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CMA Capitol Insight: "How Did It Get So Late So Soon?"



May 15, 2013

CMA Capitol Insight is a biweekly column by veteran journalist Greg Lucas, reporting on the inner workings of the state Legislature.


“How Did It Get So Late So Soon?”

That’s a quote from one of the greatest Western thinkers of all time: Dr. Seuss. (Pun intended.) While talking about life, the good doctor might as well be describing the Affordable Care Act, its January 1, 2014, implementation, and Covered California, formerly the California Health Benefit Exchange. One week ago Tuesday, the exchange approved a model contract for health plans that want to sell through the exchange. Final OK on the section relating to the acceptable performance of those health plans was postponed until May 23 – the same day the exchange says it will announce a tentative list of insurers that individuals and small businesses can buy from. Final approval of the list is July 1. Previously, the exchange has said it plans to have its online smorgasbord of coverage options up and running October 1, the beginning of a six-month open enrollment period that runs through March 2014. January 1, 2014, is a fast 232 days away.

Not A Model of Brevity

The model contract is 56 pages long. That doesn’t count the list of 16 attachments that would be appended to a “real” contract. Among the information required in the 16 attachments is the area the health plan serves, details of plan benefits, proof of “good standing” and the rates to be charged to different categories of customers. Nor does it count the seven-page glossary at the end of the contract, defining various technical terms including what constitutes a “family member.” According to the exchange, that’s “an individual who is within an enrollee’s or employee’s family, as defined in 26 U.S.C. 36B (d)(1).” The federal statute cited is quite specific – family size is “equal to the number of individuals for whom the taxpayer is allowed a deduction.” Also defined in the model contract is an “encounter.” An “encounter” is “any health care service or bundle of related health care services provided to one enrollee by one ‘Health Care Professional’ within one time period.” Apparently, there is no ambiguity about “bundle.” It has no definition in the glossary although Webster’s shows it to be both a noun and verb with several nuances of meaning. Covered California also is silent about what might constitute a “close encounter,” as well as whether a plurality of encounters would be a “group of encounters” or simply an “encounter group.”

For the Record

In case any reader might be wracked with doubt, a “health care professional” is defined by Covered California as “an individual with current and appropriate licensure, certification or accreditation in a medical or behavioral health profession, including without limitation, medical doctors – including psychiatrists – dentists, osteopathic physicians, psychologists, registered nurses, nurse practitioners, licensed practical nurses, certified medical assistants, (take breath here) licensed physician assistants, mental health professionals, chemical dependency counselors, clinical laboratory professionals, allied health care professionals, pharmacists, social workers, physical therapists, occupational therapists and others to provide health care services.” Who exactly is left to be lumped into “others?”

Just Don’t Seem Right

The Affordable Care Act requires employers with 101 or more employees to begin offering health coverage to part-time employees who work 30 hours a week or more. Rather than increase their own health care costs, some companies supposedly are reducing the hours of part-time workers to keep them below the 30-hour-a-week threshold. In most states, a percentage of those part-time employees would be eligible for care under Medicaid, which will be available to more lower income Americans starting in January, specifically those earning 138 percent of the federal poverty level or below. A person at 138 percent of the poverty level would earn $15,415. A family of four would earn $31,809. While the Golden State is expanding eligibility for Medi-Cal, its version of Medicaid, some states like Texas aren’t. And in those states like Texas, all those under-30-hours-a-week employees would be shopping on their state’s equivalent of Covered California.

The “Benefits Book” From Bentonville, Arkansas

Wal-Mart, the nation’s largest retailer and a favorite target of organized labor because of its implacable anti-union stance, issued a new “Benefits Book” for its employees late last year that says those hired after February 2012 whose hours fall below 30 per week – Wal-Mart sets the work schedules – will lose health coverage. Those hired between January 15, 2011, and February 1, 2012, must work at least 24 hours a week to retain coverage and are subject to an annual eligibility check. Several years ago, in the face of criticism about its treatment of part-time employees, Wal-Mart said it was boosting their benefits, including health coverage. Unions have happily seized on this. “The Wal-Mart Loophole” is their label for this alleged practice of shorting hours for part-time workers to push them into securing their own health coverage. Legislation claiming to combat this from happening has been introduced in the Capitol – AB 889 by Assemblyman Jimmy Gomez, a Los Angeles Democrat and former political director of the United Nurses Association of California. Gomez would require companies with 500 or more employees to pay a penalty for each worker on Medi-Cal. The penalty would be the cost of commercial health coverage for the employee, pro-rated by hours worked. The penalty would be used to cover the state’s share of Medi-Cal costs. Public employers are not included in the bill even though, as the Los Angeles Times noted in a recent story, government entities such as Long Beach are lowering the hours worked by part-time workers to keep them below the 30-hour minimum.

Writing Lesson

Among the supporters of the Gomez bill is the California Medical Association (CMA), which is less interested in counting coup on Wal-Mart and more interested in the consequences of potentially driving more individuals from employer-based coverage into Medi-Cal. Capitol Insight tips its quill to Eduardo Martinez, CMA’s associate director for government relations, who lays the issue out clearly and convincingly in an April 30 support letter for the Gomez bill: “Although Medi-Cal is intended to provide essential health care services to many of the poorest and most vulnerable Californians, it has unfortunately become a broken promise for access to health care. Largely due to low reimbursement – ranking 47 out of 50 states – physician participation in Medi-Cal is lower than it should be as we prepare to fully implement the [Affordable Care Act.] As a result, more than half of Medi-Cal patients report difficulty finding a doctor. When they are unable to find a provider, many Medi-Cal patients seek preventive and other non-urgent care in the hospital emergency department. Providing preventive and primary care through [emergency rooms] is inefficient and strains state and county coffers. Other Medi-Cal enrollees who cannot find a provider may simply go without preventive and primary care altogether and end up in the emergency department only after their condition has become severe. Given the current state of Medi-Cal, there is no question the strain on the system will be insurmountable if employers stop offering employer-based coverage to their low-wage employees.” Couldn’t have said it any better.

Smoke-Free UC

It’s been a few weeks since the University of California at Los Angeles implemented an “educational” smoking ban. Smoking has been prohibited in state buildings and vehicles for nearly 20 years but this ban covers all UCLA property – both on-campus and off-campus sites owned or leased by the university. Not only cigarettes but cigars, chewing tobacco, hookahs and e-cigarettes are covered by the ban, which was enacted for all the obvious health reasons and in response to a January missive from University of California President Mark Yudoff ordering chancellors to get their campuses smoke-free within two years. UCLA is first to do so. Enforcement – at an institution of higher learning, go figure – will be to “politely educate” violators of the new policy. In calculating how many people might be affected by the new policy, UCLA cites a 2010 system-wide survey in which 7.9 percent of undergraduates over age 18 said they had used tobacco within the past month. The California Department of Public Health says nearly 12 percent of California adults use tobacco. Ergo, the university figures, with a 12 percent prevalence rate, “this would mean that here at UCLA we have approximately 8,640 smokers, not including patients and visitors.” Exceptions: University-approved research and “ceremonial use,” which isn’t defined but requires advance approval by “the sponsoring department, the UCLA Events Office and the Fire Marshal’s Office.”

Good Advice, Whoever Said It

“It's far more important to know what person has the disease than what disease the person has,” is a quote attributed to Hippocrates of Cos, the so-called Father of Western Medicine. Like the famous oath that bears his name, that quote might not have actually been spoken or written by Hippocrates. The first biography of Hippocrates was written in the Second Century, AD – not exactly a contemporary account, since Hippocrates died in 370 BC. But, again, regardless of original authorship, who can argue with the wisdom of “Cure sometimes. Treat often. Comfort always.”

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