achieve that goal.

Robin Swanson – Swanson Communications

Our health care system is inhumane. When people are at their most vulnerable and in need of care, we’ve created a system that exploits them to feed an industry sustained on obscene profits. The fact is, health care costs have been growing at least twice the rate of inflation.

It turns out compassion and human decency are expensive commodities. So should every resident have health care coverage? Yes. Is our current system working? No.

Covered California has taken important first steps in insuring millions. This program also allows people with pre-existing conditions to be covered, and gives consumers power to bargain for better rates. Despite inevitable growing pains, we should continue to grow this program. But as we expand the pool of people who are covered, we should also expand accountability for an industry that has long had the luxury of putting profits before patients.

That means we need transparency. For those who have suffered countless hours on a dystopian loop of inane bureaucrats having to justify why they need their prescription drugs; I offer this: let’s ask those same industry bureaucrats to justify their growing profit structures.

For that, we need a whole lot of sunshine on a system that has been allowed to proliferate on the dark side of the moon.

Dr. Joseph Alvarnas – Vice President of Government Affairs and Senior Medical Director for Employer Strategy, City of Hope

As a hematologist and cancer physician, my patients have taught me a fundamental truth: Cancer care is different. We have learned that cancer is not a single disease but many different diseases that are each diagnosed and treated differently. Cancer care is complex, often requiring expertise specific to a tumor type that may only be available in a health system with clinical research and deep clinical expertise. We need to judge carefully insurance models that may expand coverage but do not necessarily ensure access to the kind of patient-centric care needed for a cancer patient to achieve good outcomes. Policymakers and the public need to understand that expanded coverage does not automatically translate into better patient access to physicians and health care systems that can effectively manage life-threatening conditions, like cancer. I recommend that as our leaders move forward in efforts to expand coverage in California, we do so with humility, thoughtfulness and with an eye toward ensuring that we focus first and foremost on assuring that the most vulnerable among us have access to high-quality care that can have life-altering impact. If we remember that cancer care is different, we can deliver a universal care model that accommodates every type of patient journey.

Zach Friend – Supervisor (Second District), Santa Cruz County

Yes - and it can be potentially be done within the system that exists. Health insurance expansion through the ACA has greatly reduced the number of uninsured and has shown to improve health outcomes for those enrolled. Even so, about three million remain uninsured - the greatest number are undocumented. The two most direct ways the state could ensure all have health insurance is expanding Medi-Cal eligibility to all low-income adults regardless of immigration status and making coverage on Covered California more affordable by supplementing federal subsidies. But health coverage isn’t just having health insurance, but also having access to health care. Since community and County-based safety net clinics are often frontline providers to this population increasing funding to these providers would ensure there are medical providers for those least likely to have regular access to medical care.

Jodi Hicks – Director, Mercury Public Affairs

California should make it its mission to ensure that every resident has equal access to healthcare. Healthcare coverage is an integral component of achieving universal access to healthcare, but it is important to recognize the distinct difference between being insured and having access to care. California has continued to achieve important gains in the number of people insured in the state by expanding its Medicaid program (Medi-Cal) and its swift implementation of the ACA. But healthcare accessibility is about more than just insuring the uninsured. One-third of California residents are now covered under Medi-Cal but the state continues to reimburse providers at roughly half the rate of Medicare, and far less than the reimbursement rate of private insurers, causing a continued decrease in the participation rate of doctors in the Medi-Cal program. California also suffers from a shortage of primary care providers, compounding the problem for low-income and vulnerable patients to find quality access to healthcare.

Polls continue to show that residents in California see healthcare as a priority. The Affordable Care Act was based on the idea that every American should be able to get health insurance and the public has come to accept this premise. While the vast majority of Californians believe healthcare coverage for all should be a goal of the state, there are varying opinions on how to get there.

Any financing model to achieve universal coverage has its strengths and challenges. Single-payer, public option or Medicare/Medicaid buy-in approach all deserve to be analyzed and debated by Californians and their elected officials. Fundamental change is needed to shift the direction of our healthcare system to one that covers all people and emphasizes equal access to quality care. Insurance plans, by definition, lose money by caring for the sick. Covering all Californians, both healthy and sick, our workforce and more vulnerable populations, requires payment transformations with better medical outcomes. Ultimately, the goal of our healthcare system should be a healthier and more productive society. Any healthcare system must also account for, and address, social determinants that have a major impact on public health outcomes and costs. Socioeconomic status, housing, food security and environmental health issues must also be a part of an overall healthcare solution for California. A healthcare system that focuses on keeping people healthy improves outcomes and saves money. Ultimately, whether we transform our healthcare system or build on to the system we already have, providing Califorians with access to care, free of fear from high medical costs, regardless of immigration status, age, disability, income or other factors provides Californians with health and quality of life. What could be a more important goal than that?

Lloyd Dean – CEO, CommonSpirit Health

“I believe health care is a basic human right. In California today, 93 percent of residents have insurance coverage and of course we must get that to 100 percent. Together, we must build upon this achievement so the remaining 7 percent of Californians have the opportunity to be healthy.

But insurance is just a part of the equation. We need to make sure not only that people are covered, but also that they can get the care they need to get and stay healthy.

That means providing transportation so that health services treatment and appointments are accessible. It means we need to make housing more affordable, nutritional food more available, and the environment cleaner to promote healthy living.

It means leveraging innovative technologies like telemedicine to make care accessible outside the four walls of the hospital. Remote monitoring and testing can enable clinicians to spot issues for patients with chronic conditions and help get them care before emergency treatment might otherwise be needed.

In California, we are fortunate to have a health care system with excellent quality and access for most of our residents. Our costs are moderate relative to other states, but still too expensive.

As we strive to reach the goal of 100 percent coverage in our great state, we also must work to provide high-quality, cost effective care that is accessible to all.”

Dan Schnur, a veteran analyst and longtime participant in California politics, is director of the California Influencers series for McClatchy.