ACTUALLY WILL GO AHEAD AND GET
STARTED SOMEWHERE OTHER MEMBERS
WILL UP WILL BE TRICKLING AND SO
BUT IN THE INTEREST OF. OF OUR
SPEAKERS WHO'VE TRAVELED MANY OF
THEM LONG DISTANCES TO BE HERE
WE WANT TO GIVE.
AMPLE OPPORTUNITY FOR THEM TO
BE ABLE TO PARTICIPATE AND.
AND MOVE FORWARD SO THIS POINT
A MINUTE JUST MAKE SOME OPENING
REMARKS AND PASS IT OFF TO MY CO
CHAIR A DOCTOR ARAMBULA SO.
FIRST OF ALL GOOD AFTERNOON AND
WELCOME TO THE FOURTH IN A
SERIES OF HEARINGS OF THE SELECT
COMMITTEE ON HEALTH CARE
DELIVERY. AND UNIVERSAL COVERAGE
AS WE DIG DEEPER INTO THIS
POLICY RECOGNIZE THAT IN ORDER
TO BE SUCCESSFUL IN DEFINING A
PATHWAY TO UNIVERSAL COVERAGE WE
MUST ADDRESS SOME OBVIOUS AND
POTENTIAL CHALLENGES RELATED
STATE. AND FEDERAL LAW.
FOR EXAMPLE MEDICARE IS FUNDED
THROUGH A PROTECTED MEDICARE
TRUST FUND AND FEDERAL LAW
ESTABLISHES THE RULES FOR HOW
THAT MONEY CAN BE SPENT.
ACCESS IN THOSE FUNDS WOULD
REQUIRE CONGRESSIONAL ACTION.
THEY'RE ALSO STATE
CONSTITUTIONAL ISSUES PROP
NINETY EIGHT REQUIRES FORTY
PERCENT OF STATE GENERAL FUND
REVENUES TO GO TO QUE TO
FOURTEEN EDUCATION.
BEGAN LIMITS FROM PROPOSITIONS
THIRTEEN FOUR IMPOSED SPENDING
LIMITS ON THE STATE.
TO ENSURE THAT REVENUE IN IT IN
EXCESS OF THOSE LIMITS WOULD BE
RETURNED TO TAXPAYERS.
IF TAXES WERE INCREASED TO FIND
A HEALTHCARE SYSTEM HOW WOULD
THOSE REVENUES BE AFFECTED.
THREE POINT THREE MILLION
CALIFORNIANS GET THEIR COVERAGE
THROUGH SELF INSURED OR SELF
FUNDED PLANS THAT ARE SUBJECT TO
A RECESS.
ADMINISTERED BY THE US
DEPARTMENT OF LABOR.
THEY ARE EXEMPT FROM THE STATE
SPECIFIC INSURANCE REGULATIONS.
TODAY WE HAVE IMPRESSIVE PANEL
OF EXPERTS WHO WILL WALK US
THROUGH THESE ISSUES AND MORE.
FOLLOWING EACH PRESENTATION THE
MEMBERS WILL HAVE A THE
OPPORTUNITY ASK QUESTIONS THE
LAST TWO PANELS WERE PRESENT
TOGETHER.
MEMBERS WILL HAVE AN OPTION AS
QUESTIONS AFTER THEY PRESENT.
WILL ALSO HAVE PUBLIC COMMENT
I'D LIKE TO ENSURE THAT DURING
THE PUBLIC COMMENT PERIOD WE
ALLOWS MANY PEOPLE TO SPEAK AS
POSSIBLE. I CRINGE EVERYONE TO
BE RESPECTFUL ND MORE AND LIMIT
THEIR PRE* INSTITUTE TWO
MINUTES DURING THE. PUBLIC
COMMENT MORE DETAILED WRITTEN
COMMENTS ARE WELCOMED AND CAN
MEET SUBMITTED DIRECTLY TO THE
COMMITTEE.
THANK YOU VERYMUCH I THAT I'D
LIKE TO INVITE MARCO CHAIR.
DOCTOR LOOKING ARAMBULA TO
OFFER THE OPENING REMARKS.
THANK YOU.
I'D LIKE TO THANK EVERYONE FOR
ATTENDING TODAY'S HEARING.
THIS HEARING IS THE FIFTH IN A
SERIES OF HEARINGS THAT WE'VE
HAD TO EXPLORE THE WAYS TO
IMPROVE OUR STATE'S HEALTH CARE
SYSTEM. AND PROVIDE UNIVERSAL
HEALTHCARE FOR ALL CALIFORNIANS.
IN OUR PREVIOUS HEARINGS WE
FOCUSED ON CALIFORNIA'S CURRENT
SYSTEM.
INCLUDING PUBLIC PROGRAMS THE
INDIVIDUAL MARKET EMPLOYER BASED
COVERAGE. SAFETY NET PROGRAMS
AND CURRENT GAPS IN COVERAGE.
WE'VE ALSO HEARD ABOUT MODELS OF
UNIVERSAL COVERAGE SYSTEMS IN
OTHER COUNTRIES.
WE'VE HAD EXPERTS SHARE DETAILS
ABOUT DIFFERENT MODELS AND
PROGRAMS FROM DIFFERENT STATES
AND OUR LAST HEARING WE HEARD
ABOUT CHALLENGES IN ACCESSING
CARE.
AND THE BECAUSE OF HIGH PRICES.
THANKS TO THESE HEARINGS THE
MEMBER OF THIS COMMITTEE HAVE A
MUCH BETTER APPRECIATION OF THE
COMPLEXITY OF OUR HEALTHCARE
SYSTEM.
THAT BEING SAID I BELIEVE
TODAY'S HEARING.
MAYBE THE MOST IMPORTANT HEARING
WE'VE HAD TO DATE.
WE WILL FOCUS ON THE
IMPLEMENTATION CHALLENGES AND
CONSIDERATIONS WILL NEED TO
ADDRESS AS WE MOVE FORWARD WITH
ANY CHANGES TO CALIFORNIA'S
HEALTH CARE SYSTEM.
THIS COMMITTEE'S CHARGE IS TO
FIND WORKABLE SOLUTIONS THAT
WILL EXPAND HEALTHCARE COVERAGE
AND INCREASED ACCESS TO CARE.
THAT IS WHY I BELIEVE THAT
TODAY'S HEARING MAYBE THE MOST
IMPORTANT HEARING.
IF WE CAN IDENTIFY THE
IMPLEMENTATION CONSIDERATIONS
AND CHALLENGES WELL UNDERSTAND
THE CHALLENGES WE FACE IN
IMPROVING OUR CURRENT HEALTHCARE
SYSTEM.
I AM INTERESTED IN HEARING ABOUT
WHAT CURRENT FEDERAL LAW WILL
ALLOW US TO DO. AND NOT TO DO.
WE ALSO NEED TO UNDERSTAND THE
CONSTRAINTS ARE STATE'S
CONSTITUTION PUT ON EXPANSION
PROPOSALS.
FINALLY WE NEED TO FIGURE OUT
HOW WE PAY FOR ANY CHANGES WE
WANT TO MAKE.
AS THE CHAIR OF THE BUDGET
SUBCOMMITTEE ON HEALTH AND HUMAN
SERVICES I BELIEVE IT IS
IMPERATIVE THAT WE UNDERSTAND
THAT IT WILL COST TAXPAYERS AND
HOW WE PAY FOR EXPANSIONS TO OUR
SYSTEM.
AS WE WORK TOWARDS THE IDEAL
THAT HEALTHCARE IS A HUMAN RIGHT
IN CALIFORNIA.
TODAY'S HEARING WILL HELP INFORM
US HOW WE MOVE FORWARD.
AS I HAVE SAID MANY TIMES NOW WE
ARE CALIFORNIA WE DON'T FOLLOW
WE LEAD.
AND NOW BEFORE WE START THE REST
OF OUR HEARING I'D LIKE TO OFFER
OUR FELLOW MEMBERS AN
OPPORTUNITY FOR AN OPENING
STATEMENT.
OKAY.
WILL GO AHEAD AND GET STARTED
THEN WE HAVE AN OVERVIEW SUSAN
PHILLIPS SENIOR HEALTH CARE
MANAGEMENT CONSULTING WITH
MILLIMAN.
SHE'S FOCUSES ON DEVELOPING
PRACTICAL SOLUTIONS TO ALIGN
INCENTIVES IN OUR HEALTHCARE
SYSTEM TO ENCOURAGE VALUE
QUALITY AND ACCESS.
SUSAN.
MEMBERS OF THE COMMITTEE I
WANTED THANK YOU FOR THE
OPPORTUNITY TO SPEAK TODAY. AS
PART OF THESE VERY IMPORTANT
SERIES OF HEARINGS. AS A
LONGTIME RESIDENT OF CALIFORNIA
AS A PATIENT AND USER OF THE
HEALTHCARE SYSTEM MYSELF. I'M
EXCITED THAT YOU'RE UNDERTAKING
EFFORTS TO CONSIDER OUR
HEALTHCARE DELIVERY SYSTEM AND
HOW TO MAKE IT BETTER AND MORE
ACCESSIBLE FOR ALL MEMBERS OF
OUR COMMUNITY.
AS MENTIONED I AM HEALTHCARE
MANAGEMENT CONSULTANT WHAT
MILLIMAN MILLMAN IS AN
INDEPENDENT CONSULTING FIRM
OFFERING ACTUARIAL AND RELATED
SERVICES TO PUBLIC AND. PRIVATE
SECTOR CLIENTS AROUND THE
COUNTRY. WE ROUTINELY ROUTINELY
WORK WITH PUBLIC PARTNERS
I INCLUDING STATE MEDICAID
PROGRAMS STATE EMPLOYEE HEALTH
INSURANCE PROGRAMS AS WELL AS
PROVIDERS PAYERS AND EMPLOYERS.
YOU ALREADY HAD A NUMBER OF
SPEAKERS THROUGHOUT THESE
INFORMATIVE HEARINGS AND ARE
ALREADY WELL VERSED IN THE
COMPLEXITY OF OUR HEALTHCARE.
SYSTEM.
MY JOB TODAY'S TO GIVE YOU AN
OVERVIEW OF IMPLEMENTATION
ISSUES. THAT WOULD ARISE
DEPENDING ON THE POLICY
SOLUTIONS YOU ARE CONSIDERING.
MY GOAL IS TO PROVIDE YOU A
USEFUL FRAMEWORK TO EVALUATE
VARIOUS PROPOSALS THAT YOU MAY
BE CONSIDERING OVER THE NEXT FEW
WEEKS OR MONTHS.
I'M GONNA T. OF THE KEY
IMPLEMENTATION ISSUES AND THE
SPEAKERS THAT ARE FOLLOWING ME
WILL PRESENT A DEEPER DIVE INTO
EACH OF THE AREAS I WILL LAY
OUT.
I WILL NOTE THAT MOST OF MY
COMMENTS.
ARE ALSO SUMMARIZED IN A REPORT
THAT WAS FUNDED BY THE
CALIFORNIA HEALTHCARE FOUNDATION
AND CO AUTHORED BY MYSELF AND
MARY MULTI CALLED KEY QUESTIONS
WHEN CONSIDERING A STATE BASED
SINGLE PAYER SYSTEM. IN
CALIFORNIA.
I BELIEVE YOU MAY ALREADY HAVE.
THAT REPORT IS PART OF YOUR
BRIEFING MATERIALS.
I'M ONE OF THE KEY THEMES I CAME
THAT HAS COME OUT OUT OF THE
HEARING SO FAR IS THAT
CALIFORNIA HAS MADE A LOT QUITE
A LOT OF PROGRESS.
IN REDUCING THE NUMBER OF
UNINSURED IN CALIFORNIA IN THE
LAST FEW YEARS AND REALLY MOVING
TOWARDS UNIVERSAL COVERAGE.
HOWEVER THERE DOES REMAIN ABOUT
THREE MILLION PEOPLE WHO ARE ARE
UNINSURED.
AND ALSO EVEN WITH PROGRESS
TOWARDS UNIVERSAL COVERAGE MUCH
WORK REMAINS TO BE DONE TO
IMPROVE AFFORDABILITY IMPROVE
ACCESS TO COMPREHENSIVE
BENEFITS.
AND REDUCE FRAGMENTATION AND
EFFICIENCIES OF OUR HEALTHCARE
SYSTEM.
THERE ARE MANY POLICY APPROACHES
TO ACHIEVING UNIVERSAL COVERAGE
AND THESE MAY INCLUDE SINGLE
PAYER A PUBLIC OPTION.
A POLICY AND OR POLICY
APPROACHES A BUILD ON EXISTING
PROGRAMS SUCH AS MEDICAL OR
COVER CALIFORNIA.
I WON'T BE GETTING INTO EACH OF
THESE UP POLICY OPTIONS IN
DETAIL BUT INSTEAD I'LL BE
RAISING KEY IMPLEMENTATION
QUESTIONS FOR YOU TO CONSIDER.
ONE OF THE FIRST THINGS I WANT
TO DO IS JUST CLARIFY SOME
TERMINOLOGY.
FIRST WHAT ARE WE TALKING ABOUT
WHEN WE REFER TO SINGLE PAYER.
AND THE DEFINITION YOU SEE ON
THIS SLIDE IS ONE THAT WE LAID
OUT IN THE PAPER AND HAS GENERAL
CONSENSUS.
BUT FUNDAMENTALLY SINGLE PAYER
IS A SINGLE CENTRALIZED PUBLIC.
PUBLICLY ORGANIZED MEANS TO
COLLECT HEALTHCARE DOLLARS AND
PAY FOR HEALTHCARE SERVICES FOR
ALL MEMBERS OF OUR COMMUNITY.
I HIGHLY THE WORD SINGLE HERE
BECAUSE IT IT DOES APPLY JUST
SAT SINGLE AND NOT A MULTIPLE
PAYER SYSTEM.
AS ALL OF YOU KNOW WE CURRENTLY
OPERATE IN A MULTIPLE PAYER
SYSTEM INCLUDING MEDICARE
MEDICAID I'LL COVER CALIFORNIA
CALPERS.
AND FEDERAL PROGRAMS SUCH AS THE
VETERANS ADMINISTRATION AND A
NUMBER OF PRIVATE PAYERS.
THE NEXT TERM I ONCE YOU DEFINE
IS UNIVERSAL COVERAGE.
SOMETIMES A NOTION OF SINGLE
PAYER AND UNIVERSAL COVERAGE
GETS A BIT MUDDLED. BUT IMPORTS
NO THAT THE IDEA OF SINGLE PAYER
AND UNIVERSAL COVERAGE ARE ARE
DISTINCT.
UNIVERSAL COVERAGE IS REALLY
TALKING ABOUT.
MAKING SURE THAT EVERYONE HAS
HEALTH INSURANCE COVERAGE.
IT'S REALLY TALKING ABOUT ALL
COVERED LIVES AND MAKING SURE
THEY'VE ACCESS TO HEALTH
INSURANCE IN SOME WAY.
SINGLE PAYER IS REALLY TALKING
ABOUT THE PAYMENT SYSTEM WHICH
USES ONE PUBLICLY ORGANIZED
CENTRAL MEANS OF PAYING FOR
HEALTHCARE SERVICES.
SO I JUST THOUGHT IT WAS HELPFUL
TO TEE UP THOSE DEFINITIONS.
AS I MENTIONED UNIVERSAL
COVERAGE CAN BE ACHIEVED THROUGH
A VARIETY OF POLICY OPTIONS.
INCLUDING SINGLE PAYER PUBLIC
OPTION OR EXTENDING CURRENT
COVERAGE PROGRAMS.
AND SOME OF THESE POLICY OPTIONS
MIGHT BE BROAD AND EXPANSIVE
WHILE OTHERS MIGHT BE CONSIDERED
INCREMENTAL.
THE ANCHOR MENTAL APPROACHES
ARE LIKELY TO HAVE FEWER
IMPLEMENTATION ISSUES THEN SAY
BROAD EXPANSIVE APPROACHES LIKE
SINGLE LIKE SINGLE PAYER.
AND THAT'S ESPECIALLY TRUE IF A
NEW POLICY APPROACH REQUIRES
PEOPLE TO CHANGE HEALTHCARE
COVERAGE.
AND.
IT TO THE TO CHANGE THE HEALTH
CARE COVERAGE THAT THEY
CURRENTLY HAVE.
SO ULTIMATELY ITS SUPPORT FOR
POLICYMAKERS TO CONSIDER THE
TRADE OFFS OF THE POLICY
APPROACHES.
THE COSTS
THE DISRUPTION THAT MIGHT MIGHT
ENSUE.
AND OF COURSE THE BENEFITS.
AND IT'S ALSO IMPORTANT TO
CONSIDER WHAT'S REALLY
ACHIEVABLE IN THE SHORT TERM
VERSUS A LONGER TERM.
AND AS YOU ALL KNOW.
NOT EVERY GOALS ACHIEVABLE
OVERNIGHT.
SO I WOULD SAY IT'S IMPORTANT
TO LAY OUT A ROADMAP
ARTICULATING WHAT THE FINAL
DESTINATION IS.
WHETHER IT BE SINGLE PAYER OR
SOME OTHER MEANS OF OF ACHIEVING
UNIVERSAL AFFORDABLE COVERAGE.
IN ADDITION TO LAYING OUT A
ROADMAP I'M A BIG PROPONENT.
OF CAREFULLY ASSESSING POLICY
OPTIONS TO MINIMIZE ANY
UNINTENDED CONSEQUENCES.
AND TO UNDERSTAND COURSE
PROJECTED COSTS AND BENEFITS OF
VARIOUS OPTIONS.
SO THE I'LL GET INTO THIS A
LITTLE BIT LATER MY PRESENTATION
WHEN I LAY OUT A FRAMEWORK OF
COMPARING VARIOUS OPTIONS.
SO I'M GONNA WALK THROUGH A
COUPLE OF ON IMPORTANT
IMPLEMENTATION QUESTIONS AND I'M
CALLING FIRST ORDER QUESTIONS.
ONE FIRST ORDER QUESTION OF
COURSES WHO'S IN AND WHO'S OUT.
AS WE'VE ALREADY HEARD OF THERE
ARE CONSIDERATIONS RELATED TO.
WHICH POPULATION OF CALIFORNIA
WOULD BE CONSIDERED.
.
UNDER A NEW UP PAYMENT MODEL.
SO WITH EVERY HOUSEHOLD IN EVERY
CONSUMER IN CALIFORNIA BE
INCLUDED IN A POLICY PROPOSAL.
SO FOR EXAMPLE FOR TALKING
ABOUT A SINGLE PAYER SYSTEM
WOULD WE INCLUDE THE SIX MILLION
MEDICARE BENEFICIARIES IN
CALIFORNIA.
ABOUT FORTY PERCENT OF THOSE
MEDICARE BENEFICIARIES SO ABOUT
TWO MILLION ARE ENROLLED IN
MEDICARE ADVANTAGE
WHICH MEANS THEY GET COVERAGE
THROUGH A HEALTH PLAN.
WITH THOSE INDIVIDUALS HAVE THE
OPTION OF SWITCHING TO A STATE
BASED SINGLE PAYER OPTION WHILE
STILL GETTING MEDICARE BENEFITS
THAT THEY'RE ELIGIBLE FOR.
AND AS YOU ALL KNOW MEDICARE IS
A FEDERAL PROGRAM SO CALIFORNIA
WOULD HAVE TO BE HAVE TO
CONSIDER WHETHER THIS IS
FEASIBLE FROM A FEDERAL
PERSPECTIVE.
SIMILAR SET OF QUESTIONS ARISE
FOR THE THIRTEEN MILLION PEOPLE
IN THE MEDICARE PROGRAM.
WITH THOSE INDIVIDUALS BE
INCLUDED IN A STATE BASED SINGLE
PAYER OPTION OR ANOTHER
UNIVERSAL COVERAGE PROPOSAL.
AND HOW ABOUT INDIVIDUALS
RECEIVE HEALTH INSURANCE THROUGH
SELF INSURED EMPLOYERS.
WHAT IS A FEASIBILITY OF MOVING
THESE EMPLOYEES AND THEIR
DEPENDENTS TO A STATE BASED
PROGRAM?
DOES THE STATE HAVE THE CURRENT
AUTHORITIES AND LEVERS TO MAKE
THESE CHANGES. AS I MENTION
OTHERS SPEAKERS WILL GET INTO
MEDICARE MEDICARE MEDICAID ALL
THE EMPLOYEE RETIREMENT INCOME
SECURITY ACT OR ERISA. AND
FEDERAL WAIVERS AND AUTHORITIES
IN MUCH MORE DETAIL.
BUT I DID WANT TO POINT OUT
POINT THESE OUT AS KEY
FUNDAMENTAL FIRST ORDER
FEASIBILITY QUESTIONS THAT
REALLY HAVE TO BE CONSIDERED.
WHEN THINKING ABOUT A
COMPREHENSIVE WIDE REACHING
POLICIES SUCH A SINGLE PAYER.
ANOTHER QUESTION IS.
THAT HAS TO DO WITH BENEFITS.
WHAT BENEFITS WOULD BE COVERED
UNDER SAY SINGLE PAYER OPTON OR
SOME OTHER UNIVERSAL COVERAGE
OPTION?
FOR EXAMPLE WOULD BE ESSENTIALLY
ADOPT ESSENTIAL HEALTH BENEFITS
WHICH IS THE MINIMUM FLOOR
THAT'S LAID OUT BY THE
AFFORDABLE CARE ACT.
OR WOULD IT BE ON MEDI CAL WOULD
THE MEDI CAL BENEFITS BE THE
RIGHT SET OF BENEFITS.
WHAT'S IT COST FOR THE TOTAL
BENEFIT PACKAGE.
WHAT ABOUT?
SPECIFIC BUT BENEFITS SUCH AS
DENTAL CARE FOR ADULTS WITHOUT
BEING CLINTON. HOW ABOUT
NUTRITIONAL COUNSELING OR NON
EMERGENCY TRANSPORTATION?
AND THEN WHAT ABOUT COST SHARING
WITH THEIR BE PAYMENTS AT THE
POINT OF SERVICE. AND IF SO HOW
MUCH.
WOULD EVERYONE BE CHARGES SAME
AMOUNT.
OR WOULD BE BASED ON INCOME.
SO THESE ARE AGAIN BIG BIG
PICTURE QUESTIONS THAT WOULD
HAVE TO BE ADDRESSED FROM
IMPLEMENTATION PERSPECTIVE.
AND OF COURSE THE NEXT BIG
QUESTION IS HOW WILL IT BE PAID
FOR.
THERE IS UNCERTAINTY REGARDING
WHETHER AND HOW DOLLARS A AND
AND WHETHER.
DOLLARS A CALIFORNIA RECEIVES
THROUGH FEDERAL CHANNELS CAN
REALLY BE REDISTRIBUTED TO SOME
KIND OF CENTRALIZED
CALIFORNIA BASED FUND.
AND THESE ARE BIG POLICY
CONSIDERATIONS THAT WOULD HAVE
TO BE.
BROUGHT UP AND DISCUSSED WITH
THE FEDERAL DEPARTMENT OF HEALTH
AND HUMAN SERVICES.
A AGAIN TO THE EXTENT THAT SELF
INSURED EMPLOYERS ARE IN THE
MIX.
RISA WOULD VERY WELL BE A
CONCERN.
WAIVERS UNDER THE ACA MEDICARE
AND MEDICAID AGAIN MAYBE A PATH
FOR OBTAINING SOME OF
APPROPRIATE PERMISSIONS FROM THE
FEDERAL GOVERNMENT.
ON AND TO SEE WHETHER CALIFORNIA
COULD STILL RECEIVE.
SOME NECESSARY FUNDS FOR FROM
THE FEDERAL GOVERNMENT.
BUT REALLY THOSE PATS DEPEND ON
THE SCOPE OF THE POLICY
APPROACH.
SO ARE SPEAKERS TODAY WILL AGAIN
FOCUS MORE ONEROUS AND MEDICARE
MEDICAID AND THE FEDERAL
AUTHORITIES AND AND WAIVERS IN
MORE DETAIL BUT I DID FIND A. T.
THOSE UP AND THOSE ARE JUST A
FEDERAL CONSIDERATIONS.
THEY'RE ALSO STATE
CONSIDERATIONS THAT AFFECT HOW
THE WEATHER THE PROGRAM WOULD
HAVE SAID.
FUNDS.
SO AS YOU ALL VERY WELL KNOWN
UNLIKE THE FEDERAL GOVERNMENT
STATES CANNOT OPERATE WITH THE
BUDGET DEFICIT.
SO IF THE STATE WERE TO CONSIDER
A COMPREHENSIVE POLICY APPROACH
SUCH A SINGLE PAYER. IT'S
IMPORTED MAKE SURE THERE'S
ENOUGH MONEY TO SUPPORT IT.
ENSURING THAT THE REVENUE TRENDS
KEEP PACE WILL HEALTHCARE COST
TRENDS IS ILLEGITIMATE AND
FUNDAMENTAL CONCERN.
SO HOT SO HOW WE ARE MAKING SURE
TO COLLECT ENOUGH FROM YOU TO
SUPPORT A NEW PROGRAM ISRAELI.
ON IS REALLY A FIRST ORDER
QUESTION.
ANOTHER A QUESTION HAS TO DO
WITH STATE CONSTITUTIONAL
CONCERNS WHICH WAS
TOUCHED ON EARLIER BY IN THE
OPENING REMARKS.
YOU'LL HEAR MORE ABOUT THIS FROM
THE CALIFORNIA BUDGET POLICY
CENTER BUT THERE ARE BURGEONING
RULES REGARDING ALLOCATION OF
STATE TROUGH FUNDS TO K. THROUGH
TWELVE EDUCATION.
SO THIS MEANS INCREASES TO THE
GENERAL FUNDS THROUGH TAXATION
COULD TRIGGER THESE
REQUIREMENTS.
THIS ISN'T IMPORTANT FEASIBILITY
CONSIDERATION WHEN THINKING
ABOUT ANY PROPOSAL THAT'S
RELYING ON.
GENERATING ENOUGH TAX REVENUE
THAT WOULD THEN AFFECT THE
GENERAL FUNDS.
SO.
.
I WOULD LIKE TO GET INTO NEXT TO
A SET OF DESIGN QUESTIONS SO WE
FIRST HAD FIRST ORDER QUESTIONS
ARE REALLY ARE IMPORTANT
FEASIBILITY QUESTIONS AND NOW
WE'RE GETTING INTO A NEXT LEVEL
OF QUESTIONS I. DO HAVE TO DO
WITH IMPLEMENTATION BUT REALLY
ARE FROM A DESIGN PERSPECTIVE.
SO IF WE WERE STARTING FROM
SCRATCH.
CIRCUS IN DESIGNING A NEW
PROGRAM THESE ARE. THEY KEY
DESIGN QUESTIONS THAT WOULD HAVE
TO BE CONSIDERED AS PART OF THE
IMPLEMENTATION PHASE.
SO STARTING WITH THE FIRST
BULLET.
HOW WOULD A SINGLE PAYER PROGRAM
ARRANGE FOR HEALTH CARE
SERVICES?
WITH THE SYSTEM USE
INTERMEDIARIES SUCH AS HELP
PLANTS.
OR WOULD PROVIDERS OF BE PAID
DIRECTLY THROUGH SOME STATE
BASED ADMINISTERED ENTITY.
ON JUST USE A COVER CALIFORNIA'S
AN EXAMPLE SINCE I WAS A PROGRAM
THAT WAS ESTABLISHED IN MORE
RECENT YEARS.
THEY HAD TO THINK THROUGH THIS
AS A DESIGN QUESTION AND THEY
DECIDED TO GO AHEAD OF CONTRACT
WITH HEALTH PLANS IN THE STATE.
TO OFFER COVERAGE AND PAY FOR
HEALTHCARE SERVICES.
SO THAT'S ONE MODEL HOW YOU
ARRANGE TO PAY FOR HEALTHCARE
SERVICES WHETHER YOU'D USE
INTERMEDIARIES SUCH AS HEALTH
PLANS ARE PAID DIRECT PAY
PROVIDERS PHYSICIANS DOCTORS.
HOSPITALS DIRECTLY IS UP A KEY
FUNDAMENTAL DESIGN QUESTION.
THE SECOND QUESTION IS REGARDING
ADEQUACY OF PAYMENT.
HOW MUCH SHOULD DOCTORS
HOSPITALS AND OTHER HEALTHCARE
PROVIDERS GET PAID FOR THE
SERVICES THEY RENDER?
HOW WOULD YOU SAID THAT PAYMENT
AMOUNT TO MAKE SHIRTS ADEQUATE?
WOULD PAYMENTS BE TIED TO SAY
FOR EXAMPLE IN EXISTING FEE
SCHEDULE SUCH AS THE MEDICARE
FEE SCHEDULES OR SOME OTHER
MECHANISM.
SENDING THE APPROPRIATE PAYMENT
AMOUNT TO MAKE SURE THAT YOUR
PROVIDERS PARTICIPATING IN THE
PROGRAM IS IMPORTANT.
AND ONE CONSIDERING PAN POLICIES
IT'S ALSO PRIME TO ENSURE THAT
PAYMENT POLICIES AND. ENCOURAGE
APPROPRIATE HEALTH CARE USE.
I THINK WE ALL KNOW FROM A
TRADITIONAL FEE FOR SERVICE
PAYMENTS THAT ON IT JUDICIAL P.
FOR SERVICE PAYMENTS REALLY PAY
PROVIDERS ON A PER SERVICE
BASIS.
AND THAT PAYMENT SYSTEM TENDS
TOWARD MORE USE AND MORE VOLUME.
AND MORE IS NOT NECESSARILY
BETTER AND CAN DRIVE UP
HEALTHCARE COSTS.
SO THE LAST SEVERAL YEARS
THERE'S BEEN A MOVEMENT BY
PUBLIC PAYERS AS WELL PRIVATE
PAYERS SHIRLEY TYPE PAYMENT TO
VALUE. OR QUALITY AND TO ENSURE
BETTER HEALTH A TO ENCOURAGE
RATHER BETTER HEALTH HEALTH
OUTCOMES AND BETTER
EFFICIENCIES.
AND JUST TO CONTINUE USING
COVERED CALIFORNIA AS AN EXAMPLE
IN THEIR PROCUREMENT PROCESS
THEY ENCOURAGE ON PAYMENT
METHODS THAT ARE ALTERNATE
ALTERNATIVE FROM FEE FOR SERVICE
MODELS. SO FOR EXAMPLE THEY
ENCOURAGE OF PAYERS TO CONSIDER.
ON VALUE BASED
PAYMENTS ON AS PART OF THEIR
PROCUREMENT PROCESS.
SO THE WAY PAYMENT SYSTEMS ARE
DESIGNED IS AN IMPORTANT DESIGN
CONSIDERATION.
THE OTHER IS A PROVIDER
PARTICIPATION I ALREADY
MENTIONED THAT PAYMENT ADEQUACY
IS REALLY IMPORTANT TO MAKE SURE
THAT STE. POSITIONS REALLY
PARTICIPATE IN THE IN THE
PROGRAM.
BUT HOW WOULD A. THIS HOW WOULD
POSITION PARTICIPATION WORK SAY
IN A TRUE SINGLE PAYER SYSTEM.
IF YOU REALLY JUST HAVE A SINGLE
PAYER SYSTEM WITH NO WHETHER
PAIRS WELL YOU'D HAVE TO INCLUDE
ALL PHYSICIANS PRACTICING IN THE
STATE. OTHERWISE HE WOULDN'T BE
ABLE TO SEE PATIENTS BECAUSE
THERE WOULD BE NO OTHER PAYERS
THEORETICALLY.
SO A SINGLE PAYER SYSTEM WOULD
HAVE TO REALLY ALLOW ANY WILLING
PROVIDER TO PARTICIPATE IN THE
SYSTEM.
SO THIS RAISES A A KEY QUESTION
ABOUT QUALITY AND HOW A SINGLES
PAYER SYSTEM CURRENTLY MAKE SURE
THE PATIENTS ARE REALLY GETTING
QUALITY CARE. FOR THEIR
PATIENTS.
SO AGAIN JUST TO CONTINUE USING
COVERED CALIFORNIA AS AN
EXAMPLE.
.
COVERED CALIFORNIA DECIDERS OKAY
TO BE SELECTIVE ABOUT WHICH
PROVIDERS.
PAGE IN THEIR NETWORKS AS LONG
AS THEY'RE SUFFICIENT ACCESS.
SO THIS WAS THE DESIGN CHOICE
THAT WAS MADE AND IT WAS MADE
TWO ENCOURAGE THE USE OF HIGH
VALUE. NETWORKS OR HIGH QUALITY
LOW COST.
THIS IS AN HEALTH SYSTEMS.
SO PROVIDER PARTICIPATION AS
WELL AS A QUALITY OF CARE
ASSOCIATED WITH THE PROVIDERS IS
REALLY AN IMPORTANT DESIGN
QUESTION.
THE NEXT IS A CONSUMER
PARTICIPATION AND I HAVE.
TOUCH ON THIS ALREADY THOSE A
BIG IMPLEMENTATION QUESTION
ABOUT FIGURING OUT YOU KNOW
WHO'S IN AND WHO'S OUT.
AND IF YOU'RE CONSIDERING THIS
FROM A SINGLE PAYER APPROACH
WHICH INCLUDES ALL CALIFORNIA
RESIDENTS.
AND THERE'S STILL SOME
ELIGIBILITY QUESTIONS TO SORT
pOUT.
SO FOR EXAMPLE WHAT IS BEING A
RESIDENT MEAN.
WITH THIS INCLUDE SOMEONE WHO
SAY FOR UP WITH.
WAS SO IF YOU'RE ON DECIDING
THAT EVERYONE THAT IS A RESIDENT
IS INCLUDED.
YOU HAVE JUST DEFINED RESIDENCY.
WOOD ON A PERSON WHO'S. LIVED IN
THE STATE FOR A FEW MONTHS BE
ELIGIBLE FOR THE PROGRAM.
WHAT ABOUT SOMEONE WHO WORKS IN
THE STATE OUR LIVES ELSEWHERE?
SO USES EXAMPLES OF ELIGIBILITY
QUESTIONS THAT HAVE TO BE SORTED
OUT.
ON ALREADY TOUCHED ON COVERED
BENEFITS AND SERVICES SO I WILL
ON. WON'T REPEAT THAT. I DO WANT
TO TOUCH ON GOVERNANCE AND
ADMINISTRATION.
SETTING UP A SOUND GOVERNANCE
MODEL IS REALLY IMPORTANT.
US SOUND GOVERNANCE MODEL
PROMOTES ACCOUNTABILITY
EFFECTIVE OVERSIGHT. AND
EVIDENCE BASED DATA DRIVEN
APPROACH TO IMPLEMENTATION AND
MANAGEMENT.
IT ALSO ENCOURAGES CONSUMER AND
STAKEHOLDER PARTICIPATION AS
WELL AS TRANSPARENCY.
SO IF WE WERE STARTING FROM
SCRATCH CONCERNING NEW PROGRAMS
SUCH AS SINGLE PAYER. THEN WE
NEED TO THINK THROUGH HOW THE
PROGRAM WOULD BE GOVERNED AND BY
WHOM.
WOULD THERE BE A NEW BOARD.
WOULD BE ADMINISTERED BY AN
EXISTINGAGENCY OR NEW AGENCY.
AND AGAIN JUST USE COVERED
CALIFORNIA JUST EXAMPLE. OF THE
STATE AT THAT POINT WHEN
IMPLEMENTING THAT PROGRAM
DECIDE TO ESTABLISH A NEW BOARD
TO OVERSEE THE EXCHANGE AND SET
THE DIRECTION FOR THE PROGRAM.
AGAIN THAT WAS ONE DESIGN CHOICE
THAT WAS MADE.
ADMINISTRATIVE FUNCTIONS ALSO
NEED TO BE HANDLED BY SOME
ENTITY.
IF WE WERE TO CONSIDER A SINGLE
PAYER PROGRAM THAT CENTRALLY
ADMINISTERED WHAT ARE THE
FUNCTIONS THAT WOULD. NEED TO BE
ARRANGED FOR A NEED TO. CONTINUE
TO OCCUR.
FOR EXAMPLE.
ASSED A STATE ADMINISTERED
AGENCY OR CENTRALLY ADMINISTERED
INTERCEDING WOULD HAVE TO.
PAY DOCTORS
HOSPITALS AND PROVIDERS FOR
HEALTHCARE SERVICES
WE NEED TO PAY FOR PRESCRIPTION
DRUGS.
IT WOULD NEED TO ENSURE THE
PAYMENTS ARE ACCURATE AND THE
NEED TO WATCH OUT FOR FRAUD AND
ABUSE.
FINANCIAL AN ACTUARIAL ANNOUNCES
TO ESTIMATE BUDGET IMPACTS WOULD
ALSO BE NECESSARY.
WE'D ALSO NEED THE FUNCTIONS OF
ANALYTICS TO TO TO DETERMINE
WHETHER THEY'RE SUFFICIENT
SUPPLY OF PRIMARY AND SPECIALTY
CARE SERVICES AND TO ASSESS
WHETHER PATRONS ARE REALLY
GETTING APPROPRIATE CARE WHEN
THEY NEED IT.
MANY OF THESE FUNCTIONS ARE
ADMINISTERED CURRENTLY IN PUBLIC
BY MULTIPLE PUBLIC AND PRIVATE
PAYERS.
SO IN A SINGLE PAYER SYSTEM
THESE FUNCTIONS DON'T
NECESSARILY GO AWAY BUT THERE'S
POTENTIAL FOR REDUCTION OF THAT
DUPLICATION ACROSS PAYERS AND
SYSTEMS.
IN THE TRANSITION HOWEVER THESE
FUNCTIONS WOULD HAVE TO BE STOOD
UP AND SOME CONSCIOUS DELIBERATE
FASHION.
SO A LAID OUT ON A LOT OF
IMPLEMENTATION ISSUES AND IT'S
QUITE A LOT OF INFORMATION SO I
THOUGHT IT WAS IMPORTANT TO
LEAVE YOU WITH SOME KIND OF
FRAMEWORK TO EVALUATE. DIFFERENT
FOR PROPOSALS THAT YOU MAY BE
CONSIDERING IN THE NEAR FUTURE.
SO ON THIS SLIDE HERE IS A A
SUGGESTED FRAMEWORK.
ON AND AND WHAT IT DOES IS I YOU
SEE ON THE LEFT HAND SIDE. OWN
I'VE LAID OUT. SUGGEST YOUR
CRITERIA TO CONSIDER WHEN YOU
ARE LOOKING AND EVALUATING BEARS
POLICY PROPOSALS.
SO IN YOU'D BE EVALUATING POLICY
PROPOSALS AGAINST THE STATUS QUO
WHAT WE HAVE NOW. AND AGAINST
EACH OTHER.
AND OF THESE CRITERIA CHRIS
COULD BE TWEAKED BASED ON YOUR
OVERALL POLICY GOALS.
SO IT'LL BE HELPFUL JUST TO TAKE
A COUPLE MINUTES TO WALK THROUGH
EACH ONE.
A FIRST OF ALL IS COVERAGE HOW
MANY ADDITIONAL AND INFO
INDIVIDUALS WERE ARE CURRENTLY
UNINSURED WOULD GAIN ACCESS TO
HEALTH INSURANCE.
AND THE SECOND IS SOMETHING WE
CALL UP IN CALLING A DISRUPTION
INDEX
HOW MANY INDIVIDUALS WHO
CURRENTLY HAVE SOME KIND OF
COVERAGE. WOULD HAVE TO CHANGE
THEIR PLANS.
THE THIRD IS SYSTEM WIDE COSTS.
WHAT IS A PROJECTED IMPACT ON
TOTAL HEALTH CARE EXPENDITURES
AND WE'RE LOOKING AT TOLL HELP
HEALTHCARE EXPENDITURES OF
COURSES?
IMPORTANT TO LOOK AT THE
ADMINISTRATIVE COSTS THAT IS
PART OF.
THE TOTAL HEALTHCARE
EXPENDITURES.
THE FOR THIS PAYMENT FOR
HEALTHCARE SERVICES.
SPECIFICALLY OBJECT IMPACTS ON
THE REIMBURSEMENT LEVELS FOR
DOCTORS HOSPITALS AND OTHER
PROVIDERS IN THE STATE.
WHAT ABOUT AVAILABILITY OF
SERVICES?
DOES A POLICY IMPACT ACCESS TO
CARE IN ANYWAY WOULD IMPROVE IT
HER WOULD EXACERBATE ANY HEALTH
CARE ACCESS ISSUES.
.
THE NEXUS QUALITY.
WITH THE PROPOSAL HAVE
ANY PROVISIONS RELATED TO SAFETY
AND QUALITY.
WOULD IT ENCOURAGE USE OF
PRIMARY CARE OR PREVENTIVE
SERVICES.
FOR EXAMPLE ENCOURAGING USE OF
CANCER SCREENINGS AND PREVENTIVE
SERVICES THAT MIGHT PREVENT.
FUTURE HEALTHCARE COSTS.
HELD UP FINANCIAL BARRIERS.
SEARCHES CO PAYMENTS OR MONTHLY
PAYMENTS IN THE FORM OF
PREMIUMS.
THOSE COULD POSE REAL BARRIERS
TO LOW INCOME CALIFORNIANS SO
THAT IS CERTAINLY A CRITERIA.
THAT THAT SHOULD BE CONSIDERED.
THE NEXT OR POTENTIAL DOWNSTREAM
EFFECTS SUCH AS THOSE.
THAT MIGHT.
AFFECT THE HEALTHCARE WORKFORCE
AND INDIVIDUALS THAT ARE AND
HELP HER WORKFORCE PIPELINE.
THE NEXT ONE IS A THAT I'VE
LISTED IS INVESTMENTS IN SOCIAL
DETERMINANTS OF HEALTH CARE.
SO THE QUESTION THERE AS DOES A
PROPOSAL ENCOURAGE OUR SYSTEM TO
REALLY LOOK AT A PERSON AS A
WHOLE. INCLUDING ALTHOUGH SOCIO
ECONOMIC FACTORS THAT AFFECT
HEALTH AND WELL BEING.
SUCH AS HOUSING AND FOOD
SECURITY.
AND OF COURSE LAST ONE IS
FEASIBILITY.
WHAT IS TRULY FEASIBLE AGAIN
FROM A FEDERAL PERSPECTIVE AND
FROM A STATE PERSPECTIVE?
AND IN TERMS OF VISIBILITY CAN
WE OBTAIN THE SUFFICIENT DOLLARS
AND GENERATE SUFFICIENT REVENUES
TO ESTABLISH AND SUSTAIN THE
PROGRAM.
AND WHAT IS FEASIBLE FROM A
STATE CONSTITUTION AND THE
BUDGETING RULES PURSE.
SO THIS THIS LAST SLIDE HERE IS
REALLY INTENDED TO SHOW HOW SUCH
A FRAMEWORK CONSISTS COMPLETELY
HYPOTHETICAL HERE. BUT HOW SUCH
A FRAMEWORK COULD BE APPLIED.
SO I A HYPOTHETICAL OPTION
NUMBER ONE HYPOTHETICAL OPTION
NUMBER TWO.
AND AGAIN THIS IS JUST TO SHOW
HOW IT GOT THE CRITERIA AND ONCE
YOU'VE ANALYZE EACH OF THE
OPTIONS HOW THEY FARED AGAINST
EACH OTHER AND AGAINST THE
STATUS QUO.
SO WHEN LOOKING AT YOU PROPOSALS
ANALYSTS COULD TAKE A LOOK AT
EACH CRITERIA.
AND THEN.
SEE HOW THEY DID FOR EACH OF
THE SPECIFIC CRITERIA. IN THIS
ONE IT LOOKS LIKE HYPOTHETICAL
OPTION NUMBER ONE IT MAY
INCREASE COVERAGE.
BY BY A LOT.
BUT IN MAY BE DIFFICULT TO
IMPLEMENT.
DO A FEASIBILITY DUE TO BEARS A
FEASIBILITY.
HYPOTHETICAL OPTION TWO MIGHT
BE MORE INCREMENTAL IN ITS
APPROACH.
AND MIGHT BE MORE FEASIBLE BUT
MAY ONLY RESULT IN A SMALL
INCREASE OF COVERAGE.
SO THE JUST ONE WAY FOR YOU TO
WELL.
COMPARE VARIOUS PROPOSALS THAT
YOU MIGHT BE CONSIDERING IN THE
NEXT FEW WEEKS AND MONTHS.
SO.
SERB THEIR OWN LIKE THAT THAT
ACTUALLY CONCLUDES MY REMARKS
SO.
.
YOU TAKE QUESTIONS NOW OR.
YEAH ACTUALLY AND WE WILL TAKE
QUESTIONS FOR YOU AND THEN WE'LL
MOVE ON TO OUR THE REST FOR
PANEL SO QUESTION. FOR SUSAN.
IN MANY OF YOURS YOU'RE
COMPARING THE STATUS QUO TO
POTENTIAL OPTIONS I WAS
WONDERING IF YOU COULD COMMENT
ON THE STATUS QUO.
AND TO DESCRIBE SOME OF THE
STRENGTHS AND WEAKNESSES THAT WE
CURRENTLY FACE TO.
HOPEFULLY INSPIRE US TO WANT TO
CHANGE.
RIGHT SO.
CERTAINLY.
I'D I THINK THE FIRST REMARK
THAT I MADE ABOUT HOW. ON THE
YOU KNOW AND ON A NOTE OF
OPTIMISM IS THAT WE HAVE MADE
QUITE A LOT OF PROGRESS IN THE
LAST FEW YEARS. TO BOMB EXPAND
COVERAGE AND REDUCE THE NUMBER
OF UNINSURED.
SO ON BUT THERE'S STILL DOES
REMAIN QUITE A LOT OF WORK TO DO
TO ENSURE THAT THE LIVE
REMAINING THREE MILLION ARE IN
FACT HAVE SOME SORT OF COVERAGE.
AND OF COURSE OUR SYSTEM DOES
HAVE ISSUES IN TERMS OF OF
FRAGMENTATION. ON THE VARIATION
IN QUALITY OF HEALTH CARE.
AFFORDABILITY AND THESE ARE
STILL ONGOING CONCERNS.
SO ON YES SO THE STATUS QUO
STILL HAS ITS ISSUES AND THERE'S
DEFINITELY QUITE A LOT OF WORK
TO BE DONE.
YOU.
MY QUESTION IS.
WREAK REGARDING YOUR YOUR
FRAMEWORK TO DO AND GO BACK IN
THE.
THE PREVIOUS SLIDE IF YOU DON'T
MIND.
SO OF THOSE MEAN YOU'VE GOT A
LOT OF THINGS AARON WHAT WOULD
YOU CONSIDER TO BE.
THE MOST CRITICAL OF THOSE OR OR
HAVE YOU GIVEN THAT.
MUCH CONSIDERATION.
WELL I AM I I THINK IT IT IS
IMPORTANT FOR.
IN TERMS OF SETTING POLICY GOALS
FOR APOLLO FOR POLICYMAKERS WHEN
WE THINK ABOUT THE ROADMAP AND
WHERE YOU WANT TO BE. AND.
WHATEVER YOU SET YOUR CRITERIA
TO BE SHOULD MATCH THE GOALS I
DO THINK THAT COVERAGE IS
PROBABLY. ONE THAT IT IS ONE OF
THOSE THAT. MIGHT BE ONE TO PUT
UP THERE AND OF COURSE
FEASIBILITY.
IF IF IT'S NOT FEASIBLE THEN
THAT'S OBVIOUSLY.
UP AND ISSUE SO. ON THOSE ARE A
COUPLE THAT I WOULD PUT UP
THERE.
DIVERT THANK YOU VERY MUCH.
WE'RE GOING TO SHIFT AROUND THE
ORDER A LITTLE BIT FOR THE THREE
FUTURE I THINK GUARDINO THAT.
SO.
.
I TWO ONE.
GONNA GO AHEAD AND INTRODUCE A.
AND AND MARIE.
MARCIA RALLY HOPE WE GOT THAT WE
GOT THAT RIGHT PROFESSOR OF LAW
UNIVERSITY OF MATT MISSOURI.
KANSAS CITY.
UM'S SHE SPECIALIZES IN HEALTH
CARE LAW AND SHE'S GOING TO BE.
TALKING TO US ABOUT A RECESS.
IN A MOMENT.
AND AFTER YOUR PRESENTATION
HENRY WE WILL ASK QUESTIONS SO
THAT WE MAKE. AND THEN WILL WAIT
ON THE OTHER TO AYE AYE AND YOU
OTHER TWO PANELISTS ASK
QUESTIONS IF YOU BOTH PRESENTED
SO I JUST WANNA MAKE SURE SHE.
WELL ISN'T STUCK IN CALIFORNIA
FOR ANOTHER DAY OR MINE WHEN HE
SAID IT WOULD BE STUCK IN ANYWAY
UP A LONGTIME RESIDENT BEFORE I
MOVED TO.
KANSAS CITY TO BECOME A FULL
TIME TENURED FULL PROFESSOR. AT
THE LAW SCHOOL THERE AND SO
REMAIN DEEPLY INTERESTED. AND
INVESTED I THINK AND.
CALIFORNIA'S ACTIVITY IN THIS
AREA.
SO MY TOPIC TODAY IS THE
IMPLEMENTATION CONSIDERATION OF
ARRESTS OF THE EMPLOYEE
RETIREMENT INCOME SECURITY ACT
OF NINETEEN SEVENTY FOUR I
ALWAYS TELL MY STUDENTS WILL
NEVER HEAR ME SAY IT THAT WAY
AGAIN. WHAT A MOUTHFUL?
?
SO WHAT IS A WRESTLER.
ALRIGHT.
IT'S A FEDERAL LAW OKAY AND WE
ARE IN THE LAND OF MY FOR YOUR
SPONSORED HEALTH INSURANCE WE
ARE NOT IN THE LAND OF MEDICARE
AND MEDICAID. FOR MY REMARKS.
RIGHT.
INNOCENTLY REGULATES PRIVATE
SECTOR WHAT WE'VE BEEN CALL
COMMERCIAL SECTOR PENSIONS AND
OTHER EMPLOYEE BENEFIT PROGRAMS
INCLUDING JOB BASED HEALTH
COVERAGE WHY AM I TELLING YOU
HISTORY. IT'S GOING TO BE REALLY
SIGNIFICANT ONE EXPLAINED TO YOU
THAT MUCH OF THE INTERPRETATION
OF A RISA HAS RESTED WITH THE
COURTS.
PART OF THE REASON IS THE
HISTORY OF HOW THE SAUSAGE BUT
MADE US LEGISLATORS I HOPE YOU
WILL BE ALTERNATELY HORRIFIED
AND AMUSED.
THAT MAY TELL YOU A TALE OF
ORISSA.
OKAY RISA WAS PASSED BY THE
CONGRESS IN THE WANING DAYS OF
THE NIXON ADMINISTRATION YES
THERE ARE ACTUAL TRANSCRIPTS OF
TAPES OF. ON.
FORMER PRESIDENT NIXON JUST
BEFORE HIS RESIGNATION TALKING
ABOUT WE SHOULD MOVE THIS ALONG
WILL DISTRACT PEOPLE.
WE KNOW THE REST OF THE STORY IT
WAS SIGNED INTO LAW BY BEEN
PRESIDENT FORD.
RIGHT NOW RISA HAD BEEN A MORNIN
SINCE ACTUALLY THE NINETEEN.
WHEN IT WAS PRIMARILY A PENSION
BILL THOSE OF YOU OLD ENOUGH TO
REMEMBER THE STUDEBAKER
AUTOMOTIVE COMPANIES. KNOW THAT
IT'S TALE OF WOE ITS DISSOLUTION
ITS ULTIMATE BANKRUPTCY AND YET
MORE TRAGICALLY THE BANKRUPTCY
IT TURNS OUT OF ITS ENTIRE
EMPLOYEE.
RETIREMENT FUND.
LEFT WHAT WE USED TO CALL WHEN I
WORKED IN A THE PENSION AREA THE
STUDEBAKER PEOPLE WHO WAS ALSO
TALKING ABOUT LIKE A VAMPIRE ó
IS TO THE BIG A PERSON IS IN THE
WAITING ROOM. AND YOU KNOW THAT
WAS A PERSON WHO HAD ABSOLUTELY
NO RETIREMENT INCOME AFTER
ENTIRE.
SUPPOSEDLY VESTED CAREER WHICH
STUDEBAKER AUTOMOTIVE.
OKAY THE TRAGEDY OF THIS PEOPLE
WHICH WAS WRITTEN LARGE ACROSS
ALL OF AMERICANS NEWSPAPER.
OKAY AND TELEVISION PROGRAM IS
ACTUALLY WHAT GENERATED THE PUSH
FIRST WITH PRESIDENT KENNEDY AND
THEN FORD ON A PENSION REFORM
BILL. WYMAN TALKING ABOUT A
PENSION REFORM BILL
BECAUSE HEALTH BENEFITS WERE
ADDED THIS FLOOR AMENDMENT.
TO A PENSION REFORM BILL.
OKAY.
AND THIS EXPLAINS WHY THE
LEGISLATIVE HISTORY IS QUITE
BEEN.
IT ALSO EXPLAINS WHY.
SPRING COURT HAS BEEN CALLED
UPON SO MANY TIMES TO EXPLAIN
WHAT THE BILL MEANS WHAT THE
LANGUAGE OF THE STATUTE MEANS
SINCE THERE'S. RELATIVELY FAMILY
LOOKING AGAIN THIS MORNING FOR
PRINTED VOLUMES OF THE
LEGISLATIVE HISTORY OF ARRESTS
AND THE CONGRESS.
SCARCELY A MENTION OF HEALTH.
BUT THEY USED TO CALL.
AND QUICKTIME'S NINETEEN SEVENTY
THREE HOSPITALIZATION COVERAGE
OKAY BUT WHAT THEY MEANT WAS
HEALTH INSURANCE OFFERED BY
EMPLOYERS.
ALRIGHT SO IT'S RELEVANT BECAUSE
EVEN THOUGH IT WAS A LATE
ADDITION I THINK WE COULD AGREE
NOW AYE AYE I THINK IF I WERE TO
CUENTA PHRASE WOULD BE SOMETHING
LIKE AMENDED HASTE REPENT AT
LEISURE.
OKAY WE PUT IT IN THERE WE
DIDN'T REALLY KNOW WHAT IT MEANT
WE'VE RELIED ON THE SUPREME
COURT OKAY TO EXPLAIN TO US AND
IT'S LIKE THAT'S WHAT THAT
MEANT.
AND IN SOME WAYS AN UNHAPPY
THAT'S WHAT THAT MEANS IT'S NO
SURPRISE THAT THE FORTIETH
ANNIVERSARY OF THE REST OF THE
CONFERENCE.
TO LOOK BACK AT IT AMONG ALL THE
SORT OF BIGGER RISK GEEKS WAS
CALLED THE EMPLOYEE RETIREMENT
INCOME SECURITY ACT OF NINETEEN
SEVENTY FOUR WHAT WERE THEY
THINKING.
AND I PERSONALLY THOUGHT I WISH
I HAD NAMED IT.
IT'S BRILLIANT.
WHAT WERE THEY THINKING I DON'T
THINK WE'LL EVER KNOW?
OKAY WHAT WE KNOW NOW IS WHAT
THE SUPREME COURT.
ALRIGHT AND THEN FINALLY
RESEARCH IS RELEVANT TO HEALTH
POLICY BECAUSE IT PREMIUMS THE
WORD OF THE DAY ALRIGHT STATE
LAWS THAT RELATE TO EMPLOYEE
PLANS.
PUSHES ALL THE AIR OUT OF THE
ROOM IS THE WAY I DESCRIBE IT.
IF YOU WANT AIR IN THE ROOM TO
DO SOMETHING ELSE YOU'RE GOING
TO HAVE TO ARGUE YOU LEFT OF
SOME HERE. OKAY HOW BY NOT
SUCKING IT ALL OUT TO CONGRESS.
FEDERAL PREEMPTION IS THE
DOCTRINE MUCH BIGGER THAN EVER
SET A MUCH BIGGER THAN HEALTH
CARE THOSE OF YOU WHO ARE
ATTORNEYS THAT ASSERTS THAT WHEN
A STATE LAW AND FEDERAL LAW
CONFLICT.
FEDERAL LAW DISPLACES OR PREEMPT
STATE LAW ARM ESSENTIALLY A
UNDER THE SUPERCENTER SUPREMACY
CLAUSE OF THE.
XIN WHICH IS OF COURSE.
ARTICLE SIX SECTION TWO. IT
MOVE EVEREST IS ADMINISTERED.
IT'S DIVISION IT'S
ADMINISTRATIONS DIVIDED AMONG
THREE ENTITIES AND THE FEDERAL
GOVERNMENT THE UNITED STATES
DEPARTMENT OF LABOR. THE
INTERNAL REVENUE SERVICE AND
ACTUALLY THE PENSION BENEFIT
GUARANTY.
OPERATION IF YOU THINK OF IT AS
PRIMARILY AS A GOAL WHICH WAS TO
CREATE WHAT.
FIDUCIARY DUTIES IN PENSION PLAN
ADMINISTRATORS JUST THINK
STUDEBAKER PEOPLE AND YOU'LL
THINK ABOUT WHY WHAT WAS THE
PURPOSE RIGHT TO CREATE. RULES
ABOUT THE ADMINISTRATION OF
PENSION PLANS THAT WOULD
SAFEGUARD THOSE WHO BELIEVE
THEMSELVES AND. ACCORDING TO
PLAN DOCUMENTS WERE VESTED TO
PROTECT THEIR RETIREMENT INCOME.
OKAY IT MAKES SENSE THEN THAT IT
WOULD FIT THIS WAY. BUT THAT
ALSO WERE HEALTH.
BENEFITS DIDN'T AS WELL THEY'RE
CONSIDERED AN EMPLOYEE WELFARE.
BENEFIT.
ALRIGHT.
SO I GOT A LOT OF CALLS ON THE
DAY AFTER A OF THE AFFORDABLE
CARE ACT WAS SIGNED INTO LAW SO
SUNLAND MARCH TWENTY THIRD
TWENTY TEN FROM PEOPLE WHO KNOW
THAT I'M. A SOMETHING OF
INTEREST SO.
GEEK IN THE CITY
DID WE JUST PEEL APPEAL REPEAL
LARISSA AND WHAT NOT.
OKAY WE AMENDED IT IN SOME WAYS
WE ACTUALLY CREATED SOME
EXEMPTIONS TO IT IN OTHER WAYS.
BUT THERE ARE ACTUALLY SPECIFIC
PROVISIONS IN THE AFFORDABLE
CARE ACT WHICH FILE.
TOURISTS AND I THOUGHT THAT'S
WORTH POINTING OUT TO YOU OKAY
SOMETIMES IT'S DESCRIBED AS IN
ON EASY RELATIONSHIP WE COULD
SAY THAT THE TWO STATUTES MIGHT.
BE SEEN AS NOT PERFECTLY DOVE
TAILING MIGHT BE A WAY TO PUT
IT.
OKAY SO.
.
WHAT DOES THAT MEAN AS A
PRACTICAL MATTER THAT MEANS
THAT?
?
IT DID AMENDED SO THAT THERE ARE
RULES RELATING TO THE
PROHIBITION OF PRE EXISTING
CONDITIONS THAT PROHIBIT
LIFETIME AND ANNUAL DOLLAR
LIMITS FOR ESSENTIAL BENEFITS.
SOME RESTRAINTS ON RECISIONS OF
INSURANCE POLICIES ON RECORD
COVERED STANDARDS BUT THERE ARE
OTHER THINGS THAT WERE NOT
CHANGED THOSE OF YOU WHO HAVE
EVER WONDERED WHY. IT MATTERS
WHETHER OR NOT SOMETHING IS
INTEREST QUALIFY PLAN WHETHER OR
NOT THE MINIMUM ESSENTIAL
BENEFIT STANDARD APPLIES THAT'S
A RISK.
pORISSA.
DIVIDING ALL EMPLOYER SPONSORED
HEALTH INSURANCE.
WHO SETS?
OKAY THOSE THAT WILL RECEIVE THE
MINIMUM ESSENTIAL BENEFITS
REQUIREMENT AND THOSE THAT ARE
OUTSIDE OF IT AND EXEMPT FROM
IT.
SO THE MOST RELEVANT QUESTION
YOU CAN ASK WHEN YOU LOOK AT THE
AFFORDABLE CARE ACT THE MINIMUM
ESSENTIAL BENEFIT STANDARD IS.
US INTERESTS.
QUALIFY PLAN.
THE MINIMUM ESSENTIAL BENEFIT
REQUIREMENTS DO NOT APPLY.
TO A SELF FUNDED PLAN SO I
THOUGHT MAYBE I SHOULD SAY A
LITTLE BIT MORE ABOUT. WHAT THAT
IS?
OKAY.
N THE PRIVATE SECTOR THE
DIFFERENCE BETWEEN A FULLY
INSURED AND A SELF INSURED
HEALTH PLAN SO OFTEN HEARD SURE
TO HEALTH PLAN IS WHERE AN
UNSURE WHERE AN EMPLOYER
TYPICALLY. VERY LARGE EMPLOYER
BUT INCREASINGLY CREEPING DOWN
WHEN I SAY VERY LARGE I MEAN
FIVE HUNDRED PLUS. EMPLOYEES.
BUT CREEPING DOWN.
FOR REASONS WILL DISCUSS IN A
SECOND.
ASSUME RISK.
THEY FUNCTION AS THEIR OWN
HEALTH INSURANCE COMPANY.
WHEN I SAY ASSUME RISK THAT
MEANS THEY HAVEN'T SHIFTED THE
RISK. OKAY OF EXTRAORDINARY
HEALTHCARE COSTS.
PERHAPS SHOWING UP IN THEIR
POPULATION RIGHT IN THEIR RISK
POOL ON TO ANYONE ELSE.
THE ONLY WAY THEY KIND OF
STRATEGIZE AROUND AS A BY
PRODUCT CALLED STOP LOSS
INSURANCE
WHICH IS JUST WHAT AT TIMES
LIKE.
RIGHT AND SOME OF YOU MAY KNOW
SOMETHING ABOUT OF BECAUSE THE
CALIFORNIA LEGISLATURE HAS GIVEN
SOME THOUGHT. TO CHANGING
CALIFORNIA LAW AND STOP LOSS
INSURANCE NEW YORK HAS JUST
CHANGED ITS LAW I BELIEVE
WISCONSIN AS WELL. ALRIGHT SO
STOP LOSS INSURANCE IS LIKE A
STOP GAP RIGHT IN CASE THE MAN
WITH THE ACTUAL SKULL AS WE SAY
LAW SCHOOL SHOWS UP IN YOUR. IN
YOUR RISK POOL OTHER THAN THAT
YOU'RE FUNCTIONING AS YOUR OWN
RISK PARA. EMPLOYEES DO NOT KNOW
THAT THIS IS HOW IT IS WORKING
BECAUSE YOU HIRE AN INSURANCE
COMPANY JUST TO ADMINISTER THE
BENEFITS AND THEY PUT OUT A CARD
THAT LOOKS JUST LIKE AN
INSURANCE CARD. THAT THEY WOULD
PUT OUT IF THEY WERE RUNNING THE
INSURANCE PROGRAM IT WILL SAY
LIKE.
AETNA ON IT SO TYPICALLY
EMPLOYEES HAVE NO IDEA.
BUT THIS IS WHAT THEY HAVE AND
THEN EXPLAIN TO ME HOW THEY FIND
OUT IN A MINUTE.
THE OTHER SIDE OF IT IS THAT SO
EMPLOYER COULD CHOOSE TO
ESSENTIALLY CONTRACT WITH
INSURANCE.
RIGHT BIG RISK GOES TO THE
INSURANCE COMPANY EVERYONE
UNDERSTANDS THAT RIGHT IF I HAVE
THE MAN WITH THE ACTUAL SCRAWL.
AND HIS WIFE AN OLDER LITTLE
EGGSHELL CHILDREN RIGHT AND THE
ONLY ONE HUMPTY DUMPTY
REPLACEMENTS OKAY.
IN THE NEXT YOU KNOW FISCAL
QUARTER WHATEVER THE RISK IS ON
YOU.
INSURANCE COMPANY RAY I'M NOT
TAKING THAT RISK YOU TOOK THAT
RISK
OKAY WHEN YOU WROTE THE POLICY
OR THE CONTRACT WITH ME.
NOW THE DIFFERENCES IS THAT RISA
PUTS OUTSIDE OF REGULATION THE
ONE THAT'S CALLED SELF INSURED.
OUTSIDE OF WHAT KIND OF
REGULATION ESSENTIALLY OUTSIDE
OF STATE REGULATION.
ALL THOSE REGULATIONS A CANNON
REQUIRED BENEFITS SPECIFIC
BENEFITS BE ADDED.
RIGHT ALL OF THAT.
SOMETIMES O. EMPLOYERS AND I
KNOW YOU'LL APPRECIATE THAT DEFY
TALK INSURANCE TALK IT'S BECAUSE
OF OR EVEN KNOW WHAT IT SOUNDS
LIKE. A WILL REFER THIS TO AS
REGULATORY BURDEN.
ALRIGHT.
AND YOU CAN IMAGINE THE BIGGEST
REGULATORY BURDEN OF ALL WOULD
HAVE BEEN WHAT THE MINIMUM
ESSENTIAL. BENEFITS REQUIREMENTS
OF THE ACA THAT IS THE LIST
CONGRESS DELEGATED THE
AUTHORITY.
TO WHAT'S NOW CALLED WHAT THE
INSTITUTE OF MEDICINE TO PRODUCE
A LIST CONTRACEPTIVES FOR WOMEN
YOU NOKIA TRICK RIGHT. POST A
LIST FOR MEN WOMEN CHILDREN OF
ALL THE MINIMUM ESSENTIAL
BENEFITS YOU COULDN'T CALLED
INSURANCE UNLESS IT.
HAD AT THEIR THEIR RIGHT FOR
THAT YOU COULD BUY WHAT HEALTH
INSURANCE WITHOUT
HOSPITALIZATION. HEALTH
INSURANCE WITHOUT A DRUG.
OUR HELL TO TRANSFER THEM
ATTORNEY COVERAGE.
RIGHT HEALTH INSURANCE WITH.
LIFETIME CAP OF FIVE THOUSAND
DOLLARS A EVERY POSSIBLE
PERMUTATION WAS OUT THERE OKAY
SO THE SOURCE OF THIS IS WHAT
HEALTH INSURER SHOULD LOOK LIKE
IMPORTED IT. YOU KNOW BE WITHIN
THE PROPER TERM FOR HEALTH
INSURANCE.
NO SUCH RULES.
ON THE A RISA.
RIGHT FULLY INSURED PLANTS NOW
THE VERY LARGEST EMPLOYERS CAN
WE THINK BOEING FOR A MINUTE
OKAY. YOU UNDERSTAND THEY MIGHT
OFFER VARIOUS PRODUCTS AND SOME
MIGHT BE SELF INSURED AND SOME
MIGHT BE FULLY INSURED TO SO
YOU'LL BE READY FOR MY ADVANCE
TO RECEIVE SOME OF OUR SOMEDAY.
YOU'LL IS ALSO NOT ALL EMPLOYERS
ARE INTO GROUPS SOME YOU KNOW
OUR FRIEND ONE FROM A ONE FROM
DEEP APPLYING LARGE ITS KEEP IT
SIMPLE TODAY. THE SORT OF OFF
INTO GROUPS IMMACULATE WHITE
SHOE TERMINUS.
BECAUSE IT TURNS OUT THAT AT
LEAST FIFTY PERCENT.
OF OF CALIFORNIANS.
PROBABLY CLOSER TO SIXTY
SEVENTY.
OKAY ARE IN A GARISSA SELF
INSURED COVERAGE.
NUMBER I SAID IT DOESN'T MATTER
IF YOU DON'T KNOW IT.
YOU STILL ARE.
ALRIGHT HOW DO YOU FIND OUT YOU
FIND IT BECAUSE THE RULES ARE
DIFFERENT ABOUT APPEALS ON
COVERAGE LIMITATIONS OF IT A LOT
LOTS AND LOTS OF WAYS YOU FIND
OUT. OF SHAPE WHEN YOU NEED TO
KNOW BELIEVE ME YOU FIND OUT.
ALRIGHT SO WHERE DOES THAT MEAN
PRACTICALLY IT MEANS THAT THERE
ARE VAST NUMBERS OF PEOPLE WHO
ALREADY ESSENTIALLY INSULATED
FROM CALIFORNIA STATE
REGULATION.
OF THE EMPLOYER SPONSORED HEALTH
INSURANCE OF THEIR IN.
ALRIGHT.
AYE AND THE REASON WHY THAT
MATTERS IS THAT SO TO TRY AND
BRING THEM BACK INSIDE THE TENT
YOU SEE WOULD REQUIRE
ESSENTIALLY.
FLYING FULL IN THE FACE.
OVERSEE.
NOW THE AFFORDABLE CARE ACT DID
NOTHING TO BREAK UP THIS IDEA OF
WE SORT. EMPLOYER SPONSORED
HEALTH COVERAGE BY THESE TWO
WAYS THAT'S WHY I GAVE YOU THE
EXAMPLE OF THE MINIMUM ESSENTIAL
BENEFITS IT BALLOTS TO.
OKAY SO IT'S NOT LIKE WILL THE
ACA BROKE THAT SO MAYBE WE COULD
BREAK THAT TO KNOW IT DOESN'T
BREAK IT AT ALL.
IN MANY WAYS THE ACA IS
INCREMENTAL STE COVERAGE.
AND THIS IS A GOOD EXAMPLE.
OKAY BECAUSE THERE'S NOT A LOT
OF RATIONALITY TO THIS DIVISION
ALRIGHT BUT THERE'S A LONG
HISTORY.
OF HONORING THIS DIVISION FOR
OTHER PURPOSES.
SO I AYE THOUGHT MIGHT BE
INTERESTING TO LOOKS.
TALK ABOUT.
WHAT'S LEFT TO THE STATE.
OKAY DIFFERENCE A COMES INTO THE
ROOM.
WHAT'S LEFT. ANY. WELL YOU THE
STATE'S MAKE TAX AND REGULATE
TRADITIONAL INSURERS PERFORMING
TRADITIONAL INSURANCE FUNCTIONS
YES I WROTE A SENTENCE WITH
TRADITIONAL AND IT TWICE.
BECAUSE THE CASE LAW HAS BEEN
VERY CLEAR.
I'M TALKING ABOUT THE CLASSIC
FUNCTIONS OF THE STATE AND RATED
INSURANCE DO YOU HAVE TO HAVE A
LICENSE TO SELL.
INSURANCE IN THIS JURISDICTION
TO OUR BROKERS AND AGENTS HAVE
TO BE LICENSE
OTHER CAPITALIZATION
REQUIREMENTS WHAT ARE THAT YOU
SEE THAT MOST COR.
RIGHT IT I CALL IT THE BUSINESS
SHARON'S AND THAT IT'S A TERM
THAT GETS REPEATED OVER AND OVER
AGAIN IN THE CASE OF.
REGULATING IT AS A BUSINESS.
ALRIGHT AS A BUSINESS ENTITY.
YOU CAN REGULATE MULTIPLE
EMPLOYER WELFARE ARRANGEMENTS
WELL WHAT ARE THOSE SAY. AMAZON.
AND JP MORGAN. AND BERKSHIRE
HATHAWAY WANTED TO COMBINE ALL
OF THEIR COVERED LIVES ONE
MILLION OR SO AND FORMA MULTI
EMPLOYER HEALTH INSURANCE PLAN.
IT'S MY SECOND BOOK.
ALRIGHT BETTING ON HOW TO SET IT
UP BUT THAT THAT'S WHERE IT
WOULD REST.
OKAY.
REGULAR HOSPITAL RATES CHARGED
TO INSURERS ANOTHER TO PAY
HEALTH CARE BILLS THE CONTAX
HEALTH CARE PROVIDERS YOU CAN
PROVIDE REMEDIES FOR INJURIES
WHEN THE HEALTH PLAN CONTROLS
MEDICAL CARE DELIVERY IN OTHER
WORDS. IT DOESN'T TAKE AWAY
TRADITIONAL MED MAL CASE YOU
NEED TO UNDERSTAND ONE ARREST
WAS FIRST PASSED SOME PEOPLE
THOUGHT IT FEDERAL EYES MET
BALBOA. NEVER ACTUALLY HAD TO BE
LITIGATION OVER TO TO JUST TAKE
THE AUTHORITY TO HAVE DIFFERENT
STANDARDS FOR MEN. YOU KNOW UP
UP TO CONGRESS ALRIGHT.
SO WHAT CAN'T THE STATE'S DO.
BECAUSE WE'RE ALSO INTERESTED IN
THE WHAT NOT TO WEAR RIGHT.
CAN'T THEY DO THEY CAN'T
DIRECTLY REGULATE PRIVATE
EMPLOYER SPONSORED HEALTH PLANS
I CANNOT SAY. YOU. MUST DO THIS
WITHIN YOUR PLAN ALRIGHT THE
PURPOSE OF A RISK IS WHAT TO
STANDARDIZE.
AND THEN ALSO I CALL IT IT'S NOT
REALLY AWARE BUT SORT OF
FIDUCIARY AYE. RIGHT IT'S ABOUT
HAVING QUALITY ADMINISTRATION
RIGHT MANDATE THAT YOU CANNOT
MANDATE THE PRIVATE EMPLOYERS
OFFER A PAY FOR INSURANCE.
RIGHT PROBABLY CAN'T TAX PRIVATE
EMPLOYER PRO CLEAR SPONSORED
HEALTH PLANS THEMSELVES.
AND YOU CAN'T REGULATE SELF
INSURED PRIVATE EMPLOYEE
BENEFITS
OR FINANCIAL SOLVENCY.
SO EVERYTHING AFTER THIS IS SO
WE ARE ON THE LINE BETWEEN WHAT
THE STATE MAY AND MAY NOT TO IS
ANYTHING ANYONE WISHES TO.
RIGHT IT'S ALL ABOUT ANALOGIZE
DOING RIGHT IS ANALOGY MONGERING
RIGHT IS IT MORE LIKE THIS ISN'T
MORE LIKE THAT AND THAT'S WHERE
THE CASE LOGOS AND THAT'S
ACTUALLY WHAT THE SUPREME COURT
SPECIALIZES IN DOING IN THIS
AREA.
OKAY SO WHAT HAPPENS IS THAT A
RECIPROCAL MERGE DIRECT
REGULATION OF EMPLOYER SUPPLANTS
BUT IT ALLOWS THE STATE
REGULATION OF THE INSURANCE
CARRIERS THAT PROVIDE THE
COVERAGE.
ALRIGHT IT ALLOWS REGULATION OF
INSURANCE COVERS BUT CANNOT
REACH INTO THE PLANT ITSELF. AS
IF TO SAY YOU ARE AN INSURANCE
PLAN WE'RE GONNA TREAT YOU LIKE
AN INSURANCE PLAN NOW. THAT'S AN
EMPLOYER SPONSORED.
RAY BENEFITS
WELFARE BENEFITS.
YOU DON'T GET TO DEMINT
AS THE WRESTLING WHICH GOES YOU
DON'T GET TO DEMAND AN INSURANCE
COMPANY. WHICH IS ACTUALLY WHAT
I THINK UNDER MANY PROPOSALS.
MIGHT ACTUALLY BE WHAT SOME
STATES HAVE TRIED TO DO WHERE'S
THE AMBIGUITY REGULATION OF STOP
LOSS INSURANCE CALIFORNIA HAS
DOUBLED IN THIS IS OF SAID NEW
YORK WISCONSIN RECENTLY.
INDEPENDENT EXTERNAL REVIEW OF
APPEALS PROGRAMS AMBIGUOUS WHERE
THE LINE IS.
EMPLOYER PAIR PLAY HEALTH CARE
PROGRAMS UP REGULATION OF THIRD
PARTY ADMINISTRATORS THAT
ADMINISTER SELF INSURED PLANS
REMEMBER I SAID ONE AETNA IN ITS
GUYS OF NOT BEING IMMATURE BUT
JUST BEING AN ADMINISTRATOR.
RUNS A PLANNING GIVES AT MY
CARDS CAN WE REGULATE THEM AS A
PROVIDER OF WHAT WE GONNA CALL
THAT ADMINISTRATION.
SERVICES RIGHT THAT'S TRICKY
BECAUSE THEY'RE NOT ASSURE
MEMBER ASSEMBLY EMPLOYER CARRIES
THE REST THURMOND MINISTRY.
THERE HEALTH MINISTER THEY'VE
PUSH PAPER
OR VIRTUAL FORMS ARE ALRIGHT AND
SO YOU CAN SEE WHERE WHERE THE
FIGHT GOES FROM THERE.
ALRIGHT SO WHAT ABOUT STATE
SPECIFIC HEALTH CARE REFORM
RIGHT ARM RESTORE MAY.
PROHIBIT AN EMPLOYER MANDATE
BECAUSE IT RELATES TO EMPLOYER
SPONSORED PLANS RECESS LANGUAGE
SAYS ANYTHING THAT RELATES TO.
OR IS IN RELATION TO EMPLOYER
SPONSORED PLANS IT WOULD ALL
DEPEND ON ITS CHARACTERISTICS ON
HOW FAR YOU COULD PUSH IT TO ONE
SIDE OF THE LINE OF THE OTHER.
AN INDIVIDUAL MANDATE MEANING
PUTTING IT ON WHAT THE
INDIVIDUAL INSURED IS MOST
LIKELY TO AVOID CHALLENGE THIS
IS MY OPINION IF IT MAKES NO
REFERENCE TO EMPLOYER SPONSORED
HEALTH.
RIGHT STAYING FAR AWAY FROM
RIGHT THINK OF RESOURCES THE
THIRD RAIL IN.
DON'T WANT TO TOUCH THE ELECTRIC
FENCE OKAY I JUST WELL IF I WANT
TO CREATE INDIVIDUAL MANDATE AYE
I WANT TO STAY AWAY. FROM
TALKING ABOUT NUCLEAR SPONSORED
HEALTH PLANS IN PARTICULAR IS MY
FOCUS.
EVEN TAXES YOU SHOULD KNOW
BECAUSE PEOPLE OFTEN THINK OF
TAXES IS BEING RELATIVELY WHAT
LAWS OF GENERAL APPLICATION.
RIGHT IT'S OF WHAT AND THEN
THERE IS A RULE THAT SAYS A LOT
GENERAL OBLIGATION INCIDENTALLY
AFFECTS ON RISA PLAN. SURELY
CAN'T BE SEEN AS ATTEMPTING TO
REGULATE IN A RESERVE PLAN IN
THERE FOR YOU KNOW GETTING
ELECTROCUTED BUT EVENTAXES CAN
REYES SARISSA PRETENSION. IN
CERTAIN CIRCUMSTANCES DEPENDING
ON HOW THE ORGANIZED.
STATE LAW CONDITIONS TAX
ADVANTAGES OR DISADVANTAGES ON
PLAN DESIGN FEATURES AND THOSE
OF YOU WHO KNOW. WHAT'S
SOMETIMES CALLED THE WALMART
CASE REALLY THE REAL PATROL CASE
OF THE STATE OF MARYLAND A
SPIEGLER. OKAY WHERE THE
MARYLAND LEGISLATURE. THEY
DIDN'T HESITATE TO HAPPEN
ELABORATE LEGISLATIVE HISTORY
WHERE THEY ESSENTIALLY SAID I
HATE WALMART.
ON AND WRITTEN REPLETE
THROUGHOUT THE LEGISLATIVE
HISTORY PASSED A LAW THAT SAID
THEY'RE GOING TO HAVE A CERTAIN
KIND OF PAPER PLATES TAX OPTION.
THE BITE WOULD ONLY BE ON
EMPLOYERS ABOVE A CERTAIN SIZE
SURPRISE THE ONLY EMPLOYER ABOVE
A CERTAIN SIZE IN THE STATE OF
MARYLAND WHAT THERE WAS JOHNS
HOPKINS BUT THERE WAS A JOHNS
HOPKINS EXCEPTION.
OTHER THAN THAT WAS WALMART.
OKAY A MOMENT WAS LIKE EXCUSE ME
YOU KNOW ALL THE SIX LITTLE LIKE
THOSE OF YOU WHO ARE ATTORNEYS A
BILL OF ATTAINDER. YOU KNOW
YOU'VE PASSED THE LAW TO TARGET
ONE CORPORATION AND IT COMES
FROM AN ANTI WALMART ANIMUS.
THIS SURELY CANNOT BE YOU KNOW
THE STATE REGULATION RIGHT SO
AND OF COURSE OF THAT STATUTE
WAS BROUGHT DEBT WAS STRUCK DOWN
THE LIGHT THEIR LOT TO TAKE WAYS
ONE MIGHT BE. A.
PROBABLY BEST NOT TO FILL YOUR
LEGISLATIVE HISTORY WITH.
.
PROTESTATIONS OF HATRED. OKAY OF
A PARTICULAR CORPORATE CITIZEN
JUST.
JUST GUESSING
BUT BECAUSE THE COURT WAS THE
JUDGE WAS QUITE STRUCK BY THAT
AS ANYONE WOULD BE GREAT BUT
ANOTHER MIGHT BE THAT HOME SO
YOU CAN'T JUST SORT OF KIND OF
MONKEY WITH IT TO KINDA.
YOU KNOW WE'RE NOT TRYING TO
KILL SMALL ENTREPRENEURIAL
BUSINESSES WERE TRYING TO YOU
KNOW TARGET WHAT WE SEE IS THE
BIGGEST OFFENDERS ARE THINGS
LIKE THIS. SO EVEN THEN THAT WAS
REALLY A TAX
BUT ATTACKS FOUND NOT TO BE
NEUTRAL RIGHT.
SO ONCE I GOT A COUPLE OF OTHER
CASES BEYOND FIEDLER IF YOU WANT
TO TALK ABOUT THEM THE GOLDEN
GATE RESTAURANT ASSOCIATION LOTS
OF PEOPLE ASK ME SOON. WILL OR
HOW DID THAT WORK. WITH THE REST
ANOTHER AND I YOU KNOW IN A
LITTLE UP ENOUGH TO BE DANGEROUS
HOW DID THAT WORK RIGHT WITH A
HEALTHY CALIFORNIA. AND YOU
SHOULD KNOW LITERACY ISSUES WERE
RAISED VERY EARLY. AS CHALLENGES
TO HELP THE CALABASAS AND
FRANCISCO EVEN THE WAY IT WAS
DESIGNED A FEW RUPAUL.
AN EXTRAORDINARY FACT SITUATION
WHERE THE CITY OF SAN FRANCISCO
ESSENTIALLY CREATES AN INSURANCE
COMPANY.
I DON'T THINK IT'S EVERY
MUNICIPALITY IN THE UNITED
STATES OR EVEN IN CALIFORNIA
THAT WOULD SAY. I'VE GOT IT I'VE
GOT A WAY AROUND IT IS A LET'S
CREATE AN INSURANCE COMPANY
ESSENTIALLY DOUBLE DELIVERS
NEVER MIND JUST FINANCES BECAUSE
RIGHT IT'S VISIBLE HEALTHCARE
DELIVERY. BUT THAT IS ACTUALLY
THE SERVE DOUBLE DIMENSION TO
THAT IS ACTUALLY WHAT SAVED IT.
FORMER US AT THE NINTH CIRCUIT.
OKAY WITH THE NINTH CIRCUIT SAID
LISTEN THEY GAVE EMPLOYERS IN
CALIFORNIA A CHOICE AND ONE OF
THEM WAS NOT TRAINED MONKEY WITH
YOUR WRISTS A PLAN YOU COULD
JUST GO AHEAD AND BE AND.
HEALTHY SAN FRANCISCO ORAL TO
COULD PAY YOU KNOW SOME AMOUNT
BUT WE WEREN'T TRYING OF IT IS
THE IDEA THAT IT WASN'T AN ALL
OR NOTHING SEEMED PRETTY
POWERFUL AND THAT IT WASN'T ALL
TRYING TO REACH YOUR HANDS IN
UNTIL PEOPLE. ALL TELL YOU HOW
TO ORGANIZE YOUR PLAN.
NOW JUST
IF IT'S HELPFUL TO PEOPLE
REMEMBER WHERE WE WERE SO THIS
CASE WHICH BEHIND CIRCUIT
OPINION CAME DOWN IN TWO
THOUSAND EIGHT IF IT'S USEFUL
FOR PEOPLE TO REMEMBER.
BUT THEN IT WAS A PETITION FOR
REHEARING ON FONG.
.
SPUR ABOUT THAT.
WHICH WAS DENIED SO IT TOOK
AWHILE BUT EVENTUALLY A PETITION
FOR CERT AT THE SUPREME COURT
WAS FILED AND THAT WOULD HAVE
BEEN LIKE JUNE OF TWO THOUSAND
NINE. THOSE OF YOU KNOW WHO
FOLLOW THE SUPREME COURT NO THAT
THEY WOULDN'T CONSIDER TAKING
THAT UP UNTIL THE FALL OF TWO
THOUSAND TEN AND THEN THEY
WOULDN'T ACTUALLY HEAR IT UNTIL
THE SPRING. BREAK AND GUESS
WHAT.
BEFORE KERRICK PATH.
SO IT UNFIT IN ESSENCE BECAME.
MOOD NOW THE SUPREME COURT
DOESN'T SAY THAT THAT DOESN'T
SAY HOW WE WOULD RULED THIS WAY
THEY JUST CLIMB. OKAY SO YOU
CANNOT READ A GREAT DEAL INTO A
BOOK BUT WE DO KNOW IS THAT SO
IT NEVER WENT BEYOND THE NINTH
CIRCUIT.
OKAY THIS IS A THEORY FROM THE
NINTH CIRCUIT RIGHT THAT THIS
MIGHT BE PERMISSIBLE THAT IT'S
SOMEWHERE I'VE PUT.
WELL THIS MIGHT BE WHERE THE
STORY CONTINUES.
RIGHT THIS IS A QUESTION WORTH
ASKING.
AND WORTH HAVING ANSWERED.
BUT I DO THINK IT WOULD TAKE A
TRIP TO THE SUPREME COURT. A
ROUNDTRIP TICKET IS OFTEN
DESCRIBED TO MY STUDENTS.
WHICH MEANS IT UP TO GO UP THERE
AND ASK FOR CERTIORARI IT'S
DISCRETIONARY JURISDICTION AND
THEN YOU'D HAVE TO GET THERE ON
THE MERITS.
OKAY.
AND I'M NOT AN INEXPENSIVE
TICKET.
ARE INTELLECTUALLY FASCINATING
STROKING
BUT MY HUSBAND'S MONEY. I WOULD
LIKE TO PRESENT THIS ISSUE.
IT NEEDS TO BE ANSWERED.
MY FATHER WANTED TO SAY A LITTLE
BIT ABOUT GO BABY OF LIBERTY
MUTUAL ANOTHER COUPLE CASES ARE
EXTREMELY RECENT OF THE SUPREME
COURT WHAT THE CONTROLS ABOUT A
RECESSION GO BAY I HAD SOME
QUESTIONS.
FROM PEOPLE.
ASKING ME WHAT COULD WE DO
SOMETHING ELSE COULD WE DO IT
ALL PAYERS CLAIMS DATABASE KIND
OF ATTEMPT AT REFORM COOLEY MAKE
A MOVE TOWARDS TRANSPARENCY.
AND SO THOSE OF YOU WHO KNOW
THIS CASE NO THE VERMONT STATUTE
FOR ALL PAYERS CLAIMS DATABASE.
STRUCK DOWN ON THE GROUNDS OF A
RECIPIENT XIN.
SIGNIFICANTLY ON JUSTICE KENNEDY
WHO WROTE THE OPINION WAS NOT
CONCERNED THAT THIS WAS THE
STATE OF VERMONT TRYING TO DO
SOMETHING IT WASN'T DUPLICATION.
DIDN'T REQUIRE DUPLICATION.
ALRIGHT ANY ALSO WASN'T
CONCERNED THAT THE STATE OF
VERMONT WAS TRYING TO DO
SOMETHING THAT SEVENTEEN OTHER
STATES WE TRY TO DO A DIFFERENT
WAY SO. IT WASN'T.
BECAUSE THAT WASN'T TRUE SO
WASN'T ADMINISTRATIVE BURDEN.
IT WAS JUST.
THE DEPARTMENT LABOR COULD DO
THIS IF THEY WANTED TO.
SO YOU SEE HOW STRONG THE
PREEMPTION IS.
EVEN JUST THE OPTION OF DOING IT
SUCKED THE AIR OUT OF THE ROOM
FOR VERMONT TO BE ABLE TO DO IT
NOW I THINK SEVENTEEN STATES
HAVE PASSED.
IN ONE FORM ANOTHER A KIND OF AU
PAIRS CLAIM DATABASE OF
PHARMACEUTICALS DIFFERENT
THINGS.
ALRIGHT AND THEY'RE ALL
STRUGGLING.
OKAY ON ON THIS SAME GROUNDS
ONES TO SAY JUST BOUGHT A COUPLE
WORDS OF HAVING COMPLETELY
OVERWHELMED ABOUT TWO VERY
RECENT CASES AT THE SUPREME
COURT NO WE WON'T OF TO THE
SEVEN ON THE FIRST AMENDMENT BUT
I WANT TO KNOW THE TO RISA.
HAS BEEN AT THIS REAP BRING CORD
AGAIN VERY RECENTLY. OKAY IN
CASES INVOLVING RELIGIOUSLY
SPONSORED HEALTH PLANS FLICK
WIFE SHE TELLING ME THIS WELL
YOU SHOULD KNOW THAT RELIGIOUS
BY RELIGIOUS ORDERS HEALTH PLAN
SPONSORED BY RELIGIOUS ORDERS
THINK A CATHOLIC ORDER. THAT
SPONSORS A PLAN YOU KNOW FOR TO
PUT DATA AT A PARTICULAR
FACILITY OKAY ARE EXEMPT FROM
ARREST.
NO IN THE COURSE OF OF MEN ARE
TWO CASES.
THE PREMISE AND THEY HAVE NOT
BEEN DOING FOR ARGUMENT TWO
SEPARATE CASES WHY DOES THIS
MATTER.
OUR SUPREME COURT WILL HAVE TO
GRAPPLE WITH HOW STRONG THE
RECIPIENT XIN IS IN THOSE CASES
YOU DO UNDERSTAND THAT RELIGIOUS
ORDERS. OR THE PEOPLE WHO ARE
RELIGIOUSLY AFFILIATED ARE ON
THE OTHER SIDE OF THE PREEMPTION
ARGUMENT THEY ARE ARGUING NO NO
IT'S GOT TO BE WEAKER WE CAN'T
BE FORCED.
VIRUSES TO DO THIS FOR THE FIRST
TIME I THINK WE HAVE QUITE
POSSIBLY FOR THE CURRENT COURT
EXTREMELY SYMPATHETIC
PLAINTIFFS.
FOR FIRST AMENDMENT REASONS.
AND THEY WILL BE RELUCTANT TO
TAKE THE SLEDGEHAMMER OVER
SUPREME XIN I BELIEVE IN GOAL.
OKAY SO I ACTUALLY THINK WE'RE
GOING TO SEE YOUR SUPREME XIN.
PERHAPS.
LUCENT.
SO OFTEN.
NOW YOU I SAID.
WELL THAT'S INTERESTING WILL
WOULD BE LOOSING A SOFTENING OF
RECIPIENTS AND I MIGHT ACTUALLY
CREATE THE SPACE.
RIGHT FOR IDEAS ABOUT STATE
SPECIFIC HEALTH REFORM
HEALTHCARE REFORM SOCIAL YOU
ULTIMATELY THAT I'M A PRAGMATIST
I PRACTICED LAW FOR OVER TWENTY
YEARS BEFORE I BECAME A LAW
PROFESSOR I'LL TELL YOU. THAT IN
MASSACHUSETTS THEY SIMPLY
NEGOTIATED THIS PROBLEM AWAY.
OKAY YOU DO REMEMBER
MASSACHUSETTS MADE OF ON THE
STATE'S PACIFIC HEALTH CARE
REFORM AT SIX YEARS BEFORE THE
PORTAL CARE ACT WHICH COURSES
FROM THE CARE BUT ON STEROIDS.
RIGHT WOULD THAT THEY NEGOTIATED
WITH.
RIGHT SO THAT'S ONE OPTION.
OKAY NO ONE EVERYONE BUT WAS ON
THEN GOES WHAT WAS ON THE
BARGAINING TABLE YOU WILL NOT
REYES NERISSA.
ATTACK.
AND THEN EVERYONE SAID WHAT IT
WOULD TAKE.
TO GET THEM TO BUY INTO THE
PROPOSITION.
OKAY ALTERNATELY YOU COULD
LITIGATED WHICH APPEARS TO BE
WHERE SORT OF LAW HEALTHY SAN
FRANCISCO WAS GOING RIGHT. YOU
COULD TRY LEGISLATIVE YOU COULD
TRY AND SEE IF YOU COULD GET A
RESEARCH AMENDED IT WAS HAS BEEN
AMENDED MANY TIMES
YOU COULD TRY TO GET AN
EXEMPTION. AS YOU MAY OR MAY NOT
KNOW HAWAII HAS HAD AN EXEMPTION
SINCE NINETEEN EIGHTY FOUR. FOR
ITS OWN STATE SPECIFIC HEALTH
CARE REFORM YOU COULD BE LIKE.
HAWAII TO.
OKAY WE WANNA. WANNA BE LIKE
THAT.
OKAY WE JUST WANNA BE
SPECIFICALLY ALLOWED TO GO OFTEN
BY ME.
AND ALLOWED TO DO OUR OWN THING.
OKAY WIDE IF WAY BROKER THIS WAY
HAD ITS OWN STATE SPECIFIC
HEALTH CARE REFORM IN THE WORKS
BEFORE A MISSILE WAS PASSED.
AND SO THE PROBABLY HAD THE
STRONGEST ARGUMENT AND THE
QUICKEST MOBILIZATION AROUND HIM
WOMEN WOMEN IN.
WE GOOD DOING THIS LONG BEFORE
YOU ARRANGE THE TEXTURES WERE
NOT. YOU KNOW. THAT WE WE DON'T
WANT TO ABANDON THIS OKAY WE
ACTUALLY WANT TO DEVELOP THIS.
AND SO AND SO THAT'S HOW IT
WORKED.
I'M I COULD BILLS AT LEAST I'M
SURE YOU CAN THINK OF MANY MORE.
ALRIGHT I'M GONNA STOP THERE.
THANK YOU AND THANK YOU FOR
LETTING ME COME A TEST.
THANK YOU VERY MUCH I'D LIKE TO
ASK IF THERE ARE ANY MEMBERS
THAT DIES HAVE QUESTIONS.
SURE I'M GETTING A STAB AT THIS.
.
AND I SHOULD PROBABLY START BY
SAYING I'M NOT A LAWYER.
PRACTICE THE OTHER SIDE I'M AS A
DOCTOR I. AM COMING TO GRIPS
WITH THIS BUT MY PROFESSION
TAUGHT ME TO BE A PROBLEM SOLVER
SO I'M REALLY LOOKING FOR
SOLUTIONS FORWARD.
AND WAS HOPING YOU COULD TALK
ABOUT THE ROLE THAT A PAYROLL
TAX MAY PLAY. IN HELPING US TO
FINANCE UNIVERSAL HEALTHCARE.
AND IF NOTHING PREVENTED
EMPLOYERS FROM MAINTAINING
MULTISTATE ERISA PLANS AMMAN.
WITH THAT TAX.
IF THEY WANTED TO DO SO WOULD A
STATE IMPOSED PAYROLL TAX PASSED
THE WRITTEN MOSTLY.
WELL AS I'VE SAID TAX HASN'T
BEEN A MIXED BAG RIGHT IF THE
TAX LOOKS LIKE.
APPEAR PLAY OPTION IN THE GUISE
OF ATTACKS.
RIGHT MEMBER IN THE MARYLAND
CASE.
HE YOU JUST GOTTA PAY A HIGHER
PERCENTAGE BUT WAIT A MINUTE
NEWLY ONE IS GONNA PUT IT CLINIC
IN.
RIGHT.
THEN NO COULD YOU TRY AND ARGUE
THAT THIS IS A LAW OF NEUTRAL
GENERAL NEUTRAL APPLICATION
INCIDENTLY AFFECTING. UNDER IS A
FAMINE BUT PLAN BUT NOT IN ITS
TARGET TO DO THAT WOULD BE THE
ARGUMENT DO I THINK THIS WOULD
HAVE TO BE LITIGATED IF THEY
WERE NOT IN AGREEMENT NOT TO
RAISE IT I THINK IT MIGHT WELL
HAVE TO BE TEST.
BUT I DO THINK THAT YES THERE'S
AN ARGUMENT.
THERE.
OKAY THERE'S A CASE CALL
TRAVELERS FROM NINETEEN NINETY
FIVE WHICH MAKES IT CLEAR. THAT
IF SOMETHING IS INCIDENTAL TO
LOVE GENERAL APPLICATION.
SO YOU TRYING GET INTO THE
TRAVELERS CRAWL INSIDE OF IT.
ANTS AND STAY IN THAT SPEAKS
THE GREAT QUESTION.
KIND OF ALONG THE LINES
A LITTLE BIT.
I WAS THERE BEEN MANY LEGAL TO.
LIKELY BE
THE MORE LEGAL.
YOU KNOW WHAT IT WHAT WOULD YOU
THINK.
CHALLENGE MIGHT LOOK LIKE AND
HOW LONG WOULD SOMETHING LIKE
THAT PLAY OUT.
WELL. IN SAN FRANCISCO THE
GOLDEN GATE RESTAURANT
ASSOCIATION WHICH SOME OF YOU
MAY KNOW WAS A VERY LARGE. VERY
LONG AND WELL ESTABLISHED RIGHT
RESTAURANT ASSOCIATION UMP.
WELL FUNDED OF. TOOK UP IT SO
YOU CAN ACTUALLY SEE PRIVATE
INDUSTRY COMING AND I THINK YOU
MIGHT SEE EMPLOYERS BECAUSE YOU
HAVE TO UNDERSTAND IF YOU TELL
PEOPLE YOU'RE NO LONGER TO HAVE
THAT RISA.
SHIELD.
RIGHT FROM STATE HEALTHCARE
REGULATION OF HOPE RIGHT THAT'S
MONEY.
THAT'S SIGNIFICANT MONEY THE
REGULATORY BURDEN TRANSLATES
INTO THE SIGNIFICANT COST.
RIGHT AND SO. SOMEONE WHO'S
CONCERNED ENOUGH ABOUT THAT
COST.
I THINK.
WAS LIKELY TO GATHER AROUND A
GROUP OF OTHER CONCERNED IF
THERE'S NO AGREEMENT AND AND I
THINK YOU'RE LIKELY TO SEE THE
CHALLENGE REGISTRY HOW LONG WILL
IT DO THINK A CASE LIKE THIS
WOULD LIKELY GO TO THE SUPREME
COURT I DON'T WANNA. BEAT YOU
KNOW DISHONEST HERE
BECAUSE A BE A CASE OF FIRST
IMPRESSION I TOLD YOU THIS WAS
NOT DECIDED.
RIGHT STUMBLED RIGHT UP TO IT
STOPPED. UCAS STUMBLED AROUND A
FEW TIMES.
AND THAT CAN TAKE A FEW YEARS
DEPENDING ON ALONG THE WAY TO
THE GOLDEN GATE RESTAURANT
ASSOCIATION A GOOD EXAMPLE OF A
TIME OF ONE AGAINST THEM THE
GOLDEN GATE RESTAURANT
ASSOCIATION WILL PETITION FOR
REHEARING. DO UNDERSTAND
PROLONGED EACH PHASE OF IT A
LITTLE BIT MORE NANBAN PRE
HEARING US DE YOU KNOW. THERE
ARE MANY PROCEDURAL MOVES TO
MADE ALONG THE WAY TO THE
SUPREME COURTS UNNECESSARILY OR
AKA.
SO A LOT DEPENDS ON CONDUCT IT
WOULDN'T KNOW ABOUT EARNERS
STRATEGY THAT I WOULDN'T KNOW
WHAT THOUGH.
BUT YES IT'S NOT INSTANTANEOUS.
THAT THEY CAN KIND OF FOCUS YOU
YOU GOT MY INTEREST EARLY ON WE
GOT THIS.
FIRST OFF THANK YOU AT THIS
POUNDS HOPING TO BE FASCINATING
I'M GLAD I AM IF I COULD PICK UP
ANOTHER RESEARCH JUNKIE OF BEEN
AWARE THE DEATH.
I'M NOT QUITE THERE YET BUT I'M
CLOSER THAN I WAS EARLIER.
WHY?
FROM MY MOTHER'S WOMB SANTA OF A
RISK.
SO I'M AND DO A LITTLE MATH HERE
AND I'M GOOD AT SMALL MATH SO.
WE HAVE BASICALLY THREE MILLION
UNINSURED. WE HAVE THIRTEEN
MILLION PEOPLE TO MEDICAID OR
MEDICARE OUT THERE EXPANSION.
SO THAT LEAVES TWENTY TWO
MILLION PEOPLE OUT THERE COVERED
BY SOME SORT OF PLANS YOU SAID.
FIFTY TO SIXTY PERCENT OF THOSE
ARE POSSIBLY COVERED BY RISA
PLANTS IS THAT.
WELL COVERED BY EMPLOYER FUNDED
OKAY A HEALTH INSURANCE NOW YOU
CAN DISCERN THAN YOU BACK THE
NUMBER OUT FROM THE FORM IRIS
FORM FIFTY FIVE HUNDRED AND THE
LAWYER HAS DONE SOME GOOD NUMBER
CRUNCHING ON THIS BUT THAT
NUMBER IT'S ALWAYS A LITTLE OLD.
NUMBERS BEEN GOING UP SINCE THE
PASSAGE OF THE AFFORDABLE CARE
ACT BECAUSE THE REGULATORY
BURDEN HAS BEEN RAISED.
RIGHT ELIZABETH REACHING DEEPER
INTO THE EMPLOYER POPULATION SO
USED TO BE YOU JUST WOULDN'T SEE
THIS KIND OF THING UNLESS THEY
HAD AT LEAST FIVE HUNDRED NOW
IT'S DIPPING LOWER.
SO I'M GONNA ASSUME THAT THAT
NUMBERS AT LEAST THAT'S WHY I'M
HESITANT TO SAY I KNOW THE
NUMBER WILL BE DON'T HAVE TO HIT
A BUTTON. BUT SOME BE BACK SO
THE DATA FROM AYE ARRESTS.
FIFTY FIVE HUNDRED AND THEN I
THE CONCERT EFFECTIVE PROJECT IS
GOING UP I WOULD SAY. IT'S
PROBABLY THE NEW NORMAL. IN
CALIFORNIA WOULD SAY THE
MAJORITY OF CALIFORNIANS I'M
GONNA GUESS FOREIGN EMPLOYER
SPONSORED HEALTH INSURANCE ARE
IN.
AN EMPLOYER SELF FUNDED PLAN
WHICH MEANS IT'S EXEMPT FROM
STATE REGULATION.
UNDER RISA.
ALREADY STATUS QUO ANTE
AND YOU UNDERSTAND WHAT IT KNOW
THAT CULTURE SHOCK THIS.
WOULD BE.
OKAY WE ALWAYS ASSUME ALL THAT
IS HIGHLY REGULATED INDUSTRY
HEALTH CARE YOU KNOW BUT
ACTUALLY WE.
THE ACA DID NOTHING TO THE STAR
OF THIS SORTING.
MECHANISM AND THIS TREATING TO
DIFFERENT GROUPS VERY
DIFFERENTLY ONE ESSENTIALLY IS
PROTECTED FROM REGULATION.
RIGHT.
PROTECT ITS THERE'S A BARRIER.
ILLEGAL THERE.
SUPERBLY BY THOSE NUMBERS
ABOUT A QUARTER OF THE
POPULATION IN CALIFORNIA.
BIG SAID.
AND I DON'T WANT TO PRETEND TO
AND EXPERTISE ON THIS I MEAN I I
READ TO LLOYDS REPORTS YOU KNOW
I READ A CONSULTING FIRMS
REPORTS ARE PUBLICLY AVAILABLE
BUT YES.
FOR A LONG TIME NOBODY KNEW WHAT
THESE NUMBERS OR BECAUSE EVEN
THE FIFTY FIVE HUNDRED AND THIS
IS OUR HOPE THAT NOW WE HAVE
THIS. AND AND SO WE CAN KIND OF
BACK IT OUT CALIFORNIA IS ONE OF
THE TOP SIX
STATES IN THE COUNTRY COUNTRY
FOR THE HIGHEST PERCENTAGE OF.
WHAT YOU BUT IT'S NOT EVEN WHAT
YOU GONNA BE KNOCKING OF HIS
RISE ON LIKE NEW YORK'S IN THERE
AND VOTE I?
BUT ACTUALLY EVEN LIKE I
BELIEVE.
INDIANA NEBRASKA IT ITS TENDS TO
BE STATEMENT THINK OF MEAT
PACKING MEAT PROCESSING POULTRY
PROCESS SIT WITH REALLY LARGE
EMPLOYERS AND THEN IT DRIBBLES.
DOWN FROM IT WHY WOULD SMALLER
EMPLOYERS BE WILLING TO TAKE
THIS RISK
BECAUSE THEY TRYING TO.
AVOID THE REGULATORY BURDEN I
AND THEY ALWAYS FEEL LIKE THEY
CAN PROTECT THEMSELVES OF STOP
LOSS INSURANCE WHICH IS WHY I
THINK THE LEGISLATURE GOT
INTERESTED AND STOP LOSS
INSURANCE BECAUSE OF CHANGE THE
RULES ON. HOW SMALL YOU CAN BE A
HOW EARLY YOU CAN ATTACH STOP
LOSS INSURANCE TO PROTECT YOU
FROM HAVING? THE ACTUAL SKULL
FAMILY THEN WE IN SOME WAYS TO
CREATE INCENTIVES AND
DISINCENTIVES FOR SELF INSURING.
RIGHT AND I THINK I DON'T WAS
ANYBODY'S MOUTH I SUSPECT THAT
THE CALIFORNIA LEGISLATURE WE
SECOND SAY IN NEW YORK AND
WISCONSIN THERE ON THE RECORD
THEY WERE CONCERNED SMALLER AND
SMALLER EMPLOYERS. WERE SELF
INSURING TAKING THEMSELVES OUT
OF THE STATE REGULATORY
INFRASTRUCTURE.
UNBEKNOWNST TO THEIR EMPLOYEES.
AND AND YOU KNOW THAT. CREATING
ESSENTIALLY HEALTH INSURANCE
PLANS THAT WERE NOT.
MINIMUM ESSENTIAL COVERAGE.
IS IT IS A SOBERING.
PROFILE.
THANK THANK YOU VERY VERY MUCH.
ANYONE ELSE AT THE.
KNOWING THAT YOU GET YOUR
WORKING STAYS ON JEWISH BUT WE
UNDERSTAND THAT YOU NEED TO
THINK CLASS WENT TO THE
PENTAGON.
THANK YOU SOME
CAPTION IT COULD I ASK SORRY MY
APOLOGIES I I CAME LATE BUT I.
BUT YEARS AGO ACTUALLY READ OF
MANY OF THE ARRESTS OF CASES I
AM A LAWYER AND A LITTLE BIT OF
INTEREST A GEEK.
AND.
AND I HAVE LIKE MANY OF US VIEW
THIS AS A A REAL BARRIER TO US
TRYING TO DO IMPORTANT THINGS
HERE IN CALIFORNIA. OF AND I
APOLOGIZE I WAS OUT OF THE ROOM
WHEN YOU WENT THROUGH YOUR
PRESENTATION BUT. I AM THERE WAS
NO RISK CHALLENGE OF THE ACA
RIGHT.
NO BECAUSE ACTUALLY THE ACA
AMENDED SARISSA WHO IN SOME
SIGNIFICANT WAYS THAT IT NEEDS
TO IN ORDER TO PERFORM SOME OF
ITS FUNCTIONS ABOUT IT IF YOU
THINK ABOUT THE ACA FROM TEMPLES
ME UP. IT ALSO TRYING TO
STANDARDIZE HEALTH INSURANCE
ONLY COMING FROM THE GOVERNMENT
I OFTEN PUT IT THIS WAY. IN
UNDER RISA THE IMPULSE WAS TO
LET THE EMPLOYER STANDARDIZE IT
YOU KNOW THE MULTI STATE
EMPLOYERS SO THEY COULD HAVE
CONSISTENCY ACROSS STATES. AND
UNDER THE ACA TO STANDARDIZE BUT
WITH THE GOVERNMENT ALL DEPENDS
ON WHO YOU WANT TO HAVE DO THE
STANDARDIZING BEFORE COME FROM A
HEALTH CARE FEDERALISM OF THE
NEED FOR BETTER STANDARDIZATION.
SO HAS SOME EXEMPTIONS THAT HAS
SOME ALTERATIONS BECAUSE THAT'S
FEDERAL LAW SO YOU CAN DO THAT
STATE LAW CANNOT AMEND A RESERVE
RIGHT THAT'S.
BECAUSE OF. YOU KNOW.
IT SUPERIORITY FEDERAL STATUTE.
PUMP IT AND I THE THE BALL POINT
A RELIGION TO ME IS THAT YOU
FEEL COMFORTABLE THAT ACCOUNT
FOR AN INDIVIDUAL MANDATE WOULD
AVOID INTEREST CHARGE AGAIN AS
LONG AS WE DON'T. REFERENCE
EMPLOYER SPONSORED OIL WOULDN'T
FEEL COMFORTABLE ABOUT ANYTHING
WITH.
ERISA IT GOES TO THE SUIT WELL
FOR SO MANY GHOST A FEDERAL
DISTRICT COURT TODAY TELL YOU
THIS SOMETIMES FILL DISK RECORD
JUDGES DECIDE THE CASES
DIFFERENTLY ON THE SAME FACTS.
PART THE REASON THIS IS SUCH A
GNARLY AREA OF LAW IS THAT WE
DON'T NECESSARILY EVEN HAVE
CONSENSUS ON HOW TO INTERPRET
AND APPLY IT.
AND IT GOES TO THE SUPREME COURT
SO FREQUENTLY.
BECAUSE IT IS SO GNARLY THAT WE
OFTEN END UP WITH CONFLICTS ON
THE CIRCUIT LEVEL SO I HAVE NO.
CONFIDENCE I'M SORRY I HOPE I
DIDN'T PROTRUDE I CITY OF
COMPANIES YOU COULD MAKE SUCH AN
ARGUMENT BUT IF I JUST SHOW YOU
IT UP KIND OF HOLLOW OPEN
CRAWLING TO TO MAKE THAT
ARGUMENT AND JUST REASONABLE AN
INDIVIDUAL MANDATE IS MOST
LIKELY TO AVOID CHALLENGE. IF IT
MAKES NO REFERENCE TO EMPLOYER
SPONSORED HEALTH PLANS ARE
SAYING THAT'S HOW YOU AVOID IT
DOES MEAN THAT WILL BE
CHALLENGED EXACTLY GO TO SHOW.
THERE ARE WAYS TO DO THINGS I
THINK MAKE YOU LESS AND MORE
VULNERABLE. SAWS AND SOME
PRACTICAL ON THINKING THAT WAY
RIGHT. THEN THEN.
AS A REPRESENTATIVE OF SAN
FRANCISCO IS VERY FAMILIAR WITH
THE LAWSUIT BROUGHT BY THE GOING
GET RESTAURANT ASSOCIATION I
HAVEN'T SEEN A LEGAL MOUSE.
HOW MUCH ROOM WITH THEIR BE?
A AROUND WHAT SAN FRANCISCO DID
ANOTHER WORDS I'M FAMILIAR WITH
WHAT SAN FRANCISCO DID WITH THAT
PETER PLAY ORDINANCE.
BUT HAVE THERE BEEN.
LAW REVIEW ARTICLES ARE OTHERS
TALK ABOUT HOW MUCH ROOM IS
THERE BEYOND WHAT SAN FRANCISCO
DID THAT WOULD AVOID THE PIN
NUMBER.
I THINK EVERYONE AGREES THAT IF
YOU THE COURAGE AND THE
FORTITUDE IN THE FINANCING TO
SET UP YOUR OWN HEALTH INSURANCE
COMPANY COULD PROBABLY IT DIDN'T
MAKE AS MUCH OR A RUN THAT AT
THIS GOAL AS THE GOLDEN GATE
RESTAURANT ASSOCIATION IS.
HELP THE SAN FRANCISCO DID
MEMBER THAT DID NOT GO TO THE
SUPREME COURT BUT THAT MIGHT BE
YOUR STRONGEST I GIVE YOU THE
OTHER POINT OF LIGHT AT THE
OTHER END OF THE FIEDLER CASE
AMERICA ON THE WALMART CASE.
SOMEWHERE BETWEEN WOULD BE THE
TRAVELER CASE FROM NINETEEN
NINETY FIVE OR CIVIL YOU MIGHT
HAVE A STATUTE. THAT WAS WHAT OF
GENERAL APPLICATION THAT ONLY
INCIDENTALLY BURDEN GENEROUS
SUPPLANTING OR YOUR SO NO I KNOW
OF NO LAW REVIEW ARTICLE THAT
SORT OF. MEDICINE THAT THERE ARE
A COUPLE OF PEOPLE IN THE
COUNTRY WHO RIGHT ON THIS. IS
PETER JACOBSEN.
ATTIC LUCK.
IF YOU WANT BUT I DON'T HIDE IT
PUT MY EMAIL ON THAT FIRST THE
VERY FIRST SLIDE AS A BE HAPPY
TO SEND YOU LIKE. LINKS TO THAT
WHAT THEY WRITE ABOUT YOU GUYS
THEIR PEOPLE ALWAYS LIKE ME
TRYING TO PUT THESE PIECES
TOGETHER LIKE. LIKE A MOSAIC.
YOU KNOW BECAUSE THIS HAS NOT
BEEN RULED ON. LIVES ALL AGREE
OKAY THIS WOULD BE A CASE OF
FIRST IMPRESSION.
AND IN A SENSE WITH THE GORSUCH
WELL THEN THE THE NEWLY
CONSTITUTED COURT WHETHER THEY
BE MORE OR LESS LIKELY. YOUR WAS
LOOKING FOR WHO.
UP IN A COURT WHOEVER HAS A BACK
ON AND HIGHLY TECHNICAL
EXTREMELY DIFFICULT AND
COMPLICATED AREA LIKE A RESERVE
THERE'S A LOT OF DIFFERENCE IF
ANYBODY HAS IN A RESERVE
BACKGROUND.
NOT GONNA BE SUPPRESSED KNOW
THAT RIGHT I ALSO PRACTICE IN
ANY TRUST. I CAN TELL YOU ON THE
SUPREME COURT HAS A BACKGROUND
IN ANY TOUGHEST
AND PEOPLE TEND TO FOR.
OKAY EVEN SOMETIMES ACROSS THE
POLITICAL SPECTRUM BECAUSE IT'S
JUST SO COMPLICATED.
SO I'D LIKE REALLY CAN'T SAY WE
HAVE A COUPLE OF BUSINESS
LITIGATORS.
ON THERE AND SO YES I THINK
THEY'RE GOING TO BE PEOPLE WHO
ARE GOING TO KNOW SOMETHING
ABOUT THIS.
THAT I CAN'T SAY MORE THAN THAT
IT'S NOT WE'RE GONNA KNOW WHO
CARES THE MOST ABOUT RISK BY WHO
GETS TO WRITE THE OPINIONS IN
THE TWO CASES INVOLVING.
RELIGIOUS PLANTS.
RIGHT THAT I TALKED ABOUT
BECAUSE THEY WERE GONNA WHO
STEPS FORWARD TO SAY I WANNA
WRITE A GNARLY A RECIPIENT.
IT IMPLICATES THE FIRST SUMMIT
WE'RE GOING TO FIGURE OUT WHO.
SO JUSTICE KENNEDY WROTE THE
OPINION RIGHT AND SO BAKER.
THAT TELLS US SOMETHING ARGUES
INTERESTED IN HE WAS A BUSINESS
LITIGATOR RIGHT IN SACRAMENTO.
M..
BUT THIS IS VERY MUCH YOU KNOW
KILLING IT TO CAN IN MEANING THE
ENTRANCES SO I I DON'T WANT TO
PRETEND YOU DON'T KNOW WHO WOULD
BE IF THIS ONE TO THE RECORD WHO
WOULD STEP FORWARD TO WRITE YOU
DO KNOW THAT THE. CHIEF JUSTICE
ASSIGNS THE WRITING.
SO AND IF HE IF HE IN THIS CASE
IS IN THE MAJORITY HIS IT CAN'T
EVEN ASSIGN IT TO HIMSELF.
SO IT'S POSSIBLE.
YOU KNOW ANYTHING FROM CHIEF
JUSTICE JOHN ROBERTS TO.
THANK YOU.
FOR WHAT IT'S WORTH THE DISSENT
IN THE US SO TAKE CASE WAS.
.
KAGAN.
AND GINSBURG.
KENNEDY AND BRIAR WORLD
OPPOSITION AND THEN.
IF YOU CARE ABOUT THESE KIND
COUNTING NOSES.
THANK YOU.
THANK.
NEXT WE HAVE DOCTOR Q. PENSKE
WHO IS AN ASSOCIATE DIRECTOR OF
THE PROGRAM ON MEDICARE POLICY
AT THE. KAISER FAMILY
FOUNDATION.
AS AN EXPERT ON MEDICARE POLICY
DOCTOR COULD DANCE HE FOCUSES ON
PRODUCING TIMELY AND
AUTHORITATIVE ANALYSIS.
I'M WAITING MEDICARE REFORM
PROPOSALS AND ON INFORMING THE
DEBATE ABOUT THE FUTURE OF THE
MEDICARE PROGRAM.
THANK YOU FOR COMING. GOOD
AFTERNOON AND THANK YOU FOR THE
OPPORTUNITY TO BE WITH YOU.
AT TODAY'S COMMITTEE HEARING ON
IMPLEMENTATION CONSIDERATIONS
FOR UNIVERSAL COVERAGE.
MY NAME IS JULIA QB ON SKI AND I
ASSOCIATE DIRECTOR OF THE
PROGRAM ON MEDICARE POLICY AT
THE KAISER FAMILY FOUNDATION.
KAISER IS A NONPROFIT
ORGANIZATION FOCUSING ON
NATIONAL HEALTH ISSUES AND WE
SERVICE THE NONPARTISAN SOURCE
OF FACTS ANALYSIS AND
JOURNALISM.
FOR POLICY MAKERS THE MEDIA THE
HEALTH POLICY COMMUNITY AND THE
PUBLIC.
AND FOR THE RECORD WE ARE NOT
AFFILIATED WITH KAISER
PERMANENTE A.
MY ROLE TODAY IS TO PROVIDE YOU
WITH INFORMATION ABOUT THE
FEDERAL LAW CONSIDERATIONS
RELATED TO MEDICARE. THAT ARE
RELEVANT TO THE STATE'S
DISCUSSION ABOUT IMPLEMENTATION
OF A SINGLE PAYER SYSTEM.
LET ME BEGIN BY PROVIDING YOU
WITH A QUICK OVERVIEW OF
MEDICARE TO SET SOME CONTEXT.
MEDICARE COVER SIXTY MILLION
PEOPLE IN THE U. S. AND SIX
MILLION PEOPLE IN CALIFORNIA OR
ONE IN SIX STATE RESIDENTS.
MOST PEOPLE WITH MEDICARE ARE
AGES SIXTY FIVE AND OLDER BUT A
SMALL SHARE QUALIFY BECAUSE
THEY'RE UNDER AGE SIXTY FIVE AND
HAVE A PERMANENT DISABILITY.
AND WHILE MOST PEOPLE WITH
MEDICARE ARE IN TRADITIONAL
MEDICARE ALSO KNOWN AS FEE FOR
SERVICE MEDICARE. MORE THAN FOUR
IN TEN BENEFICIARIES IN
CALIFORNIA ARE ENROLLED IN
MEDICARE ADVANTAGE.
WHERE THERE MEDICARE COVERED
BENEFITS ARE DELIVERED THROUGH
PRIVATE PLANS LIKE HMOS AND PPO
DOES THAT CONTRACT WITH
MEDICARE?
MEDICARE BENEFITS ARE DIVIDED UP
INTO FOUR PARTS A. B. C. AND D..
GENERALLY SPEAKING A COVERS
HOSPITAL SERVICES BE COVERS
PHYSICIAN SERVICES D. COVERS
PRESCRIPTION DRUGS AND SEE
REFERS TO MEDICARE ADVANTAGE.
IN TWENTY SIXTEEN SPENDING ON
THESE BENEFITS WAS SIX HUNDRED
AND SEVENTY FIVE BILLION DOLLARS
AND HERE AND FIGURE TO YOU CAN
SEE HOW THE SPENDING WAS
DISTRIBUTED.
THIS TOTAL INCLUDES MEDICARE'S
ADMINISTRATIVE COSTS BOTH THE
COST TO THE GOVERNMENT TO
OPERATE THE MEDICARE PROGRAM.
AND THE COSTS TO PRIVATE
MEDICARE ADVANTAGE AND PARTY
PLANS.
TOGETHER THESE ADMINISTRATIVE
EXPENSES WERE ABOUT SEVEN
PERCENT OF TOTAL SPENDING IN
TENTY SIXTEEN.
FOR PEOPLE TURNING SIXTY FIVE IN
ROLLING IN PART A AND B. IS
AUTOMATIC IF THEY'RE ALREADY
GETTING SOCIAL SECURITY BENEFITS
AT THAT POINT. THOUGH
TECHNICALLY PART BE IS VOLUNTARY
BUT IF PEOPLE DON'T WANT PART
BEEP BEEP PARTY COVERAGE THEY
HAVE TO OPT OUT OF THE PARTY
PROGRAM.
IF PEOPLE WANT PART DEED DRUG
COVERAGE THEY MUST SIGN UP FOR A
PLAN THAT OFFERS THIS COVERAGE
IS NOT AUTOMATIC LIKE A AND B.
ENROLLMENT.
THE DIFFERENT PARTS OF MEDICARE
ARE FINANCED DIFFERENTLY.
PART A LOT IS FUNDED MAINLY BY
A TWO POINT NINE PERCENT PAYROLL
TAX
ON EARNINGS THAT.
IS EQUALLY SPLIT BETWEEN
EMPLOYERS AND EMPLOYEES.
AND THIS MONEY IS DEPOSITED INTO
THE HOSPITAL INSURANCE TRUST
FUND.
HIGHER INCOME TAX PAYERS
PAY AN ADDITIONAL ZERO POINT
NINE PERCENT MAYOR MEDICARE
PAYROLL TAX.
PART B. IS FUNDED BY A GENERAL
REVENUES FROM THE FEDERAL
GOVERNMENT WHICH IS MOSTLY
INCOME TAX.
WHICH ARE SAID TO COVER SEVENTY
FIVE PERCENT OF PROGRAM COSTS
EACH YEAR. AND BENEFICIARIES
ALSO PAY MONTHLY PREMIUMS WHICH
COVER THE OTHER TWENTY FIVE
PERCENT.
HIGHER INCOME BENEFICIARIES PAY
A HIGHER SHARE OF PROGRAM
COSTING RECEIVE A LOWER FEDERAL
SUBSIDY.
PARTY IS FUNDED SIMILAR LEAD TO
PART BE WITH GENERAL REVENUES
COVERING ABOUT SEVENTY FIVE
PERCENT OF PROGRAM COSTS EACH
YEAR AND BENEFICIARY PREMIUMS
AND STATE TRANSFERS COVERING THE
REST. AND LIKE PART BE HIGHER
INCOME BENEFICIARIES PAY A
HIGHER SHARE OF PROGRAM COSTS
FOR PART D. COVERAGE.
SO LET ME TRANSLATE THESE
DIFFERENT FUNDING STREAMS AND
ACTUAL DOLLAR AMOUNTS.
FOR TWENTY SIXTEEN FOR PARTS A
BMD.
PART SEE IS NOT SHOWN
SEPARATELY HERE BECAUSE IT
DOESN'T HAVE ITS OWN FINANCING
STREAM.
SO TOTAL REVENUE TO MEDICARE AND
TWENTY SIXTEEN WAS SEVEN HUNDRED
AND TEN BILLION DOLLARS.
PART A REVENUE IN TWENTY
SIXTEEN TOTAL TWO HUNDRED AND
NINETY ONE BILLION DOLLARS OF
WHICH THE VAST MAJORITY TWO
HUNDRED AND FIFTY FOUR BILLION
DOLLARS WAS FOUND PAYROLL TAXES.
PART BE REVENUE IN TWENTY
SIXTEEN WAS THREE HUNDRED AND
THIRTEEN BILLION DOLLARS. OF
WHICH THREE QUARTERS OR TWO
HUNDRED AND THIRTY SIX BILLION
DOLLARS WAS FROM GENERAL
REVENUE.
BENEFICIARIESPAID SEVENTY TWO
BILLION DOLLARS IN PART B.
PREMIUMS IN TWENTY SIXTEEN.
PARDEE REVENUE WAS A HUNDRED AND
SIX BILLION DOLLARS IN TWENTY
SIXTEEN OF WHICH EIGHTY TWO
BILLION WAS FROM GENERAL
REVENUES AND BENEFICIARIES PAID
FOURTEEN BILLION DOLLARS IN
PARTY PREMIUMS.
SO I KNOW I JUST MENTIONED A LOT
OF NUMBERS AND YOU MAY REMEMBER
NOT OF THEM BUT THE POINT I'D
LIKE TO EMPHASIZE IS THAT.
MEDICARE RECEIVES A SIGNIFICANT
INVESTMENT OF FEDERAL DOLLARS
FROM PAYROLL TAXES AND GENERAL
REVENUES BUT ALSO A NOT
INSIGNIFICANT PORTION OF FUNDING
IS FROM BENEFICIARIES
THEMSELVES.
IN THE FORM OF MONTHLY PREMIUM
PAYMENTS.
SO NOW WE FOCUS IN ON THE
SPECIFICS OF MEDICARE WAIVER
AUTHORITY WHICH I KNOW YOU'RE
VERY INTERESTED IN.
SO TITLE EIGHTEEN OF THE SOCIAL
SECURITY ACT IS HEALTH INSURANCE
FOR THE AGED AND DISABLED WHICH
WE KNOW AS MEDICARE.
WHO QUALIFIES FOR THE PROGRAM
THAT BENEFITS TO WHICH THEY ARE
ENTITLED THE MONTHLY PREMIUMS
THAT PEOPLE PAY THE COST SHARING
PAYMENTS THAT THEY PAY FOR
SERVICES? HOW PROVIDERS ARE PAID
AND HOW THE PROGRAM IS FINANCED
ARE ALL GOVERNED BY STATUTE?
BUT FEDERAL LAW ALSO PERMITS THE
SECRETARY OF HEALTH AND HUMAN
SERVICES OR HHS TO WAIVE CERTAIN
PROVISIONS OF MEDICARE LAW IN
ORDER TO CONDUCT DEMONSTRATION
PROJECTS.
AND TEST MODELS OF PAYMENT AND
DELIVERY SYSTEM REFORMS RELATED
TO MEDICARE.
I WANT TO TALK ABOUT TO SPECIFIC
PROVISIONS THAT ALLOW FOR THIS
TYPE OF WAIVER ACTIVITY.
ONE IS SECTION FOUR OH TWO OF
THE SOCIAL SECURITY AMENDMENTS
OF NINETEEN SIXTY SEVEN WHICH.
AIMS TO IMPROVE THE EFFICIENCY
AND ECONOMY OF MEDICARE ALLOWING
FOR EXPERIMENTS AND
DEMONSTRATIONS TO TEST
ALTERNATIVE METHODS OF PAYING
FOR MEDICARE SERVICES.
OR COVERING OTHER BENEFITS THAT
ARE NOT ALREADY PAID FOR.
BY MEDICARE.
THE WAIVER AUTHORIZES THE
SECRETARY TO WAIVE MEDICARE
PAYMENTS.
THAT ARE REQUIRED TO CARRY OUT
THE DEMONSTRATION UNDER THE
SECTION FOUR OH TO AUTHORITY.
THAT.
SECTION ELEVEN FIFTEEN A
ESTABLISH A CENTER FOR MEDICARE
AND MEDICAID INNOVATION THIS WAS
AUTHORIZED OR CREATED BY THE
AFFORDABLE CARE ACT.
DOES SENATOR MEDICARE AND
MEDICARE AND MEDICAID INNOVATION
ALSO KNOWN AS THE INNOVATION
CENTER OR CMMI. HAS BROAD
AUTHORITY TO TEST INNOVATIVE
MODELS FOR SERVICE DELIVERY AND
PAYMENT METHODS THAT DECREASE
COSTS AND OR IMPROVE.
OR MAINTAIN QUALITY IN MEDICARE
MEDICAID AND CHIP.
SINCE TWENTY ELEVEN THIS HAS
BEEN THE PRIMARY VEHICLE FOR
TESTING INNOVATIONS AND MEDICARE
PAYMENT AND SERVICE DELIVERY.
IN ADDITION CONGRESS CAN ALSO
MANDATE.
SPECIFIC MEDICARE
DEMONSTRATIONS THROUGH
LEGISLATION.
I WANT NOTE THAT THESE MEDICARE
WAIVERS AND DEMONSTRATIONS ARE
DIFFERENT FROM MEDICAID AND ACA
WAIVERS WHICH CHIQUITA WILL BE
TELLING YOU MORE ABOUT SHORTLY.
THOSE WAIVERS MAY BE MORE OF A
VEHICLE FOR EXPANDING STATE'S
DISCRETION OVER PROGRAM RULES
GOVERNING ELIGIBILITY BENEFITS
AT CETERA. BUT THIS IS GENERALLY
NOT THE CASE
FOR MEDICARE WAIVERS.
AT UNLIKE MEDICAID AN ACA THERE
IS REALLY LITTLE PRECEDENT FOR
STATES TO SEEK BROAD WAIVERS OF
FEDERAL LAW RELATED TO MEDICARE
IN LARGE PART I THINK BECAUSE
MEDICARE IS A NATIONAL PROGRAM.
AND STATES ARE NOT REALLY
RESPONSIBLE FOR ADMINISTERING
IT.
SO AND BECAUSE THE SECTION FOR
O. TO AUTHORITY HAS REALLY NOT
BEEN USED
IN THE CONTEXT OF A STATE BASED
HEALTH CARE PROGRAM. AND THE
SECRETARY WAIVER AUTHORITY UNDER
SECTION ODE TO IS LIMITED TO
MEDICARE'S PAYMENT RULES I WANT
TO FOCUS MORE ON THE INNOVATION
CENTER AND WHAT IT DOES.
SO AS I SAID THE CENTER HAS
BROAD AUTHORITY TO TEST AND
DEVELOP NEW PAYMENT AND SERVICE
DELIVERY MODELS AND MEDICARE AND
THIS INCLUDES STATEWIDE
INITIATIVES.
THE INNOVATION CENTER PLAYS AN
INTEGRAL ROLE IN THE PROCESS OF
GOING FROM THE IDEA OF A MODEL
TO ACTUALLY TESTING IT.
THE GENERAL OUTLINE OF THIS
PROCESS IS THAT THE INNOVATION
CENTER SOLICITS IDEAS FOR NEW
MODELS.
IT REVIEWS SELECTS AND DEVELOPS
THE MOST PROMISING MODELS.
IT DETERMINES THE APPROPRIATE
BENCHMARKS.
TO MEASURE THE PERFORMANCE OF
THE MODEL.
AND SELECT PARTNERS TO TEST THE
MODELS TYPICALLY THROUGH A
COMPETITIVE PROCESS.
THESE MODELS REQUIRE RIGOROUS
MONITORING TESTING AND
INDEPENDENT EVALUATIONS OF
THEIR.
PROGRESS.
TYPICALLY THESE MODELS HAVE AN
END DATE ALTHOUGH THE DURATION
AND THE SCOPE OF THE MODELS CAN
BE EXPANDED THROUGH A FORMAL
RULE MAKING PROCESS. IF THE HHS
SECRETARY DETERMINES THAT
EXPANSION OF THE MODEL WILL
REDUCE PROGRAM SPENDING AND BY
THAT I MEAN MEDICARE PROGRAM
SPENDING SPECIFICALLY. WITHOUT
REDUCING QUALITY OR WILL IMPROVE
QUALITY. INCREASING SPENDING.
THESE MODELS ARE NOT INITIALLY
REQUIRED TO BE BUDGET NEUTRAL.
BUT THE MODELS CAN BE TERMINATED
OR MODIFIED UNLESS THE HHS
SECRETARY DETERMINES THAT A
MODEL AS MODIFIED. IS EXPECTED
TO IMPROVE QUALITY WITHOUT
INCREASING SPENDING REDUCE
SPENDING WITHOUT REDUCING
QUALITY OR IMPROVE QUALITY AND
REDUCE SPENDING.
SO JUST TO BE CLEAR THE CORE
PURPOSE OF THE INNOVATION CENTER
IS TO TEST INNOVATIVE PAYMENT
AND SERVICE DELIVERY MODELS TO
REDUCE PROGRAM EXPENDITURES
WHILE PRESERVING OR ENHANCING
THE QUALITY OF CARE.
THERE ARE SEVERAL DIFFERENT
CATEGORIES OF INNOVATION MODELS
THAT THE CENTER CARRIES OUT AND
I DON'T HAVE TIME TO FOCUS ON
THE SPECIFICS OF EACH OF THESE
CATEGORIES. BUT I DID WANT YOU
TO SEE THE RANGE OF MODELS THAT
THE INNOVATION CENTER HAS
AUTHORITY TO TEST.
AND CALIFORNIA ACTUALLY DOES
HAVE INITIATIVES UNDERWAY IN
SEVERAL OF THESE CATEGORIES.
BUT I WANT TO HIGHLIGHT THIS
LAST CATEGORY INNOVATION I IN
INITIATIVES TO ACCELERATE. THE
DEVELOPMENT AND TESTING OF NEW
PAYMENT AND SERVICE DELIVERY
MODELS.
THIS IS WHERE SEVERAL STATE
BASED INITIATIVES.
THAT INVOLVE MEDICARE
PARTICIPATION ARE BEING
IMPLEMENTED INCLUDING MARYLAND'S
ALL PAYER MODEL I KNOW YOU'VE
ALREADY HEARD.
AT A PREVIOUS HEARING DETAILS
ABOUT MARYLAND'S MODEL SO I
WON'T GO INTO DETAIL ABOUT IT
HERE. BUT ORIGINALLY OUT I WON
AND I MENTION A COUPLE POINTS
ABOUT IT MARYLAND'S MODEL
ORIGINALLY TOOK THE FORM OF A
WAIVER ESTABLISHED IN FEDERAL
LAW.
UNDER THE ORIGINAL WAIVER
MEDICARE PAYS HOSPITAL RATES
THAT MEDICARE'S BUT THAT MARILYN
STATS NOT THE RATES THAT
MEDICARE'S SETS.
AND I ALSO THINK IT'S IMPORTANT
TO EMPHASIZE THAT MARILYN'S
WEAVER IS UNIQUE.
AND SOMEWHAT LIMITED IN SCOPE
AND THAT IT DOESN'T CHANGE
MEDICARE BENEFITS OR ELIGIBILITY
OR COST SHARING OR FINANCING OR
THE FUNDING STREAMS ASSOCIATED
WITH THE MEDICARE TRUST FUNDS.
NOR THE UNDERLYING COVERAGE
ARRANGEMENTS OF PEOPLE WITH WITH
MEDICARE IN THE STATE OF
MARYLAND.
IT'S ALSO IMPORTANT TO KNOW
THAT MARILYN'S ORIGINAL WAIVER
IS SHIFTING AWAY FROM THE
STATUTORY WAIVER THAT THE STATE
RECEIVED.
TO THIS NEW ALL PAYER MODEL
WHICH WAS DEVELOPED IN
PARTNERSHIP WITH THE INNOVATION
CENTER. AND HAS VERY SPECIFIC
MEDICARE SAVINGS TARGETS TO
MEET.
IN ORDER TO CONTINUE.
I ALSO WANT TO CALL YOUR
ATTENTION TO THE STATE
INNOVATION MODELS.
WHICH FALLS WITHIN THIS
CATEGORY WHICH IS WHERE STATES
CAN DESIGN AND TEST NEW A MULTI
PAYER.
AT PAYMENT AND DELIVERY MODELS
WHICH WITH POTENTIAL TO IMPROVE
CARE AND LOWER COSTS NOT AND TO
IMPROVE HEALTH SYSTEM
PERFORMANCE.
THIS MODEL HAS BEEN ROLLING OUT
IN SEVERAL STAGES AND IN FACT
CALIFORNIA DID RECEIVE TWO
ROUNDS OF FUNDING IN THE DESIGN
STAGES.
OF THIS INITIATIVE.
CURRENTLY THERE ARE ELEVEN
STATES IN THE TESTING STAGE
WITH THE WIDE RANGE OF PROPOSALS
BEING TESTED AND THESE STATE
INNOVATION MODELS ARE BURIED.
AND ALSO AMBITIOUS.
IT'S DIFFICULT TO SUMMARIZE
THEM IN A SENTENCE OR TWO.
BUT BUT I WOULD SAY IN GENERAL
SEVERAL STATES HAVE BUILT THEIR
PLANS AROUND PATIENT CENTERED
MEDICAL HOMES.
INTEGRATING PRIMARY CARE AND
BEHAVIORAL HEALTH CARE.
EXPANDING HEALTH INFORMATION
TECHNOLOGY EFFORTS LIKE
TELEHEALTH. AND MOVING TO VALUE
BASED PAYMENTS SHARED SAVINGS
AND ACCOUNTABLE CARE PAYMENT
MODELS.
CMS HAS SOMEWHAT HOPEFULLY I
THINK RELEASED GUIDANCE
IN SUPPORT OF MEDICARE
PARTICIPATION IN THESE MODELS
THOUGH I'D ALSO NOTE THAT THE
INTEGRATION OF MEDICARE IN STATE
INNOVATION MODELS IS SUBJECT TO
ADDITIONAL SCRUTINY. BY CMS.
FOR STATES THAT WANT TO
INCORPORATE MEDICARE
PARTICIPATION IN A STATE
INNOVATION MODEL THE PLAN MUST
ADHERE TO SEVERAL SPECIFIC
PRINCIPLES AND IT MUST HAVE A
CLEARLY DEFINED TARGET
POPULATION EITHER.
AFFECTED PATIENTS OR AFFECTED
PROVIDERS OR BOTH.
IT MUST HAVE A CLEAR POTENTIAL
TO IMPROVE QUALITY AND REDUCE
THE SPENDING FOR THE COVERED
POPULATION. AND THE STATE MUST
HAVE DEMONSTRATED PREPAREDNESS
TO UNDERTAKE THE PROPOSAL.
AND I WOULD SAY THAT AT THE END
OF THE DAY THE DECISION RESTS
WITH THE INNOVATION CENTER AND
ITS FEDERAL PARTNERS. AS TO
WHETHER TO MOVE FORWARD WITH THE
STATE'S PLAN UNDER THE STATE
INNOVATIONS MODEL OR ANY OF THE
OTHER MODELS.
THAT THE INNOVATION CENTER HAS
STATUTORY AUTHORITY TO PURSUE.
SO OBVIOUSLY A KEY QUESTION IT.
FOR CALIFORNIA IS WHETHER THE
STATE CAN USE EXISTING CMMI
AUTHORITY OR SECTION FOUR OH TO
MEDICARE WAIVER AUTHORITY. IN
THE IMPLEMENTATION OF A SINGLE
PAYER SYSTEM.
I THINK IT'S CLEAR THAT THE
FEDERAL GOVERNMENT DOES
RECOGNIZE THAT STATES PLAY A KEY
ROLE IN HEALTH CARE DELIVERY AND
REFORM EFFORTS.
AND HAS IN FACT OPENS THE DOOR
TO STATE INITIATIVES THAT
INCLUDE MEDICARE PARTICIPATION.
EXISTING AUTHORITY DOES IN FACT
ALLOW FOR MODELS TESTING CHANGES
TO MEDICARE PAYMENT AND SERVICE
DELIVERY TO IMPROVE QUALITY AND
A CHIEF PROGRAM SAVINGS I'VE
SAID THAT OVER AND OVER AGAIN.
AND THERE'S CLEARLY THE
POTENTIAL TO TAKE STEPS TOWARD
TRANSFORMATIVE SYSTEM CHANGE IN
THE STATE INNOVATION MODELS
UNDER THE INNOVATION CENTERS
EXISTING AUTHORITY.
BUT FOR IMPLEMENTATION OF A
SINGLE PAYER SYSTEM THE STATE
WOULD NEED MORE THAN JUST A
WAIVER OF STATUTORY PROVISIONS
RELATED TO MEDICARE PAYMENT AND
SERVICE DELIVERY. AND WOULD NEED
TO SEEK PERMISSION TO MAKE
BROADER CHANGES WHICH MAY NOT BE
ENVISIONED IN THEIR ENTIRETY IN
THE CURRENT ROSTER OF INNOVATION
CENTER ACTIVITIES. AND WHICH DO
NOT SEEM TO FALL WITHIN THE
SCOPE OF SECTION FOUR OH TO
AUTHORITY.
SEEKING PERMISSION FOR THE
MEDICARE CHANGES THAT ARE LIKELY
TO BE NEEDED FOR IMPLEMENTATION
OF A STATE BASED SINGLE PAYER
SYSTEM WOULD BE A A DEPARTURE
FROM EXISTING APPLICATIONS OF
THE DEMONSTRATION AND MODEL
TESTING PROCESS. WHEREBY THE
STATE WOULD BE SEEKING TO MAKE
PERMANENT CHANGES TO THE STATE'S
ENTIRE HEALTH CARE DELIVERY
SYSTEM FOR ALL OF THE STATE'S
RESIDENTS. AND NOT JUST ON A
TIME LIMITED BASIS.
WITH THAT WITH THEM FOCUSED
MUCH BROADER THAN JUST MEDICARE
PAYMENT AND SERVICE DELIVERY.
AND AS SUCH I THINK THERE IS A
REALLY A GREAT DEAL OF
UNCERTAINTY AS TO WHAT AT
ADMINISTRATION AND PERHAPS
ADMINISTRATION. WILL ENTERTAIN
THROUGH WAIVERS OR INNOVATION
CENTER MODELS.
SO I WOULD CONCLUDE BY SAYING
THAT I I THINK USING CMMI
AUTHORITY OR OTHER MEDICARE
WAIVER AUTHORITY. TO IMPLEMENT A
SINGLE PAYER SYSTEM IN
CALIFORNIA WOULD BE NECESSARY.
BUT IT DOES NOT APPEAR TO BE
SUFFICIENT.
BEYONCE SEEKING PERMISSION FROM
HHS FOR CHANGES THAT CAN BE MADE
UNDER EXISTING AUTHORITY
FLEXIBLE AS IT MIGHT BE WITH
REGARD TO STATE INNOVATIVE
ACTIVITY. IT IS STILL THE CASE
THAT FEDERAL STATUTORY CHANGES
WOULD BE NEEDED MEANING CONGRESS
WOULD NEED TO PASS AND THE
PRESIDENT WOULD NEED TO SIGN
LEGISLATION TO MAKE NUMEROUS
CHANGES.
I I THINK PERHAPS MOST
IMPORTANTLY THE EXISTING
STATUTORY WAIVER PROCESS AND THE
AUTHORITY GRANTED THE INNOVATION
CENTER DO NOT APPEAR TO PERMIT
THE HHS SECRETARY TO SIMPLY
REDIRECTS. MEDICARE'S FUNDING
STREAMS.
INCLUDING THE PAYROLL TAXES THE
GENERAL REVENUES AND BENEFICIARY
PREMIUMS OR TRUST FUND DOLLARS
TO STATES TO OVERSEE AND MANAGE
THESE FUNDS IN THEIR ENTIRETY ON
BEHALF OF THE STATE'S ENTIRE
MEDICARE POPULATION THROUGH A
STATE BASED HEALTH CARE PROGRAM.
THE SECRETARY ALSO HAS NO
AUTHORITY TO CHANGE MEDICARE
ELIGIBILITY OR ENROLLMENT RULES.
OR TO CHANGE THE RULES RELATED
TO HOW MUCH BENEFICIARIES PAY IN
PREMIUMS AND COST SHARING.
THESE ARE ALL THINGS THAT WOULD
NEED TO BE CHANGED THROUGH
FEDERAL LEGISLATION TO FULLY
INCORPORATE MEDICARE
BENEFICIARIES IN THE STATE
SINGLE PAYER SYSTEM.
AND BEYOND THE LEGISLATIVE
CHANGES THAT WOULD BE NEEDED
INCORPORATING MEDICARE IN A
SINGLE PAYER SYSTEM AT THE STATE
LEVEL WOULD REQUIRE A HIGH
DEGREE OF COLLABORATION. BETWEEN
THE FEDERAL GOVERNMENT AND THE
STATE TO MAKE IT WORK AND I
THINK IT'S AN OPEN QUESTION AS
TO THE WILLINGNESS OF THIS
ADMINISTRATION TO COLLABORATE.
ON CHANGES OF THIS MAGNITUDE AT
THIS TIME.
BUT EVEN THEN A CONDUCIVE
POLITICAL ENVIRONMENT WHERE THAT
COLLABORATION EXISTED THE STATE
WOULD REALLY NEED TO WORK
CLOSELY WITH THE FEDERAL
GOVERNMENT TO ADDRESS MANY
STATUTORY. FIVE REGULATORY AND
ADMINISTRATIVE ISSUES RELATED TO
INTEGRATING MEDICARE INTO THE
STATE'S SINGLE PAYER SYSTEM.
BUT I DON'T AND.
CHIQUITA.
SO OUR NEXT SPEAKER HANG ON
SECOND.
CHIQUITA BROOKS.
WITH YOUR. OKAY ARE A GOOD
THOUGHT.
MANAGING DIRECTOR FROM AN THAT
HELP. OF FORMER POLICY IF ISSUE
PLAYED A KEY ROLE IN GUIDING THE
AFFORDABLE CARE ACT THROUGH
PASSAGE AND IMPLEMENTATION.
PLEASE CLICK THANK YOU IT'S A
PLEASURE TO BE HERE WITH YOU
THANK YOU FOR INVITING ME.
IT'S ALWAYS WONDERFUL TO TALK
ABOUT COVERAGE AND SO I'M REALLY
EXCITED TO BE HERE. I'M GONNA
FOCUS NEXT ON MEDICAID AND
MARKETPLACE WHICH I KNOW YOU'RE
PRETTY FAMILIAR WITH GIVEN
CALIFORNIA'S.
VERY IMPORTANT ROLE IN
IMPLEMENTATION.
OF BOTH OF THOSE PROGRAMS AS
YOU KNOW.
MEDICAID IS A JOINTLY FUNDED
PROGRAM I'VE JOINTLY FEDERAL AND
STATE PROGRAM AND THE MEDICAID
STATUTE ESTABLISHES CERTAIN
RULES. THAT STATES MUST ME AND
IN ORDER TO RECEIVE FEDERAL
FUNDING.
UNDER SECTION ELEVEN FIFTEEN OF
THE SOCIAL SECURITY ACT THE
SECRETARY OF HEALTH AND HUMAN
SERVICES HAS BROAD BUT NOT
UNLIMITED. AUTHORITY TO WAIVE
CERTAIN FEDERAL REQUIREMENTS.
FOR THE MEDICAID PROGRAM. AND
THE SLIDE YOU CAN SEE A COUPLE
OF THE KEY PROVISIONS.
THE FEDERAL.
MEDICAID LAW REQUIRES THAT
WEAVERS FURTHER THE OBJECTIVES
OF THE PROGRAM SO I THE INTENT
OF A DEMONSTRATION IS TO IN IN
SOME WAY MOVE FORWARD WHAT THE
MEDICAID PROGRAM I. WAS INTENDED
TO DO.
IT'S AUTHORIZED FOR
DEMONSTRATION PURPOSES SUBJECT
TO EVALUATION SIMILAR TO WHAT
JULIET WAS SAYING ABOUT
INNOVATION CENTER AUTHORITY. AND
YOU KNOW IT'S IMPORTANT TO NOTE
THAT WAIVERS ARE SUPPOSED TO BE
TESTING SOMETHING SO THEY'RE
SUPPOSED TO BE. DOING SOMETHING
DIFFERENT THAN WHAT THE FEDERAL
LAW REQUIRES IN ORDER TO
EVALUATE AND.
I IT IS THOSE EFFORTS
AND A WAIVER NEEDS TO AFFECT A
SECTION OF THE MEDICAID LOT THAT
IS SUBJECT TO WAVER AND WE'LL
TALK ABOUT THAT MORE DEATH.
BY LONG STANDING OF PRACTICE
WAIVERS MONTHS MUST BE BUDGET
NEUTRAL TO THE FEDERAL
GOVERNMENT THAT MEANS THAT OVER
A FIVE YEAR PERIOD THE STATE'S
DEMONSTRATION SHOULD NOT COST
MORE. ADDED TO THE FEDERAL
GOVERNMENT ON THE MEDICAID SIDE
THEN IT WOULD IN ABSENCE OF THE
WEAVER. THIS IS TYPICALLY
EVALUATED ON A PER MEMBER PER
MONTH BASIS
BUDGET NEUTRALITY IS A BIG PART
OF NEGOTIATIONS BETWEEN THE
FEDERAL GOVERNMENT IN THE
STATE'S.
PUBLIC COMMENT PERIODS ARE ALSO
REQUIRED BOTH AT THE STATE
LEVEL.
AND THE AND THE FEDERAL LEVEL
GIVEN JUST THE IMPORTANCE OF AYE
THE AUTHORITY OF THE ELEVEN
FIFTEEN AND THE CHANGES THAT
THAT CAN BE CONTEMPLATED.
I THE ON THE OTHER SIDE OF THE
SLIDE SHE GIVES YOU A.
BASICALLY AN OVERVIEW OF A LOT
OF THE COMMON.
WAIVERS THAT WE'VE SEEN ACROSS
THE STATES. FOR ELEVEN FIFTEEN
AUTHORITY IN FACT CALIFORNIA HAS
SOME OF THESE WAIVERS ARE NO
THEIR FAMILIAR TO YOU. I'VE
MANAGED CARE MANY STATES
IMPLEMENTED MANAGED CARE IN
THEIR STATES THROUGH ELEVEN
FIFTEEN AUTHORITY PARTICULARLY.
IN THE EARLY YEARS BEFORE IT
BECAME EASIER TO DO THAT.
UNDER.
UNDER REGULAR MEDICAID LAW.
DELIVERY SYSTEM REFORM WAIVERS
ó OF WHICH CALIFORNIA HAS ONE.
AYE UNCOMPENSATED CARE POOL
SWEAR TYPICALLY HOSPITALS ARE
GIVEN AT PAYMENTS FOR
UNCOMPENSATED CARE.
AND EXPANSION RELATED OF WAIVERS
AGAIN A NUMBER OF STATES BEFORE
THE ACA EXPANDED COVERAGE TO
ADDITIONAL POPULATION.
SOME AFTER BUT MADE SOME
ADJUSTMENTS TO MEDICAID
COVERAGE.
SO THIS NEXT SLIDE REALLY
OUTLINES WHAT ARE SOME OF THE
IMPORTANT PROVISIONS THAT THE
STATUTE MAKES CLEAR THAT ELEVEN
FIFTEEN WAIVER CAN.
.
CAN CHANGE
THE FIRST IS STATEWIDE MRS
REQUIREMENT IN THE FEDERAL LAW
THAT THE MEDICAID PROGRAM REALLY
LOOK CONSISTENT ACROSS THE
STATE.
I IN TERMS OF. HOW IT OPERATES
AND THAT'S ACTUALLY SOMETHING
THAT CAN BE WAIVED?
THERE'S ALSO REQUIREMENT FOR
SINGLE STATE AGENCY TO IMPLEMENT
AND SET THE RULES ANOTHER
PROVISION THAT CAN BE WAIVED IN
MOST THESE KEY PROVISIONS ARE
ACTUALLY IN.
THE TEMPLATE THAT CMS PUTS OUT
FOR STATES IS THEY'RE THINKING
ABOUT THEIR WAIVERS.
THE NEXT IS ELIGIBILITY AND
REALLY CAN GO IN TWO DIRECTIONS
STATES HAVE USED THAT AND THEIR
ABILITY TO EXPAND. IT TO WAVE
ELIGIBILITY TO EXPAND COVERAGE
THEY CAN ALSO GO IN A MORE
RESTRICTIVE WAY WHERE SOME
STATES HAVE IMPOSED TIME LIMITS
ENROLLMENT CAPS.
UNCERTAIN POPULATIONS
AND I STATES MAY ALSO I WAVED
THE REQUIREMENTS FOR PRESUMPTIVE
ELIGIBILITY AND RETROACTIVE
COVERAGE.
FOR BENEFITS AND SERVICES.
AGAIN STATES HAVE USED THAT
KIND OF AUTHORITY TO VARY
BENEFITS PARTICULARLY FOR AYE IS
THEY EXPANDED COVERAGE TO NEW
POPULATIONS THEY MIGHT HAVE
IMPOSED NEW THINGS LIKE.
PREMIUMS WITHIN CERTAIN LIMITS
OR BURIED THE BENEFITS.
FOR DIFFERENT POPULATIONS.
COST SHARING CAN BE WAIVED BUT
WITH SOME SIGNIFICANT
RESTRICTIONS IN THE LA.
THERE ARE REQUIREMENTS THAT
COST SHARING.
IN THE FORM OF DEDUCTIBLES AND
COPAYS.
MOSTLY BE ON A VOLUNTARY BASIS
STATES ARE SUPPOSED TO ONLY
IMPLEMENT THOSE FOR TWO YEARS
THERE ARE YOU AGAIN THERE IS
SOME FLEXIBILITY TO IMPOSE COST
SHARING ABOVE. CURRENT STATUTORY
REQUIREMENTS BY.
THOSE PROVISIONS THAT IT CANNOT
BE WAIVED ENTIRELY.
THE DELIVERY SYSTEM.
AT ONE THAT STATES HAVE WAVES
AND IN TERMS OF FREEDOM AND
CHOICE PARTICULARLY. WHEN
THINKING ABOUT MANAGED CARE AND
OTHER TYPES OF.
OF.
CHANGES THEIR.
AND THEN IF FINANCING
REIMBURSEMENT WHICH IS OFTEN A
CORE PART OF ELEVEN FIFTEEN
WAIVER AUTHORITY WHERE THE STATE
IS ASKING THE FEDERAL GOVERNMENT
TO PAY FOR SOMETHING THAT THEY
WOULDN'T NORMALLY PAY COSTS THAT
ARE NOT OTHERWISE MAGICAL.
AND SO I. AGAIN WITH CONSTRAINTS
ON BUDGET NEUTRALITY IS A BIG
PART OF WAIVERS BUT I. DID BUT
UNDER ELEVEN FIFTEEN AUTHORITY
MANY STATES HAVE GOTTEN
AUTHORITY TO GET. COVERAGE FOR
THINGS THAT OTHERWISE WOULD NOT
A THING.
SO WHILE THAT'S ALREADY IN.
MEDICAID ISRAEL IS QUITE BROAD
THERE ARE SOME RESTRICTIONS.
I'M WHAT CANNOT BE WAIVED.
UNDER THE STATUTE
AND ONE OF THE FIRST.
AT KEY ONES IS THE FEDERAL
MEDICAL ASSISTANCE PERCENTAGE OR
F. MAP THAT FORMULA THAT IS
REALLY THE SPLIT BETWEEN WHAT
THE FEDERAL GOVERNMENT AND THE
STATE OUR PAIN. I'M IT VARIES
ACROSS THE STATES AND IT DOES
VERY.
IN PARTICULAR FOR CERTAIN
SERVICES IN CALIFORNIA.
FOR MOST SERVICES LESS COVERAGE
IT'S FIFTY PERCENT.
ANOTHER IMPORTANT PROVISION.
OF NOTE THAT CANNOT BE WAIVED
IF THE F. MAP CLAIMING
PROPHECIES.
AND WHAT I MEAN THERE IS THAT
WHILE THE FEDERAL GOVERNMENT CAN
WAVE WHAT CAN BE MATCHED.
IT'S STILL.
IT IT IT'S STILL NEEDS TO BE A
MATCHING DOLLAR SO IN OTHER
WORDS THE STATE PUTS UP FUNDS
AND THE FEDERAL GOVERNMENT
MATCHES THOSE FUNDS. SO THAT'S
SOMETHING THAT WE DO NOT THINK I
CAN BE WAIVED UNDER THE STATUTE.
EVER END UNDER THE ELEVEN
FIFTEEN AUTHORITY THEIR OTHER
PROVISIONS I MENTION THE COST
SHARING REQUIREMENTS THAT THERE
ARE RESTRICTIONS ON HOW MUCH
COST SHARING CAN BE WAIVED.
INCOME COUNTING ROLES SO FOR THE
COR POPULATION COVERED UNDER THE
ACA.
SO NOT THAT DISABLED AND I'M.
AND NOT AT THE ELDERLY THERE
ARE. RESTRICTIONS ON CHANGING
HOW INCOME IS COUNTED AND AND
ASSETS TEST CANNOT BE IMPOSED.
SO THOSE ARE KIND OF AN OVERVIEW
OF SOME OF THAT THAT KEY
PROVISIONS.
AND YEAH I I THINK YOU ALL HAVE
WITH YOU THAT WE JUST FINISHED A
PAPER FOR THE CALIFORNIA
HEALTHCARE FOUNDATION. THAT
LOOKS AT THE LEGAL
CONSIDERATIONS AND AND WE TALK
ABOUT SINGLE PAYER BUT WE ALSO
TALK ABOUT SOME OF THE OTHER
PROPOSALS THAT YOU MIGHT.
CONSIDER PUBLIC OPTION ANOTHER
AFFORDABILITY PROPOSALS AND.
I WOULD LEAVE YOU WITH AND THE
MEDICAID SIDE ONE IMPORTANT NOTE
AND JULIET MADE THIS POINT.
THAT WAIVERS ARE DISCRETIONARY
AND YOU KNOW I'VE GIVEN YOU AN
OUTLINE OF SOME OF THE
PROVISIONS THAT ARE SEEN.
EXPECTED. TO NOT BE WAIVED IN
THOSE THAT CAN BE WAIVED.
AND IT'S TYPICALLY THE CASE
THAT ONCE SOMETHING HAS BEEN
WAIVED THAT THAT IS PERMITTED
BY.
FUTURE ADMINISTRATIONS I'M BUT
WE DO NOTE THAT.
DIFFERENT ADMINISTRATIONS.
CERTAINLY HAVE DISCRETION ABOUT
WHETHER OR NOT THEY'RE GOING TO
APPROVE WAIVERS.
SO IMPORTANT TO NOTE THAT
WAIVERS ARE DISCRETIONARY.
SOFT UP WITH MEDICAID AND NOW
SWITCH GEARS AND TALK ABOUT THE
MARKETPLACE.
AS YOU KNOW THE AFFORDABLE CARE
ACT.
FIVE IT WAS PASSED IN TWO
THOUSAND AND TEN AND EXPANDED
COVERAGE AYE GIVING STATES MORE
FLEXIBILITY TO.
ESTABLISH EXCHANGES AND OF
COURSE CALIFORNIA EX OF THAT
STAB WISH COVERED CALIFORNIA.
GAVE A. SIGNIFICANT.
STEWART WAIVER AUTHORITY UNDER
SECTION THIRTEEN THIRTY TWO
STATE AND. WAIVERS AND WE'RE
JUST STARTING GET EXPERIENCE
WITH THESE WAIVERS.
THE BULK OF THE ACA STARTED IN.
TWENTY FOURTEEN.
AND I REALLY THIS WAIVER
AUTHORITY JUST KICKED IN IN TWO
THOUSAND AND SEVENTEEN SO WE'RE
STARTING GOT OUR FIRST TASTE OF
WHAT ADMINISTRATIONS WILL
APPROVE UNDER THIS AUTHORITY.
AS I MENTIONED IT'S IT'S FAIRLY
BROAD.
THE STATE'S CAN.
A PROPOSED A WAVE FOUR KEY
PARTS OF THE AFFORDABLE CARE
ACT.
THE INDIVIDUAL MANDATE WHICH WE
ALL KNOW WAS RECENTLY ALTERED BY
AND. BE A BY THE CONGRESS AND
SIGNED INTO LAW THAT THE PENALTY
IS NOW REDUCED TO ZERO BUT THAT
IS STILL IN THE STATUTE A PART
OF THE.
A. STATUTE THAT STATES CAN WAVE
AS WELL AS THE EMPLOYER MANDATE
IS ALSO A PROVISION THAT STATES
CAN WAIVE THE FEE CHOOSE TO.
BENEFITS AND SUBSIDIES SO THE
AFFORDABLE CARE ACT CREATED THE
ESSENTIAL HEALTH BENEFIT
REQUIREMENT THAT IS SOMETHING
THAT CAN BE WAIVED UNDER
THIRTEEN THIRTY TWO AUTHORITY.
AS CAN THE SUBSIDIES THEIR
PREMIUM TAX CREDITS THAT ARE
AVAILABLE TO PEOPLE BETWEEN
THREE HUNT EXCUSE ME ONE HUNDRED
AND THIRTY THREE PERCENT OF THE
FEDERAL POVERTY LEVEL TO FOUR
HUNDRED PERCENT OF THE FOUGHT
FEDERAL POWERLESS. DE LEVEL. ARE
ALSO AND FOR THE PROVISIONS THAT
THE STATE'S CAN WAVE AND I'LL
TALK ABOUT THAT IN A LITTLE MORE
DEPTH BUT I KNOW THAT STATES CAN
USE THOSE DOLLARS AND REPURPOSE
THOSE.
FOR ALTERNATIVE APPROACHES.
AND ALSO EXCHANGE RULES SEE
STATES CAN MODIFY OR ELIMINATE.
EXCHANGE RULES IF THEY CHOOSE
TO.
A PARTICULARLY IF THEY'RE MAKING
MAJOR CHANGES TO THE BENEFITS.
CITIES.
THERE ARE RESTRICTIONS ON.
THE.
THIRTEEN THIRTY TWO A WAIVER
AUTHORITY.
MOST SAID THE CONSUMER
PROTECTIONS BETTER IN THE A. C.
A. ARE ACTUALLY NOT WAY ABLE SO
THINGS LIKE EACH RATING.
PROHIBITION ON.
HEALTH STATUS IS GENDER EXCITER.
THOSE ARE NOT WEAVERVILLE
PROVISIONS UNDER THIRTEEN THIRTY
TWO.
AND THEN THERE ARE SIGNIFICANT
STATUTORY GUARDRAILS WHICH ARE
ALSO IMPORTANT TO KEEP IN MIND
AND WHEN THINKING ABOUT.
THIRTEEN THIRTY TWO A WAIVER
AUTHORITY. THE FIRST THE SCOPE
OF COVERAGE WAIVERS MUST PROVIDE
COVERAGE TO AT LEAST AS MANY
PEOPLE AS THE ACA WOULD.
IN ABSENCE OF THE WAIVER.
I'D THE WAIVER MUST ALSO A
PROVIDE COVERAGE THAT IS LEAST
AS LEAST AS COMPREHENSIVE AS THE
COVERAGE OFFERED A ON IT.
THROUGH THE EXCHANGE
THE WAIVER MUST PROVIDE COVERAGE
AND COST SHARING PROTECTIONS
AGAINST EXCESSIVE OUT OF POCKET
SPENDING THAT IS AT LEAST AS
AFFORDABLE. OF THE EXCHANGE
COVERAGE AND THE WAIVER MUST NOT
INCREASE THE FEDERAL DEFICIT
INCLUDING CHANGES TO INCOME
PAYROLL FOR EXCISE TAX REVENUE.
AND SO I THINK YOU KNOW YOU CAN
REALLY TELL FROM THE FIRST THREE
THAT THOSE. RESTRICTIONS ARE
REALLY ABOUT MAKING SURE THAT IF
THE STATE IS GOING TO COME IN
AND AND MAKE CHANGES UNDER
THIRTEEN THIRTY TWO THAT THERE
REALLY PROPOSING TO PROVIDE.
ADDITIONAL BENEFITS AND.
AT A REALLY COMPREHENSIVE
PACKAGE I KNOW THE DEFICIT
NEUTRALITY DOES.
EXTEND TO.
IT YOUR YOUR EMPLOYMENT TO YOUR.
TALKING ABOUT BOTH TREASURY AND
HHS WHEN THINKING ABOUT DEFICIT
NEUTRALITY AND IT'S.
IT IS A DIFFERENT STANDARD THAN
WHAT WE'VE SEEN ON IN THE BUDGET
NEUTRALITY.
IN THE MEDICAID PROGRAM BECAUSE
THAT'S.
A LITTLE BIT BROADER.
SO THIS NEXT SLIDE JUST GIVES
YOU AN OVERVIEW OF SOME OF THE
KEY.
WAIVERS THAT HAVE BEEN PROPOSED
BY STATES.
UNDER THIRTEEN THIRTY TWO AND
DEFINITE COUPLE OF.
PROPOSALS THAT WOULD HAVE SOME
SIGNIFICANT CHANGES TO THE EAST
CA.
HOWEVER WE REALLY HAVEN'T SEEN
AN APPROVAL YET. OF THE MAJOR
MAJOR CHAINS MOST OF THE WAIVERS
THAT HAVE BEEN APPROVED FALL
INTO THIS CATEGORY OF
REINSURANCE AND THOSE OF THE
WAIVERS.
AT THE BOTTOM ALASKA OREGON
MINNESOTA.
ARE THE ONES WITH.
.
AT WITH.
APPROVED REINSURANCE WE VARIOUS
AND WHAT WE SEE IN THESE WAIVERS
IS THAT THE STATE HAS PROVIDED
SOME FUNDING TO HELP COVER A
PORTION OF HIGH COST CLAIMS FOR
HIGH COST INDIVIDUALS. IN THE
INDIVIDUAL MARKET AND THIS
REALLY LOWERS PREMIUMS FOR
PEOPLE INSIDE AND OUTSIDE THE
EXCHANGE.
AND IT'S REALLY I THINK I WORTH
NOTING WHEN TALKING ABOUT
AFFORDABILITY UP PROPOSALS TO
LOOK A LITTLE BIT AT REINSURANCE
A NUMBER OF STATES ARE
CONSIDERING IT. REINSURANCE
PARTICULARLY BENEFITS THOSE WHO
GET COVERAGE IN THE INDIVIDUAL
MARKET AND WHO DO NOT QUALIFY
FOR TAX CREDITS.
SO.
FOR SOME OF THE STATES THAT ARE
CONSIDERING PROPOSALS BECAUSE
THEY'RE CONCERNED ABOUT PREMIUMS
THE TAX CREDITS REALLY DO ASSIST
INDIVIDUALS.
WHEN PREMIUMS INCREASE BUT
REINSURANCE IS ONE OF THE
STRATEGIES.
THAT STATES ARE CONSIDERING.
.
TO TRY TO LOWER PREMIUMS OVERALL
AND WHEN A STATE DOES THAT THEY
BENEFIT THE FEDERAL GOVERNMENT
BECAUSE THEY AYE TAX CREDITS ARE
LOWER THAN THEY WOULD BE
OTHERWISE AND SO THROUGH THESE
ELEVEN FIFTEEN WAIVERS STATES
BEEN ABLE TO GET. FEDERAL
FUNDING TO HELP OFFSET THE COSTS
AND THE AMOUNTS HAVE A HAVE
VARIED A BIT BASED ON CONDITIONS
WITHIN THE STATE'S. BUT ON THE
STATE'S OBSCENE AND SOME OF
THEIR COSTS OFFSET. UNDER THESE
REINSURANCE WAIVERS.
SO.
.
THINKING AGAIN A LITTLE BIT MORE
BROADLY.
L. AGAIN ELEVEN AT THIRTEEN
THIRTY TWO AUTHORITY IS PRETTY
BROAD WHERE STATES COULD TOTALLY
RE PURPOSE.
THOSE FUNDS AND USE THEM IN A
DIFFERENT WAY THAT'S A LITTLE
DIFFERENT THAN WHAT WE'RE SEEING
WITH THE REINSURANCE WAIVERS
THEY'RE GETTING PASSED THROUGH
FUNDING WHICH IS THEY'RE MAKING
SOME KIND OF CHANGE TO. I'D THE
ACA AS IT IS AND THE FEDERAL
GOVERNMENT IS GIVING THEM AS
SOME SAVINGS AS A RESULT OF THAT
SO. JUST TO KIND OF DISPUTE DRAW
DISTINCTION BETWEEN TOTALLY RE
PURPOSING THE DOLLARS VERSES ON
A PROPOSAL THAT ACTUALLY ACHIEVE
SAVINGS TO THE FEDERAL
GOVERNMENT. THERE REALLY ARE TWO
DIFFERENT APPROACHES THAT STATES
COULD THINK ABOUT WHEN THINKING
ABOUT THIRTEEN THIRTY TWO WAIVER
AUTHORITY.
ANOTHER IMPORTANT POINT AGAIN
IS JUST THE DEFICIT NEUTRALITY
IS A LITTLE BIT BROADER THAN
JUST WHAT'S HAPPENING WITH THE
TAX CREDITS.
THE TREASURY IS LOOKING AT.
OTHER PARTS OF THE HEALTHCARE
SYSTEM AND IT'S ABOUT THE
OVERALL COSTS NOT HER
INDIVIDUAL.
AND AGAIN WE HAVE LIMITED
EXPERIENCE THERE BEEN A COUPLE
OF WAIVERS SOME OF THEM WITH
WITHDRAWN.
SO WE DON'T HAVE A FULL SENSE
OF WHAT MIGHT BE A APPROVED.
.
BY THAT THIS ADMINISTRATION OUR
FUTURE ADMINISTRATIONS.
IN THE GUIDANCE ITSELF IT DOES
NOTE THAT THAT HHS AND TREASURY
CAN REJECT A WAIVER EVEN IF IT
MEETS THE FOR GUARD RAILS SO.
JUST IMPORTANT TO KNOW.
AS THE IN TERMS OF THINKING
THROUGH THE WAIVER AUTHORITY.
SO AS I SAID IN OUR PAPER WE
TALK IN MORE DEPTH ABOUT.
MANY OF THE COVERAGE PROPOSALS
CERTAINLY.
SINGLE PAPER YOU SINGLE PAYER
AND I'M HAPPY TO ANSWER REALLY
SPECIFIC QUESTIONS I JUST LEAVE
YOU WITH.
THESE THOUGHTS THERE'S
CONSIDERABLE FLEXIBILITY FOR.
WAIVERS IN BOTH MEDICAID AND
MARKETPLACE COVERAGE.
BUT YOU KNOW SOME OF YOUR
PROPOSALS MAY TEST NEW IDEAS AND
SO.
YOU KNOW WE DON'T HAVE AS MUCH
EXPERIENCE WITH WHETHER HOW
ADMINISTRATION WILL. WILL
PERCEIVE THOSE
THANK YOU. GREAT THANK YOU VERY
MUCH SHOULD QUESTIONS FOR OUR
PANEL.
I HAVE.
START WITH.
I'M. THERE'S A LOT OF QUESTIONS
SO I WANNA ASK ALL OF THEM AND
I'M NOT EXACTLY SURE WHO TO
ADDRESS TWO. BUT.
.
YOU KNOW WE KNOW THE CURRENT
SYSTEM IS NOT WORKING AND THAT'S
WHY WE'RE TRYING TO LOOK AT
ALTERNATIVES.
EVERYTHING FROM YOU KNOW THE
COVERAGE AVAILABLE BEING
RESTRICTED IN SO MANY DIFFERENT
WAYS YOU KNOW AS FAR AS THE
PATIENT.
EX AGAIN CARE THEY MAY NEED.
WITHOUT HAVING TO GO THROUGH
HOOPS AND ALL KINDS OF
BUREAUCRACY.
AND ACTUALLY ACCESS COVERAGE IS
WORTHLESS WITHOUT
ACCESS SO YOU KNOW I'M HOPING
THAT AS WE REALLY. MOVES FORWARD
TO TRY TO CREATE A PLAN FOR
CALIFORNIA THAT WE ACTUALLY
SOLVE SOME OF THE PROBLEMS. THAT
WE'RE EXPERIENCING.
CURRENTLY I'M ONE OF THE
QUESTIONS I HAD IS.
WE KNOW THAT GENERALLY THE
GOVERNMENT PLANS HAVE NOT
INCLUDED LONG TERM CARE.
VISION OR DENTAL.
WOULD THAT BE.
IT ARE IS ANYONE DOING THAT IN
THEIR STATE YOU KNOW OPTIONS OR.
HILL COULD THAT BE.
PART OF A.
YOU KNOW AND UNIVERSAL.
A PLAN THAT WE PUT FORWARD.
AND I.
THERE IT AT THAT. AREA RIGHT A
SO I THINK VISION AND DENTAL IN
PARTICULAR ARE.
AREAS THAT I THINK A NUMBER OF
STATES FIRE. SEE IS PRIORITIES.
AND.
DO AND THINK ABOUT HOW THEY CAN
PROVIDE COVERAGE FOR THOSE TWO I
TO. FIND THE MARKETPLACE SIDE.
THAT ESTATE.
IT IT DOWN IT SP CAN EXPAND THE
ESSENTIAL HEALTH BENEFIT PACKAGE
IN THE SENSE OF IF THE STATE
WANTS TO REQUIRE BENEFITS ABOVE
THE AFFORDABLE CARE ACT THEY CAN
DO SO THE ISSUE IS SHOW US. THAT
THEY NEED TO DO IT USING STATE
FUNDS SO ON THE FEDERAL
GOVERNMENT DOESN'T.
AT IT IS IS THAT FUNDING AS.
ON THE MEDICARE SIDE.
AS I MENTIONED.
UNDER SECTION FOUR OH TO THERE
IS AN OPTION TO TASK TO THE
ADDITION OF BENEFITS
UNDER MEDICARE THAT AREN'T THAT
AREN'T CURRENTLY PAID FOR BY
MEDICARE.
THAT COULD INCLUDE THINGS LIKE
VISION AND DENTAL SERVICES.
BUT BECAUSE THE SECTION FOR AU
TO AUTHORITY RELATES TO.
PAYMENT FORSERVICES THAT ARE
DESIGNED TO IMPROVE THE
EFFICIENCY AND THE ECONOMY OF
THE PROGRAM THOSE AT THEIR WORDS
IN THE STATUTE. I THINK IT WOULD
BE A STRETCH TO FIT LONG TERM
CARE.
UNDER THAT AUTHORITY. PRIMARILY
BECAUSE IT'S SUCH AN EXPENSIVE.
SERVICE.
IT'S HARD TO IMAGINE A SCENARIO
WHERE ADDING THE LONG TERM CARE
BENEFIT.
ACTUALLY LOWERS
COSTS AND NOT REALLY IS A HIGH
BAR FOR A BENEFIT LIKE LONG TERM
CARE VISION AND DENTAL I THINK
MAYBE.
LESS OF A STRETCH.
PARTICULARLY BECAUSE THEY CAN
BE VERY ESSENTIAL TO QUALITY OF
LIFE AND AND MIGHT ACTUALLY YOU
KNOW IMPROVE PEOPLE'S ABILITY TO
GET ABOUT ACCESS SERVICES KIND
OF. LIVE THEIR DAILY LIVES.
BUT BUT LONG TERM CARE AND
MEDICARE ARE OBVIOUSLY TWO VERY
DIFFERENT THINGS.
AND YOU KNOW BECAUSE LONG TERM
CARE IS A MEDICAID BENEFIT NOT A
MEDICARE BENEFIT IT TYPICALLY
HASN'T REALLY BEEN WITHIN THE
PURVIEW OF MEDICARE TO CONSIDER.
REFORMS THAT MIGHT AND LONG TERM
CARE TO THE MEDICARE BENEFIT
PACKAGE.
AND I WOULD JUST ADD IN
CALIFORNIA MEDI CAL DOES COVER A
LONG TERM CARE. OF COURSE THAT'S
THE MEDI CAL PROGRAM. AND.
AND IN TERMS OF THE ESSENTIAL
HEALTH BENEFITS BENCHMARK THE
CALIFORNIA HAS SET FOR. THE
MARKETPLACE PLANS ON CURRENTLY.
ADULT A DENTAL BENEFITS FOR
EXAMPLE ARE NOT INCLUDED SO.
THAT YOU KNOW SO ON THE
ESSENTIAL HEALTH BENEFITS
BENCHMARK PLAN THAT CHIQUITA WAS
REFERRING TO EARLIER THAT IS THE
AVENUE BY WHICH YOU COULD
EXPAND.
WHAT IS CONSIDERED ESSENTIAL
HEALTH BENEFITS ON THE FLOOR FOR
CALIFORNIA?
OKAY I'M JUST A QUICK FOLLOW UP
TO. THEM.
IN ONE OF OUR PREVIOUS HEARINGS.
WE DISCUSSED COST CONTAINMENT
AND WHEN WE.
HEARD ABOUT THE DIFFERENT PLANS
AND OTHER STATES.
IN THEY WERE GIVING ADVICE ON
YOU KNOW HOW.
SET UP YOU WANNA DO COST
CONTAINMENT UP FRONT BECAUSE.
SOME OF THE STATE'S THAT HAD
GONE DOWN THE ROAD.
FOUND THEY WEREN'T REALLY
EXPERIENCING SAVINGS AND MAYBE
EVEN HAVE. ADDITIONAL COSTS.
.
HOW WOULD YOU RECOMMEND WE GO
ABOUT STREAMLINING EFFICIENCIES?
AND THE BUREAUCRACY I MEAN YOU
KNOW WE HAVE ALREADY IN THE
SYSTEM THAT IS.
.
WHAT'S SPECIFIC GOALS SHOULD WE
BE LOOKING FOR. AS WE LOOK TO A
PLAN FOR CALIFORNIA THAT WOULD
HELP.
IN THE COST CONTAINMENT HOA BE
ACCOUNTABLE NOSES GOES DOWN THE
LINE WHO IS ACCOUNTABLE. IS THAT
THE LEGISLATURE IS IT YOU KNOW.
THE SIR I'M.
SOMEBODY THAT.
AND WILL BE LOOKING AT THAT.
AND WHO THE LA AU PAIR.
I DON'T EVEN KNOW HOW TO BEGIN
TO ANSWER THAT QUESTION IT'S
OBVIOUSLY A CENTRAL QUESTION IN.
DISCUSSIONS ABOUT YOU KNOW
TRANSFORMING OUR HEALTHCARE
SYSTEM.
YOU KNOW CLEARLY WITHIN
MEDICARE I THINK THIS IS ONE OF
THE PRIMARY GOALS OF THE
INNOVATION CENTER THAT IT WAS IT
WAS SET UP.
TO TRY TO TEST THESE NEW MODELS
OF PAYING FOR CARE RECOGNIZING
THAT.
YOU KNOW THE WAY WE DO IT NOW IS
NOT. WORKING SO WELL FOR
EVERYBODY IT'S IT'S IT'S NOT
EVEN WORKING SO WELL WITHIN
MEDICARE AND I THINK THAT'S WHY.
CMS HAS BEEN OR YOU KNOW AT
LEAST HAD BEEN PRETTY AGGRESSIVE
IN TRYING TO TEST A LOT OF
DIFFERENT NEW IDEAS IT'S KIND OF
LIKE THROW EVERYTHING AT THE
WALL AND SEE WHAT STICKS.
BUT IT'S IT'S ALSO A STRUGGLE I
THINK.
TOOK TO FIND SAVINGS TO SOME
EXTENT WHEN YOU'RE TESTING SO
MANY DIFFERENT THINGS.
YOU KNOW AS AS I SHOWED AND IN
THAT ONE SLIDE ALL THE DIFFERENT
CATEGORIES THAT ARE BEING TESTED
WITHIN THE INNOVATION CENTER
THERE IS A TREMENDOUS AMOUNT OF
INNOVATIVE ACTIVITY GOING ON AT
THE STATE LEVEL AT THE PROVIDER
LEVEL. AT LOTS OF DIFFERENT
LEVELS WITHIN OUR HEALTHCARE
SYSTEM.
AND SO WHILE THAT'S GREAT.
IT ALSO MAKES IT DIFFICULT TO
REALLY UNDERSTAND EXACTLY WHAT
IT IS THAT'S HAVING AN EFFECTIVE
FOR ACTUALLY SEEING SAVINGS
WHICH IS ALSO WHY THEY.
THE INNOVATION CENTER REALLY
TRIES VERY CAREFULLY TO SET UP
EVALUATIONS.
SEC TEST.
YOU KNOW THERE THE MODEL VERSES
VIENEN NOT MODEL TO FIGURE OUT
EXACTLY WHAT IS WORKING AND A
MODEL OR WHAT'S NOT WORKING.
SO THAT WE KNOW WE DON'T INVEST
FURTHER RESOURCES AND THINGS
THAT DON'T WORK.
SO THERE'S BEEN A LOT OF
SUPPORT FOR IDEAS LIKE PATIENT
CENTERED MEDICAL HOMES AND
ACCOUNTABLE CARE ORGANIZATIONS
AND.
I PROVIDERS TALKING TO EACH
OTHER AND NOT ORDERING
DUPLICATIVE TESTS AND THINGS
LIKE THAT THESE THINGS ARE ALL
GREAT IDEAS BUT THEY DO TAKE A
LOT OF TIME TO. BUILD UP TO GET
PROVIDERS TO TO WORK TOGETHER
AND AND SPEAK TO EACH OTHER.
AND TO GET PATIENTS INTO THE
SYSTEM AS WELL AND TO REALLY
MAKE THE MOST OUT OF THIS TYPE
OF COORDINATED CARE SYSTEM SO I
DON'T KNOW THAT'S ANSWERING YOUR
QUESTION DIRECTLY BUT THERE'S
CLEARLY A LOT OF INTEREST.
IN PURSUING. BETTER WAY TO YOU
KNOW BRING ABOUT PAYMENT REFORMS
AND DELIVERY SYSTEM REFORMS SO
TO THE EXTENT THAT YOU HAVE
GOALS THAT YOU'RE INTERESTED IN
ACHIEVING. THAT REQUIRE
PARTNERSHIP WITH THE FEDERAL
GOVERNMENT TO TEST THEM IN
MEDICARE AND MEDICAID AND THE
MARKET.
WILLING PARTNER.
IN CM MASS.
BUT YOU OBVIOUSLY HAVE TO THINK
THROUGH VERY CAREFULLY WHAT YOUR
GOALS ARE AND THE TARGET
POPULATIONS THAT YOU HAVE IN
MIND. TO DEVELOP VERY SPECIFIC.
THINGS THAT YOU WANT TO TEST.
IN TERMS OF ACHIEVING SAVINGS
AND IMPROVING QUALITY WITHIN.
THE CONTEXT OF THOSE PRO.
I. JUST I HAVE A LOT BUT I'LL
JUST DO ONE AND THEN SAVE IT FOR
THAT THE NEXT HEARING HOW.
AT ONE OF THE BIGGEST THINGS IS.
PATIENT TRYING TO NAVIGATE.
YOU KNOW THE WHOLE PROCESS AND
YOU KNOW I JUST LOOK AT. PEOPLE
I KNOW HAVE TO GO AND THEN YOU
KNOW THEY GO TO PRIMARY CARE BUT
THERE IMMEDIATELY REFER. AND
THEN THEY HAVE A NEED BUT THE
SPECIAL SAY SEND THEM TO NEVER.
GIVES THEM THE THING THAT THE
INITIAL REQUEST WAS FORMED IN
THE BACK WITH THE PRIMARY CARE
DOCTOR IN THEIR QUESTIONING WHY
THAT'S IN HAPPEN THEY CAN'T FIND
THE FILE WITH ALL THE TECHNOLOGY
WE HAVE RIGHT NOW THEY COULDN'T
FIND THE PATIENT'S FILE. AND
THEN YOU GET THE BILLS IN THE
MAIL ANNUAL WILL I HAVE
INSURANCE HOW COME I'M GETTING
THIS BILL AND. YOU KNOW JUST FOR
ME PERSONALLY HAVING GONE TO THE
EMERGENCY ROOM LAST YEAR WHEN
DURING SESSION.
FOR A.
ANALOGY. SOMETHING AND IN THE I
WAS ALLERGIC TO.
EXCEPT FOR THE TECHNICIAN AT THE
DOOR NO ONE EVEN LOOKED AT ME
THE DOCTOR SHOOK MY HAND ON THE
WAY OUT AND THEN I GOT A THREE
THOUSAND DOLLAR BILL. AND I
FOUND OUT THAT.
THE DOCTOR HAS TO PAY THE HIGH
IN ORDER FOR THE TECHNICIAN TO
GET PAID A LITTLE BIT.
AND THIS IS A WHOLE LOT OF
BUREAUCRACY IN.
NO AS WE GO DOWN THIS ROAD I.
REALLY WANT US TO MAKE SURE WE.
SPEND A LOT OF TIME ON THE COST
CONTAINMENT PART THIS ONE.
THANK YOU.
FIRST I'D LIKE TO JUST THANK THE
PANEL HEALTHCARE IS AWFULLY
COMPLICATED AND UNDERSTANDING
WHERE SOME OF THOSE ROADBLOCKS
ARE IS BENEFICIAL.
I WANTED TO SEE IF I COULD FIND
THE NEEDLE WITHIN THE HAYSTACK
THOUGH AND DOCTOR COMMANDS CAN.
A LITTLE BIT ON. UNDER YOUR
CATEGORIES FOR INNOVATION CENTER
MODELS.
YOU NOT GLOSSED OVER THE STRONG
STARTS FROM MOTHERS AND NEWBORN
INITIATIVES AND.
I HAVE
QUITE AN INTEREST IN THIS BOTH
BECAUSE I HAVE A TWO FIVE AND
SIX YEAR OLD AT HOME BUT ALSO
IN.
TRYING TO IMPLEMENT A HOME
VISITING PROGRAM HERE IN OUR
STATE AND WANT TO HEAR MORE
ABOUT THAT PROGRAM IN
PARTICULAR.
SO I DIDN'T REALLY TALK MUCH
ABOUT THOSE OTHER CATEGORIES TO
SOME EXTENT BECAUSE THEY'RE NOT
AS FOCUSED ON MEDICARE.
THAT SAID.
CLEARLY YOU KNOW BASED ON THE.
THE CATEGORIES THAT THE
INNOVATION CENTER IS PURSUING
AND EVEN IF YOU READ THE STATUTE
THERE ARE A LOT MORE.
OPPORTUNITIES.
THAT ARE LISTED IN THE STATUTE
AS FAR AS.
MODELS THAT CAN BE TESTED.
THERE IS A TREMENDOUS AMOUNT OF
ACTIVITY THAT THE STATE CAN
PURSUE WITH REGARD TO THESE
INNOVATION MODELS AND BY
GLOSSING OVER IT I DIDN'T MEAN
TO MAKE LIGHT OF IT.
AYE I JUST MOSTLY I MEANT TO
CONVEY THAT THAT'S TO SOME
EXTENT OUTSIDE MY AREA OF
EXPERTISE.
BUT.
BUT HE YOU KNOW THERE'S THERE'S
VERY MUCH AN INTEREST WITHIN THE
INNOVATION CENTER AT HEARING
FROM PEOPLE WHO HAVE IDEAS IT
DOESN'T EVEN HAVE TO BE A STATE
IT CAN BE AN INDIVIDUAL
PROVIDER.
OR A PROVIDER GROUP.
OR ANYBODY REALLY CAN CAN GO TO
THE INNOVATION CENTER WITH AN
IDEA.
ABOUT HOW TO YOU KNOW IMPROVE
QUALITY AND REDUCE SPENDING.
WITHIN MEDICARE MEDICAID AND
CHIP.
AND SO TO THE EXTENT THAT THE
STATE HAD COMES UP WITH SPECIFIC
THINGS THAT.
THAT IS THAT THEY'RE INTERESTED
IN IF YOU HAVE SPECIFIC IDEAS
THAT YOU WOULD LIKE.
TO TRY TO TEST WITH THEN UP YOU
KNOW THE STATE HEALTH CARE
DELIVERY SYSTEM I THINK THE CMMI
WOULD BE VERY INTERESTED IN
HEARING.
FROM FROM YOU ABOUT THOSE IDEAS
AND I'M AND WORKING WITH YEAR
TWO TO TRY TO MAKE IT WORK.
SO FOLLOW UP A FIVE MAN OF
HEART AND DIRECT SOMEONE
ABSOLUTELY WILL WANTS TO. MAKE
SURE WE'RE TALKING ABOUT IF IF I
CAN HOW MISS BROOKS WILSHIRE.
YOU POINT OUT THAT THE STATE
CANNOT GET A WAIVER FROM HER
THAT MEDICAID F. MAP CLAIMING
PROCESS ISN'T.
SO IF CALIFORNIA HAS A PUBLICLY
FINANCED HEALTHCARE SYSTEMS AS A
SINGLE PAYER SYSTEM.
WHAT CALIFORNIA BE ABLE TO GET A
WAIVER TO MORE EFFICIENTLY BILL
THE?
FEDERAL GOVERNMENT PRINT SHARE
OF THOSE QUALIFIED FOR MEDICARE.
IT SOUNDS AS THOUGH CALIFORNIA
WOULD NEED TO RETAIN THE
ADMINISTRATIVE SYSTEMS AND FOR
ELIGIBILITY DETERMINATION AND
OTHER RECORD KEEPING TO CAPTURE
THE FEDERAL FUNDS
IS THAT RIGHT. SO AND WE TALK
ABOUT THIS MORE IN THE PAPER I
THINK THEY'RE A COUPLE OF WAYS
THAT CALIFORNIA COULD GO UP THE
COULD GO.
TO DRAWDOWN MEDICAID FUNDS THE
ONE WAY WOULD BE CERTAINLY TO
FOLLOW ALL THE MEDICAID RULES
WHICH REALLY WOULD REQUIRE.
AND UP FRONT ELIGIBILITY
DETERMINATION.
AND IT MAY BE THAT TO THE
CONSUMER TO PEOPLE IT'S NOT AS
OBVIOUS.
BUT THERE'S A LITTLE BIT MORE
OF A BACK DOOR.
ENROLLMENT PROCESS IN PLACE.
THIS SECOND WAY THAT YOU COULD
GO IS LOOK FOR FEDERAL FUNDS.
IT IS LOOK FOR A FEDERAL WAIVER
AND TRY TO GET SOME FLEXIBILITY
ON THE ELIGIBILITY DETERMINATION
WE DO SAY THAT WE DO YOU THINK
THAT YOU WOULD HAVE TO DO SOME
KIND OF ELIGIBILITY
DETERMINATION. THAT SENSE OF BUT
IT MIGHT BE.
A LITTLE BIT DIFFERENT SO
INSTEAD OF DOING IT UP FRONT
MAYBE IT'S SOMETHING THAT YOU
DO.
AFTER PEOPLE ARE ALREADY
ENROLLED.
AND AND SO WE DO THINK THERE
ARE SOME POSSIBILITIES THAT.
THAT CALIFORNIA COULD TRY THAT
APPROACH WE DO THINK THAT WOULD
THAT THAT AT SOME POINT THERE'S
GOT TO BE SOME KIND OF
ELIGIBILITY DETERMINATION.
AND.
.
YOU KNOW I'M THE.
GO LEAVE IT THERE THANK YOU ALL
FOR YOUR EXPERTISE.
THANK YOU AND.
I AM.
STRUGGLING TO TRY TO UNDERSTAND
THIS ON SOME ASK YOU A COUPLE
QUESTIONS FIRST OF ALL DE DO YOU
HAVE KNOWLEDGE OF.
HOW VERMONT PROCEEDED AND AND
HOW FAR DID DATE YET?
THROUGH A PROCESS OF OVERWEIGHT
OF WAIVERS AND AND.
DO YOU HAVE KNOWLEDGE OF THAT.
MY UNDERSTANDING IS THAT VERMONT
GOT SO FAR AS.
TO TRIP UP ON THAT.
HOW TO PAY FOR IT
QUESTION AND DIDN'T ACTUALLY
RESOLVE THE QUESTION OF WHAT TO
DO WITH MEDICARE?
SO I I BELIEVE THEY'RE IT WAS
AN OPEN QUESTION AS TO HOW THE
EXTENT TO WHICH.
THEY WOULD INCORPORATE MEDICARE
PARTICIPATION IN THEIR SINGLE
PAYER SYSTEM AND IF THEY WENT
DOWN THAT PASSED HOW THEY WOULD
GO ABOUT IT IN TERMS OF SEEKING
WAIVER AUTHORITY. THROUGH
SECTION FOUR OH TO ARE THE
INNOVATION CENTER. BUT I DON'T
BELIEVE THOSE DETAILS GOT IRONED
OUT SO UNFORTUNATELY THAT
DOESN'T OFFER YOU. MUCH
GUIDANCE.
.
AT THIS POINT.
SO IT WOULD GET IT OBVIOUSLY
WAIVERS ARE SUPPOSED TO BE
TESTING TESTING SOMETHING I.
AND.
THEY HAVE TO BE RENEWED. AFTER
FIVE TYPICALLY.
DO DOES THE FEDERAL GOVERNMENT
TO DO THEY SAY YOU KNOW WHAT
WHOA WHOA WHOA WE'RE TWO YEARS
INTO THIS.
WE'RE GONNA.
STOP THE WAVER ME DECIDE EVER
HAPPENED OR.
I I I DON'T DO DOES THAT HAPPEN
I DON'T KNOW.
SO THE FEDERAL GOVERNMENT IS.
IS MONITORING THAT.
AND THEY DO LOOK AT WAIVERS AYE
THE AGAIN THEY'RE SUPPOSED TO
BE.
A FIVE YEAR PERIOD BUT THEY DO
CHECK IN TO SAY.
WITH THE STATE ON A YEARLY
BASIS TO DO AN EVALUATION AND.
.
AND LOOK TO SEE IF THINGS ARE
GOING AWRY SO.
I CAN'T THINK OF A SPECIFIC
EXAMPLE DOESN'T MEAN THAT THERE
IS ONE ISN'T ONE.
WHERE THAT FEDERAL GOVERNMENT
HAS ACTUALLY PULLED A WAIVER
BEFORE THE FIVE YEARS THAT
SOMETHING WE CAN LOOK INTO AND
GET BACK TO YOU ON BUT BUT THERE
IS?
IT. REALLY IS A YEARLY LOOK TO
SEE HOW THE STATE IS DOING BUT
THEY ARE STILL EVALUATED. THAT
THEIR VALUE WAITED OVER A FIVE
YEAR PERIOD ON THE MEDICAID.
I WOULD SAY ON THE MEDICARE SIDE
AND AGAIN I KNOW YOU HEARD MORE
IN FAR MORE DETAIL ON ON ALAN'S.
WAIVER AND THEY'RE ALL PAYER
MODEL BUT I BELIEVE THAT.
YOU KNOW THAT WAS IT ORIGINALLY
INCORPORATED IN STATUTE.
AS BASICALLY YOU KNOW MEDICARE
ALLOWING MARYLAND TO PAY
HOSPITAL'S DIFFERENTLY THAN THE
WAY MEDICARE NORMALLY PAYS
HOSPITALS.
BUT THAT WAS CONTINGENT UPON
ACHIEVING SPECIFIC SAVINGS
TARGETS.
AND.
YOU KNOW THAT THE PAYMENT
MECHANISM WAS BASICALLY A
PAYMENT PER HOSPITAL ADMISSION.
AND MARYLAND REALIZED THAT THEY
WERE AT SOME POINT NOT GOING TO
CONTINUE TO BE ACHIEVING THOSE
SAVINGS TARGETS AND THAT THAT
THERE WOULD NOT HAVE THAT
AUTHORITY RENEWED.
THE SO THEY NEEDED TO.
AND UNDERTAKE CHANGES TO THE
THEIR AND IT ORIGINAL WAIVER
WHICH IS WHICH RESULTED IN THE
ALL PAYER MODEL THAT THEY NOW
HAVE WHICH IS TRANSFORMING FROM
THERE YOU KNOW PAYMENT PER
ADMISSION TO MORE OF A GLOBAL
PAYMENT.
FOR A PATIENT FOR AN ENTIRE
YEAR.
SO IT IT'S TRANSFORMING RATHER
THAN.
YOU KNOW JUST PAYING A SPECIFIC
RATE FOR HOSPITAL ADMISSION
TRANSFORMING THE HOSPITAL'S
INCENTIVES TO REALLY TRY TO KEEP
PATIENTS OUT OF THE HOSPITAL. AS
OPPOSED TO BRING THEM INTO THE
HOSPITAL THE POINT IS THERE
ORIGINAL WAIVER IS MORPHING FROM
THE STATUTORY WAIVER TO THE CMMI
INNOVATION CENTER AUTHORITY. AND
THAT DOES HAVE TO BE RENEWED
EVERY FOUR YEARS IT IT SEEMS TO
ME THAT.
THEY MAY BE MOVING AWAY FROM.
YOU KNOW GRANTING SORT OF
PERMANENT WAIVERS OR STATUTORY
CHANGES
TO THEY.
YOU KNOW TRYING TO TEST THINGS
AND DEMONSTRATE THINGS THROUGH
THE THEY INNOVATION CENTER WITH
REGARD TO MEDICARE PAYMENTS.
WE THAT'S NOT THE CASE I THINK
FROM MEDICARE IN A CA.
BUT AGAIN YOU KNOW THEY'RE SO
THE DRIVING INTEREST IS IS
PROGRAM SAVINGS.
AND SO TO THE EXTENT THAT YOU
KNOW YOUR WAY FOR WHATEVER IT IS
HOWEVER IT'S DESIGNED CONTINUES
TO DEMONSTRATE PROGRAM SAVINGS.
IT'S IT'S KIND OF HARD TO AS
LONG AS QUALITY IS NOT
SUFFERING.
THEN I DON'T SEE WHY THE
GOVERNMENT WOULD NECESSARILY
STEP INTO POLITICAL ACT. IF
THEIR SAVINGS THAT THAT'S YOU
KNOW THAT'S ONE OF THE PRIMARY
GOALS SO.
I'M THINKING ABOUT.
.
THIS WOULD.
OBVIOUSLY AT A MINIMUM THE
REVIEW IF WE WERE TO MOVE
TOWARDS A SINGLE PAYER SYSTEM
WOULD REQUIRE A MEDICAID WAIVER.
AND MEDICARE WAIVER AT A MINIMUM
BUT.
I SENSE THAT IT'S MORE BECAUSE
OBVIOUSLY MORE COMPLICATED MEET
IT FEELS LIKE MORE MULTIPLE
WAIVERS WITHIN EACH OF THOSE
CATEGORIES ARE MY MISSING SO.
AT YOU WOULD I THINK YOU IF
IT'S YOUR PROBABLY AMANDA
MEDICAID WAIVER YOU'RE. GONNA
NEED A THIRTEEN THIRTY TO WAVER
ON THE MARKETPLACE SIDE.
ANDS
YEAH YEAH AND WHAT KIND OF
AUTHORITY YOU NEED ON THE
MEDICARE SIDE IS NOT ENTIRELY
CLEAR. BUT IN ADDITION TO
WHATEVER AUTHORITY YOU SEEK AS
FAR AS THE WAY FOR.
YOU'RE GOING TO NEED LEGISLATIVE
CHANGE AT THE FEDERAL LEVEL IF
THE SENATE ETHICS IT YEAH IT'S
INCOMPLETE TO JUST SEEK A
WAIVER.
BECAUSE EVEN THOUGH THE EXISTING
AUTHORITY IS PRETTY BROAD.
THERE'S NO READING OF THE
STATUTE IN AT AS FAR AS I READ
IT.
TO ALLOW THE STATE TO SORT OF
LAY CLAIM TO ALL OF THE MEDICARE
AND TRUST FUND DOLLARS AND USE
THEM.
IN THE STATE'S
HEALTH CARE PROGRAM.
THAT DOESN'T REALLY COMPORT
WITH THE EXISTING AUTHORITY THAT
THE SECRETARY OF HHS HAS.
SO FOR THAT YOU NEED
LEGISLATIVE CHANGE IF YOU WANTED
TO DO SOMETHING NOT QUITE AS
COMPLETE AS SINGLE PAYER.
LIKE MAYBE IN ALL PAYER SYSTEM
THAT THERE IS LANGUAGE IN THIS
STATUTE GOVERNING CMMI THAT
DOES.
ALLOW FOR OPPORTUNITIES FOR
STATES TO TEST ALL PAYER SYSTEMS
SO THAT I THINK IS AN AVENUE
THAT YOU COULD PURSUE IT'S
OBVIOUSLY NOT THE SAME AS
UNIVERSAL COVERAGE.
BUT IT COULD GET YOU SOMEWHERE
DOWN THE PATH TOWARDS PERHAPS
DEALING WITH SOME OF THESE
ADMINISTRATIVE COST ISSUES THAT
YOU MENTIONED.
ASSEMBLY MEMBER WALTER AND THAT.
ARE REALLY KIND OF.
PAIN IN THE* FOR A LOT OF
PEOPLE IN OUR CURRENT HEALTHCARE
SYSTEM.
REALISTICALLY.
THE WAIVER PROCESS IN GENERAL
FOR SOME OF THESE.
INITIATIVES THAT HAVE GONE
FORWARD.
HOW LONG DOES SOMETHING LIKE
THAT TAKE?
AS I START THINKING ABOUT OKAY
WE WANNA WANNA PUSH SOMETHING
FOR YOU.
HOW LONG?
THIS WOULD BE A. AN ENORMOUS.
LEFT I.
ON ON OUR AND IS A STATE YES
HOW LONG DEEP WITH THAT
POTENTIALLY PROSPER SAYS
POTENTIALLY TAPE.
I WOULD SAY YEARS.
AYE I THINK PROBABLY THAT YOU
COULDN'T DO IT IN LESS THAN
TWELVE MONTHS AND I WOULD SAY
PROBABLY MORE LIKE TWO TO THREE
YEARS.
.
THAT'S AND I DO WANNA MENTION
THAT IT YOU KNOW CALIFORNIA DOES
HAVE AN ELEVEN FIFTEEN MEDICAID
WAIVER AS IT IS SO. AND THERE
ARE QUITE A LOT OF.
.
EXPERIMENTS BEING DONE UNDER
ELEVEN FIFTEEN LIKE THE WHOLE
PERSON PROGRAM THAT LOOKS AT
DIFFERENT TYPES OF WAYS TO
IMPROVE THE DELIVERY SYSTEM AND
IMPROVE EFFICIENCIES WITHIN.
MEDICAID AND EVEN WITH THE DUAL
DUALLY ELIGIBLE PROGRAM SO FOLKS
WHO HAVE BOTH MEDICARE AND
MEDICAID SO.
I DO THINK IT'S IMPORTANT FOR
US TO MAKE SURE BUILDING ON ALL
THE EFFORTS THAT WE HAVE.
HAVE DONE SO FAR.
THANK YOU THANK YOU VERY MUCH
ANYONE.
OWNER WERE BUILT ON SOME
QUESTIONS A DOCTOR WOULD JUST
ASK
SO GIVEN THAT IT'LL TAKE TWO TO
THREE YEARS.
AND LET'S JUST.
TALK ABOUT REAL POLITIQUE.
AT THIS MOMENT WE'VE AN
ADMINISTRATION THAT WOULD NOT BE
OPEN TO WHAT WE'RE TALKING ABOUT
BUT MAYBE AFTER TWENTY TWENTY WE
WE MIGHT. WOULD IT MAKE SENSE
FOR US TO APPLY. TO THREE ARE
THE YEARS OUT BEFORE TWENTY
TWENTY OR. OR IF YOU HAVE AN
ADMINISTRATION THAT IS ADVERSE
TO THE TYPE AWAY FROM WERE
THINKING ABOUT.
A APPLYING IN TWO THOUSAND
EIGHTEEN OR TWO THOUSAND
NINETEEN WHAT WITH THAT. WITH
THAT.
LACK OF SUPPORT STYMIE RIGHT UP
THAT THE AT THE FRONT SUCH THAT
IT IT DOESN'T MAKE SENSE TO
APPLY FOR. THE WAIVER IF YOU
DON'T HAVE A SYMPATHETIC
ADMINISTRATION FROM THE
BEGINNING.
WELL I MIGHT START BY THE END BY
THINKING AND I THINK SUSAN YOU
WERE ALLUDING TO THIS THING
ABOUT SOME OF THE STEPS THAT
WOULD NEED WOULD BE NECESSARY
AND THOUGHT THROUGH BEFORE EVEN
GOING TO THE ADMINISTRATION SO
JUST TO LOOK AT. ON THE
MARKETPLACE SIDE TYPICALLY.
PLANS NEED TO KNOW SIX MONTHS
IN ADVANCE WHAT COVERAGE IS
GONNA LOOK LIKE SO YOU KNOW YOU
WOULD WANT TO HAVE AUTHORIZING
LEGISLATION MAKING A MAJOR
CHANGE. ALMOST.
.
DE.
I NOW HAVE TIME FOR THE PLANS TO
MAKE THAT KIND OF AND AN
ADJUSTMENT AND ENOUGH TIME FOR
THE FEDERAL GOVERNMENT TO PROVE
THAT SO WHEN YOU BACK INTO JUST
A CHANGE THAT WOULD BE ON THE
MARKETPLACE SIDE. YOU'RE REALLY
THINKING ABOUT PROBABLY A YEAR
BEFORE YOU WANT TO CHANGE JUST.
.
EH AGAIN THINKING ABOUT A
RELATIVELY STRAIGHTFORWARD
POLICY BUT WHERE THE PLANS WE
NEED TO DO SOMETHING. SO I MIGHT
THINK ABOUT OKAY THAN ON THE
MEDICAID SIDE IF WE'RE MAKING A
MAJOR CHANGE HOW DOES THAT FIT
IN WITH ALL OF THE OTHER.
CHANGES THAT WE ALREADY HAVE
BEEN MEDI CAL TIME AND AND AND.
REALLY START THERE.
BUT.
IT IS SO THAT I WOULD WOULD BE
MY SUGGESTION ABOUT PUBLIC THE
FIRST PLACE TO START TO REALLY
MAKE SURE OKAY WHAT'S
WHAT'S ARE COHESIVE PLAN.
MOVING FORWARD AND THEN THEN
GETTING MAKING SURE YOU MOVED IT
THROUGH. YOUR LEGISLATIVE
BODIES.
BEFORE STARTING THAT IS
STARTING THE WAIVER PROCESS IT'S
IT'S VERY POSSIBLE THAT THEY'LL
BE ANOTHER ADMINISTRATION WHO IS
MORE INTERESTED.
IN SOME OF THESE POLICIES BUT
IN SOME WAYS.
THINGS NEED TO BE TESTED AND.
SO I WOULDN'T I WOULDN'T
SPECULATE ON WHETHER YOU WANT TO
WAIT FOR THE NEXT ADMINISTRATION
OR.
.
OR ARE TESTED WITH THIS ONE.
BRENDA GUESS I WOULD ADD TO THE
EXTENT THAT. YOU KNOW AS I'VE
MENTIONED.
C. M. A MAIS AUTHORITY IS IS.
TO SOME EXTENT PRETTY BROAD.
SO IF YOU WERE INTERESTED AND
PERHAPS PURSUING SOME
INITIATIVES WITHIN THE EXISTING
AUTHORITY OF CMMI THAT MAY LAY
THE GROUNDWORK FOR EXAMPLE ALL
PAYER REFORM. THAT MIGHT GET YOU
SOMEWHERE DOWN THE PATH TOWARDS
A SINGLE PAYER SYSTEM THE NOT
COMPLETELY THERE.
THAT MIGHT GIVE YOU SOME.
YOU KNOW LEAD TIME TO DO SOME
OF THE OTHER PLANNING THAT MIGHT
NEED TO BE DONE FOR A MORE
COMPREHENSIVE STATE BASED SINGLE
PAYER SYSTEM.
THAT YOU KNOW PERHAPS YOU'RE
NOT GONNA FIND AS MUCH OF A
FRIENDLY AUDIENCE WITH THE
CURRENT ADMINISTRATION BUT YOU
WOULD. IN A FUTURE
ADMINISTRATION.
IF YOU KNOW THAT YOU KNOW THE
INNOVATION CENTER IS SEEKING YOU
KNOW PROPOSAL'S UNDERNEATH AND
ACCOUNTABLE CARE ORGANIZATION.
INITIATIVE FOR EXAMPLE THAT
COULD BE SOMETHING.
THAT YOU MIGHT WANT TO PURSUE
OR MORE TESTING WITHIN THE STATE
INNOVATION MODELS.
CATEGORY AND THERE ARE THOSE
AVENUES THAT YOU COULD PURSUE
INSTEAD OF JUST HOLDING OFF
APPLYING FOR ANYTHING. DOING
THINGS A LITTLE BIT MORE
INCREMENTALLY MY.
MIGHT HELP.
GET YOU SOMEWHERE DOWN DOWN THE
ROAD TOWARDS
TOWARDS THE END GOAL.
AND THEN IT JUST FALL BELOW BUT
I THINK THE CONVENTIONAL PUBLIC
WISDOM IS OR CONVENTIONAL
UNDERSTANDING OF THIS IS THAT WE
WOULD NEED TO GET WAIVERS FROM
AND A PRESIDENTIAL MINISTRATION
BUT I THINK WHAT YOU'RE LAYING
OUT HERE IS. AND MANY INSTANCES
OF WHAT WE'RE TALKING ABOUT
SINGLE PAYER
CONGRESSIONAL APPROVAL SO IT'S
IT'S NOT JUST SUPPORT FROM THE
EXECUTIVE BRANCH FEDERALLY ITS
SUPPORT FROM THE LEGISLATIVE
BRANCH AND AND CONGRESS. ON THAT
BUT IN YOUR IN YOUR PRESENTATION
YOU SAY THAT AS LONG AS THE
MEDICARE CHANGES ARE ORIENTED
AROUND IMPROVING QUALITY OR
SPENDING REDUCING SPENDING A
MEDICARE. IT'S A FAIRLY BROAD.
DEFINITION BUT THEN YOU ALSO SEE
BROADER CHANGES WOULD BE NEEDED
FOR THE IMPLEMENTATION OF A
SINGLE PAYER SYSTEM
COULD WE DEFINE A PILOT LIKE
FIVE YEAR.
.
DEMONSTRATION OF WHAT SINGLE
PAYER COULD LOOK LIKE IN
CALIFORNIA AND HAVE THAT.
BE CONSIDERED UNDER THIS BROAD
DEFINITION OF WHAT WOULD COME
UNDER MEDICARE WAIVER OR YOUR
YOU THINK THAT IT'S HOW YOU
SLICE IT AND DICE IT YOU REALLY
WOULD NEED CONGRESSIONAL.
I THINK IT'S POSSIBLE BUT I BUT
I WOULD JUST BE A LITTLE BIT
CAUTIOUS ABOUT.
YOU KNOW THE PILOT IN TERMS OF
HOW YOU'RE CHANGING.
ENROLLMENT IN MEDICARE OR
ELIGIBILITY FOR MEDICARE OR COST
SHARING FOR EXAMPLE THOSE THINGS
ARE ALL SPECIFIED IN STATUTE.
AND THERE'S NO WAIVER AUTHORITY
THAT ALLOWS STATES TO CHANGE
THOSE THINGS.
SO TO THE EXTENT THAT YOU
WANTED TO YOU KNOW.
MAKE PEOPLE ON MEDICARE.
HOLE IN TERMS OF NOT PAYING ANY
COST SHARING OR PREMIUMS.
THOSE THINGS ARE ALLOWED TO BE
CHANGED BY STATES EVEN IF IT
WOULD BE GREAT FOR A PATIENT
PERSPECTIVE. THOSE THINGS ARE
KIND OF SPECIFIED IN THE
STATUTE.
IT AND THIS HAS NEVER BEEN DONE
BEFORE SO IT'S NOT ENTIRELY
CLEAR TO ME THAT THE FEDERAL
GOVERNMENT WOULD SAY NO BUT YOU
REALLY HAVE TO BE VERY SPECIFIC
AND DEFINING YOUR GOALS. AND
DEMONSTRATING OVER THE COURSE OF
WHATEVER THE WAIVER PERIOD IS
THAT YOU ACHIEVE THOSE GOALS
SPECIFICALLY REFER GUARD TO
PROGRAM SAVINGS.
AND QUALITY IMPROVEMENTS
SO YOU KNOW I THINK YOU CAN
CERTAINLY TRY TO BE AS CREATIVE
AS POSSIBLE.
BUT AGAIN IT COMES BACK TO IT'S
A WAY FOR ITS TIME OMITTED IT'S
NOT.
IT'S NOT DESIGNED TO BE A
PERMANENT CHANGE TO THE MEDICARE
PROGRAM IT'S DESIGNED TO BE A
PERMANENT CHANGE TO THE STATE'S
HEALTH CARE DELIVERY SYSTEM THE
FEDERAL GOVERNMENT'S INTEREST IS
IN THE MEDICARE PROGRAM.
AND SO THAT THAT WILL BE THE
LENS THROUGH WHICH THEY
EVALUATE.
WHATEVER THE STATE.
PROPOSES TO DO AND WITH REGARD
TO A PILOT OR SOME OTHER TYPE
OF.
I'M CHINA. INTERNET LISTEN TO
WHAT YOU'RE SAYING AND WONDERING
AGAIN IF WE PROPOSED A PILOT. UP
THAT CHANGED HOW MEDICARE.
SPENDING WAS REDUCED OR QUALITY
IMPROVED AND AND AND SAID OUR
INTENT IS TO OBVIOUSLY DO
SOMETHING MORE PERMANENT BUT FOR
NOW WILL BRING INTO A FIGHTER
PILOT SURE. AND I AM YEAH AND I
THINK THAT CMS DOES ENVISION
THAT TYPE OF MEDICARE
PARTICIPATION IN THE STATE
INNOVATION MODELS.
INITIATIVE WITH WITHIN THE
INNOVATION CENTER SO I WOULD
ENCOURAGE YOU AND I'D BE HAPPY
TO CONNECT YOU WITH MORE
INFORMATION SO THAT YOU CAN SEE.
HOW ON THE ONE HAND?
THE INNOVATION CENTER IS
ENCOURAGING THAT THIS TYPE OF
IDEA AND ON THE OTHER HAND HOLD
STATES UP TO A VERY HIGH
STANDARD WITH REGARD TO MEDICARE
PARTICIPATION.
IN STATE INNOVATION MODELS.
AND I AND I MEAN I CAN TELL YOU
A LITTLE BIT MORE ABOUT THE
PRINCIPLES THAT THEY USE TO
EVALUATE THE DIFFERENCE STATE
INNOVATION MODELS WITH REGARD TO
MEDICARE PARTICIPATION. BUT I
THINK WHAT YOU BASICALLY NEED TO
KNOW IS THAT WHILE IT'S POSSIBLE
YOU CAN PROPOSE THIS TYPE OF.
OF.
PILOT TEST
THERE'S OBVIOUSLY NO GUARANTEE
THAT THE FEDERAL GOVERNMENT WILL
APPROVE IT SO IT LEAVES YOU TO
SOME EXTENT.
AT YOU KNOW AT THEIR MY HALF
THEIR MERCY IF YOU WELL.
IN TERMS OF MOVING FORWARD AND
JUST A BUT I GUESS STATISTICALLY
HOW OFTEN ARE MEDICARE MEDICAID
WAIVERS
A TONIGHT.
I DON'T KNOW THAT NUMBER OF NO I
WOULD SAY THAT PLAYED ON THE
MEDICARE SIDE OF LOOKED INTO
HISTORICALLY A LOT OF THE
MEDICARE WAIVERS WERE
CONGRESSIONALLY.
EITHER CONGRESSIONALLY MANDATED
SO THEY THEY HAD TO HAPPEN.
OR CMS.
UNDERTOOK THEM OF THEIR OWN
INITIATIVE
SO THEY ALSO KIND OF HAD TO
HAPPEN BECAUSE THE EN MASSE WAS
RUNNING THEM.
SO ON THE MEDICARE SIDE.
IT HASN'T HISTORICALLY BEEN THE
CASE THAT THEY'RE DENIED BECAUSE
THE VIEW OF THE ENTITIES THAT
ARE INITIATING THEIR WAY FURTHER
DEMONSTRATION IS THE FEDERAL
GOVERNMENT ITSELF. IT'S
DIFFERENT ON THE MEDICAID
DIFFERENT ON THE MEDICAID SIDE
AND I CAN'T I DON'T KNOW I DON'T
KNOW IF THAT STATISTIC IS KNOWN
BUT SOMETIMES IT'S HARD TO TELL
IN THE SENSE THAT.
THEN IF THE NEGOTIATIONS ARE
GOING THE WAY THE STATE ONCE
THEY MAY WITHDRAW THAT WAIVER IS
THAT BECAUSE OF WHAT THE FEDERAL
GOVERNMENT SAID.
.
YOU KNOW YOU CAN ALWAYS TELL
WORSE SEEING THIS A LITTLE BIT
WITH THAT THIRTEEN THIRTY TWOS
WHERE SOME OF THE STATES HAVE
PULLED BACK.
I'M SO WE HAVEN'T SEEN THE
ADMINISTRATION ACTUALLY DENY
THEM ONE WAS DEEMED INCOMPLETE.
THINK VERY MUCH.
YOU.
THANK YOU ALL VERY MUCH A
FIGURE.
NEXT I'D LIKE TO HAVE.
BE ENTIRE PANEL OF SCOTT GRAVES
BEN JOHNSON RYAN MILLER TO COME
FORWARD AND I'M GOING TO START
WITH CONCRETE
.
DOCTOR GRAVES JOINED THE BUDGET
CENTER IN TWO THOUSAND TWO AND I
SERVED AS DIRECTOR OF RESEARCH
SINCE TWO THOUSAND AND FOURTEEN.
IN THIS ROLE HE OVERSEES THE
BUDGET CENTERS ANALYTICAL WORK.
CONDUCTS RESEARCH AND ANALYSIS
RELATED TO HEALTH AND HUMAN
SERVICES AND CORRECTIONS.
AND AS THE ORGANIZATIONS LEAD
ANALYST ON THE STATE AND COUNTY
BUDGET PROCESS THANK YOU FOR
JOINING US.
THANK YOU THANK YOU FOR INVITING
THE BUDGET CENTER TO PARTICIPATE
IN THIS VERY IMPORTANT HEARING.
SO WHAT I'D LIKE TO DO TODAY.
OR THIS AFTERNOON.
IS TO TRY TO MAINTAIN YOUR
INTEREST FOR A FEW MINUTES IN
OUR STATE CONSTITUTION BECAUSE I
THINK IT'S IMPORTANT FOR
EVERYONE ON THIS COMMITTEE AND
EVERYONE IN THE LEGISLATURE TO
UNDERSTAND.
THAT EFFORTS TO MOVE CALIFORNIA
TOWARD UNIVERSAL COVERAGE.
WOULD ENTAIL CONSTRAINTS THAT
ARE BUILT IN OUGHT TO OUR STATE
CONSTITUTION SO IT'S IMPORTANT
TO UNDERSTAND OUT WHAT THOSE
CONSTRAINTS ARE.
AND HOW THE STATE MAY BE ABLE
TO ADDRESS THEM.
SO ONE STARTING POINT FOR
THINKING ABOUT MOVING TOWARD
UNIVERSAL COVERAGE IN CALIFORNIA
IS THAT.
SUCH COVERAGE WOULD VERY LIKELY
REQUIRE TAX INCREASES I GUESS
YOU COULD THINK THERE WOULD BE A
WAY THAT THE LEGISLATURE COULD
CUT HERE OR THERE AND USE THAT
SPENDING EXISTING EXPENDITURES
TO FIND UNIFORMS WENT UNIVERSAL
COVERAGE. WHAT'S MORE LIKELY IS
THAT A TAX INCREASE WOULD BE
REQUIRED AND IN FACT PRIOR
ESTIMATES HAVE SHOWN THAT FOR
EXAMPLE MOVING TOWARD A SINGLE
PAYER SYSTEM. COULD ENTAIL A TAX
INCREASE OF WELL OVER ONE
HUNDRED BILLION DOLLARS AND I
BELIEVE OF THE LEGISLATIVE
ANALYST'S OFFICE WILL BE
SUBSTANTIATING THAT I'M IN A FEW
MOMENTS.
SO TAX INCREASES ARE POSSIBLE
AS YOU KNOW AS LONG AS THE
LEGISLATURE CAN MUSTER A TWO
THIRDS VOTE OF EACH CHAMBER.
HARM BUT WE ALSO KNOW THAT THERE
ARE PROVISIONS WITHIN THE
CONSTITUTION.
THAT CONSTRAIN THE
LEGISLATURE'S ABILITY.
TO RAISE TAXES AND TO DEDICATE
THE REVENUES TO PARTICULAR
PURPOSES OKAY JUST RATHER THAN
I'M ALLOWING THEM TO FLOW INTO
THE GENERAL FUND SO WHAT I
WANTED TO DO TODAY IS TO TALK
ABOUT A COUPLE PROVISIONS IN
PARTICULAR. ONE YOU ARE VERY
FAMILIAR WITH PROPOSITION NINETY
EIGHT APPROVED BY THE VOTERS IN
NINETEEN EIGHTY EIGHT.
WHICH AMENDED ARTICLE SIXTEEN
SECTION EIGHT OF THE STATE
CONSTITUTION I'M AND WAS LATER
AMENDED BY PROPER LEVIN OF
NINETEEN NINETY. I'M A SECOND
PROVISION THAT YOU'RE PROBABLY
LESS FAMILIAR WITH AT LEAST UP
UNTIL THIS YEAR AMEND MAYBE LAST
YEAR.
IS PROP FOUR OF NINETEEN
SEVENTY NINE WHICH ADDED ARTICLE
THIRTEEN BE TO THE STATE
CONSTITUTION AND ITSELF WAS
LATER AMENDED BOTH BY PROP
NINETY EIGHT AS WELL AS BY PROP
ONE ELEVEN.
SO.
ARTICLE THIRTEEN BE ESSENTIALLY
IS THE GANG LIMIT.
AND I'LL BE GETTING INTO BOTH
OF THOSE ISSUES.
IN A MOMENT.
SO.
I CAN HAPPILY REPORT THAT I'M
NOT GOING TO BE GETTING INTO THE
COMPLEXITIES THE MECHANICS THE
FORMULAS ASSOCIATED WITH THE
PROPOSITION NINETY EIGHT OF
MINIMUM FUNDING GUARANTEE I WILL
JUST REMIND I'M ALL OF US IN THE
ROOM. THAT IT ESSENTIALLY
PROVIDES A MECHANISM ON FOR
PROVIDING EACH YEAR A GUARANTEED
LEVEL OF FUNDING TO K. TWELVE
SCHOOLS AND COMMUNITY COLLEGES
I'M ALSO KNOWN AS K. FOURTEEN
EDUCATION.
SO THE KEY ISSUE HERE RELATED TO
UNIVERSAL HEALTH COVERAGE IS
THIS
WOOD CAPE FOURTEEN EDUCATION BE
REQUIRED TO RECEIVE A PORTION OF
ANY TAX REVENUES.
RAISED TO FIND UNIVERSAL
COVERAGE.
EVEN IF THE LEGISLATURE DECIDED
TO DIRECT THOSE REVENUES INTO A
SPECIAL FUND RATHER THAN INTO
THE GENERAL FUND THAT IS
ESSENTIALLY THE KEY QUESTION.
ARM AROUND HOW PROPOSITION
NINETY EIGHT RELATES TO THE
STATE'S OF EFFORTS TO ACHIEVE
UNIVERSAL COVERAGE.
SO WHAT I WANT TO DO NOW IS
SPEAK FROM THIS VERY SIMPLE
GRAPHIC HERE.
TO LAY OUT SOME OF THE ISSUES.
THAT ARE PRESENT.
IN VARIOUS DEBATES AROUND
PROPOSITION NINETY EIGHT SO THE
FIRST THING TO UNDERSTAND IS
THAT IN ARTICLE SIXTEEN SECTION
IGHT.
ARE THE TERM A GENERAL FUND
REVENUES IS USE THE TERM GENERAL
FUND PROCEEDS OF TAXES IS USED
WHEN TALKING ABOUT HOW THE PROP
NINETY EIGHT GUARANTEE GETS
CALCULATED EACH YEAR. THE
CONSTITUTION DOES NOT TALK
SPECIFICALLY ABOUT SPECIAL FUND
REVENUES.
IN IN HAPPENED IN DISCUSSING
ARE DESCRIBING HOW THE PROP
NINETY EIGHT CALCULATIONS ARE
INTENDED TO BE DONE. SO. THERE
ARE VARYING INTERPRETATIONS.
OF WHAT THIS ACTUALLY MEANS ONE
INTERPRETATION.
YOU MIGHT CALL IT THE STRONG
INTERPRETATION ARGUES THAT
BECAUSE SPECIAL FUND REVENUES
ARE NOT MENTIONED.
IN THE STATE CONSTITUTION IN
THE CONTEXT OF NINETY EIGHT. AND
BECAUSE GENERAL FUND REVENUES
AND SPECIAL FUND REVENUES.
ARE DISTINCT FROM ONE ANOTHER
THEN SPECIAL FUND REVENUES WOULD
NEVER COUNT IN CALCULATING THE
PROPOSITION NINETY EIGHT
SPENDING GUARANTEE SO ONE
EXAMPLE OF HOW THIS COULD WORK.
THE LEGISLATURE TO PASS A TAX
INCREASE INTENDED TO ACHIEVE
UNIVERSAL COVERAGE.
IT COULD DIRECT THOSE REVENUES
INTO A SPECIAL FUND.
AND IT COULD PERMANENTLY EXCLUDE
THOSE REVENUES FROM THE
CALCULATION OF THE PROPOSITION
NINETY EIGHT GUARANTEE EACH YEAR
WHICHWOULD EFFECTIVELY MAIN
THAT K. FOURTEEN EDUCATION WOULD
DERIVE NO UP FINANCIAL BENEFIT
FROM THE REVENUES REYES TO
SUPPORT. UNIVERSAL COVERAGE
SO THAT'S ONE VEHICLE OUT AND
THAT VIEW WAS EXPRESSED IN A
LAWSUIT VERY CLEARLY BY THE
BROWN ADMINISTRATION IT WAS A
LAWSUIT THAT WAS BROUGHT IN TWO
THOUSAND TWELVE.
GOT BY K. TWELVE SCHOOL
OFFICIALS IN THE WAKE OF THE TWO
THOUSAND ELEVEN REALIGNMENT IN
WHICH THE STATE SHIFTED VARIOUS
PROGRAMS AND SERVICES TO THE
COUNTIES ALONG WITH BILLIONS OF
DOLLARS.
NEWS THAT PREVIOUSLY WERE
GENERAL FUND REVENUES.
BUT WERE SORT OF RE IMAGINED AS
SPECIAL FUND REVENUES.
THAT LAWSUIT WAS LATER MOVED
BECAUSE PROPOSITION THIRTY
PASSED IN TWO THOUSAND TWELVE
WHICH ESSENTIALLY GAVE K.
FOURTEEN EDUCATION BACK THE
REVENUES THAT WERE LOST AS A
RESULT OF THAT TRANSFERS OF THE
WAS NEVER ANY CONTROLLING
DECISION. THEY CAME OUT OF THAT
LAWSUIT SO THAT'S THE FIRST
INTERPRETATION THERE ON THE LEFT
UP LOOKING DOWN AT THE OTHER BOX
ON THE BOTTOM THE ONE ON THE
RIGHT. THERE'S ALSO ANOTHER
INTERPRETATION OF HOW TO THINK
ABOUT THE RELATIONSHIP BETWEEN
PROPOSITION NINETY EIGHT AND I
GENERAL FUND IN SPECIAL FUND
REVENUES IN THIS INTERPRETATION.
SORT OF ARGUES THAT THE GENERAL
FUND AS USED IN THE CONSTITUTION
SHOULD BE THOUGHT OF MORE
BROADLY TO ENCOMPASS REVENUES
THAT GO BEYOND THOSE THAT ARE
DEPOSITED INTO THE STATE'S
GENERAL FUND. EACH YEAR BY STATE
LAW ARE AS REQUIRED BY STATE LAW
SO THIS INTERPRETATION SHOWS UP
FROM TIME TO TIME WITHIN THE
LEGISLATURE IT WAS EXPRESSED IN
THE SENATE APPROPRIATIONS
COMMITTEE IS ANALYSIS OF SENATE
BILL FIVE SIXTY TWO. WHICH AIM
TO CREATE A SINGLE PAYER SYSTEM
IN CALIFORNIA SO IT WAS VERY
CLEARLY EXPRESS THEIR. IT IT HAS
ALSO BEEN IMPLIED IN A NUMBER OF
BALLOT MEASURES THAT HAVE RAISE
REVENUES FOR EXAMPLE EACH OF THE
THREE BALLOT MEASURES THAT HAVE
GONE TO THE VOTERS ASKING THEM
TO INCREASE TOBACCO TAX REVENUES
IN NINETEEN EIGHTY EIGHT.
NINETEEN NINETY EIGHT AND MOST
RECENTLY IN TWO THOUSAND SIXTEEN
HAVE RAISED A STATES EXCISE TAX
ON TOBACCO DEPOSITED THE
REVENUES INTO A SPECIAL FUND.
DIDN'T GO TO THE GENERAL FUND
BUT IN EACH CASE THEY FELT THAT
IT WOULD BE PRUDENT TO ADD
LANGUAGE TO THEIR MEASURE THAT
SAID BY THE WAY. A THESE ARE
REALLY SPECIAL FUND REVENUES
THEY'RE NOT ENTER DEPLETES DON
INTERPRET THEM AS GENERAL FUND
REVENUES SUBJECT TO THE
PROPOSITION NINETY EIGHT
GUARANTEE THEY FELT IT PRUDENT
TO ADD THAT LANGUAGE. EVEN
THOUGH THEY WERE RAISING AN
EXCISE TAX AND DEPOSITING THE
REVENUES INTO A BRAND NEW
SPECIAL FUNDS.
I'M GOING TO SKIP A FEW TECH
SLIDES HERE AND GO.
RIGHT TO THIS ONE I'M.
GIVEN THE VARYING
INTERPRETATIONS HERE I'M IT
SEEMS TO US THAT THE STATE COULD
BE VULNERABLE TO LEGAL
CHALLENGES I'M IF IT DECIDED TO
IF THE LEGISLATURE DECIDED TO
RAISE TAXES.
DEPOSIT THOSE DOLLARS INTO A
SPECIAL FUND AND EXCLUDE THEM
FROM THE PROPOSITION NINETY
EIGHT CALCULATIONS NOW LAWMAKERS
ARE COULD ATTEMPT TO DISSUADE
LIT AGAINST BY ADDING WHAT ARE
CALLED POISON PILLS TO A BILL.
I'M A POISON PILL WOULD
ESSENTIALLY BLOW UP THE
STRUCTURE WOULD SAY IF ANYONE
SUES ON THE BASIS OF PROPOSITION
NINETY EIGHT AND THE STATE LOSES
THAT LAWSUIT. THESE REVENUES
WOULD AUTOMATICALLY GO AWAY ON
THE LA AL POINTED OUT IN A
REPORT RELEASED LAST YEAR.
THAT THERE WERE FOR POISON
PILLS THAT THE LEGISLATURE
ADOPTED IN THE LATE EIGHTIES AND
EARLY NINETIES WHEN PROP NINETY
EIGHT WAS RELATIVELY NEW. AND NO
CONSEQUENCES EVER CAME FORTH
FROM THEM AND OTHER WORDS THAT
WERE NEVER LAWSUITS THAT SORT OF
TESTED ON WHETHER SOMEONE WOULD
TAKE IT ALL THE WAY SUE THE
STATE AND ARGUE THAT THE REVENUE
SHOULD INDEED BE COUNTED TOWARD
THE NINETY EIGHT GUARANTEE.
SO A POISON PILL IS ONE WAY TO
GO ANOTHER WAY TO GO IS TO
SIMPLY SOMEPLACE ON TO THE
BALLOT. A MEASURE THAT WOULD ASK
CALIFORNIA'S VOTERS TO RAISE THE
REVENUES NEEDED TO ACHIEVE
UNIVERSAL COVERAGE.
AND IT TO EXCLUDE THOSE REVENUES
EXPLICITLY FROM THE CALCULATION
OF THE PROPOSITION NINETY EIGHT
GUARANTEES SO THERE MAY BE A
LEGISLATIVE WAY TO ADDRESS THE
ISSUE THIS CONSTRAINT POSED BY
THESE VARYING INTERPRETATIONS.
BUT THERE'S ALSO MAYBE A MORE
OBVIOUS WAY THAT'S BEEN USED
MANY TIMES OVER THE DECADES
WHICH IS TO SIMPLY GO TO THE
VOTERS.
AND PASSED UP WE THE PEOPLE OF
CALIFORNIA TO AMEND OUR
CONSTITUTION IN ORDER TO ALLOW
REVENUES RAISED FOR UNIVERSAL
COVERAGE I'M TO UNAMBIGUOUSLY BE
USED FOR UNIVERSAL COVERAGE
RATHER THAN ONLY SORT OF HAVING
A CLOUD OVER YOUR HEAD.
WONDERING O. OF SOMEDAY THIS MAY
BE SUBJECT TO PROPOSITION NINETY
EIGHT AND WILL LOSE A
SIGNIFICANT PORTION OF THESE
REVENUES.
TO ANOTHER SERVICE AS OPPOSED
TO K. FOURTEEN ARE AS OPPOSED TO
UNIVERSAL COVERAGE.
I'M GONNA SKIP TO THE NEXT ISSUE
NOW WHICH IS PROPOSITION FOR AS
I MENTIONED A PASSED ORIGINALLY
IN NINETEEN SEVENTY NINE.
ESSENTIALLY THIS IS A
LIMITATION ON STATE AND LOCAL
SPENDING AND I WANTED TO LAY OUT
FIRST THE KEY ISSUE HERE I'M FOR
YOU RELATED TO UNIVERSAL
COVERAGE WHICH IS. IF THE
LEGISLATURE INCREASED TAXES TO
ACHIEVE UNIVERSAL COVERAGE.
WITH THESE TAXES ESSENTIALLY BE
SO HIGH THESE NEW REVENUES
BUT THEY WOULD CAUSE THE STATE
TO EXCEED ITS APPROPRIATIONS
LIMIT WHAT IS.
OFTEN KNOWN AS THE CAN LIMIT
AFTER ONE OF THE AUTHORS OF
PROPOSITION FOR IN NINETEEN
SEVENTY NINE.
SO I'VE GOT HERE.
HOPEFULLY A RELATIVELY SIMPLE
ILLUSTRATION I'M SORRY THERE
EVEN FOR BOXES ON THEIR MORE
TEXT THAN I WOULD HAVE LIKED.
THIS IS MY EFFORT TO SORT OF DO
STILL FOR YOU SO I DON'T HAVE TO
TALK ABOUT THIS WITH TECH SLIDES
THAT I'M GONNA SKIP THE NEXT
THREE AFTER THIS BUT I JUST
WANTED EVERYONE TO SORT OF BE ON
THE SAME PAGE OF JUST ABOUT HOW
BEGAN LIMIT WORKS. SO THAT THEN
YOU CAN USE THAT TO THINK ABOUT
WHETHER THIS WOULD AFFECT YOUR
EFFORTS TO MOVE TOWARD UNIVERSAL
COVERAGE IN CALIFORNIA SO THE
FIRST THING THAT HAPPENS AND IT
AGAIN LIMIT. IS THE STATE PASSED
TO CALCULATE ITS ANNUAL LIMIT
ESSENTIALLY THE LIMIT IS BASED
ON SPENDING BY THE STATE OF
CALIFORNIA CERTAIN TYPES OF
SPENDING BACK IN NINETEEN
SEVENTY EIGHT SEVENTY NINE SO
YOU HAVE WE'RE SENSUALLY
SETTING.
OUR LIMIT BASED ON THE DISCO ERA
EXPENDITURES OF CALIFORNIA
DURING JERRY BROWN'S.
PROBABLY HIS SECOND TERM AT
THAT POINT MAYBE HIS FIRST TERM
THE LIMIT IS ADJUSTED EACH YEAR
FOR VARIOUS FACTORS SUCH AS THE
POPPY THAT THE POPULATION
GROWING CALIFORNIA. DO WE HAVE
MORE KIDS THAT ARE K. TWELVE
SCHOOL SYSTEM.
DID OUR PER CAPITA PERSONAL
INCOME GO UP ALL OF THOSE THINGS
GET FACTORED INTO CALCULATING
AND NEW LIMITS SO ESSENTIALLY
EVERY YEAR YOU TAKE THE BASE
WHERE YOU ARE. YOU APPLY THE
ADJUSTMENT FACTORS AND YOU GET A
NEW BASE THAT IS YOUR NEW BEGAN
LIMIT EACH YEAR AND ALL LOCAL
GUY I BELIEVE ALMOST ALL LOCAL
GOVERNMENTS IN CALIFORNIA ARE
REQUIRED TO GO THROUGH THE SAME
EXERCISE EACH YEAR.
THE SECOND THING THE STATE HAS
TO DO IS TO DETERMINE THE
APPROPRIATIONS THAT ARE SUBJECT
TO THE LIMIT THAT WAS JUST
CALCULATED
SO A COUPLE IMPORTANT THINGS TO
KEEP IN MIND HERE. WE'RE TALKING
ABOUT APPROPRIATIONS FROM WHAT
ARE CALLED PROCEEDS OF TAXES TAX
PROCEEDS WHETHER TAX PROCEEDS
THERE THEY ARE THERE ARE VARIOUS
THINGS THAT FACTOR INTO PROCEEDS
OF TAXES I'M JUST GONNA TELL YOU
THE MAIN ONE. WHICH IS REVENUES
FROM.
STATES GENERAL TAXES THE
PERSONAL INCOME TAX
SALES AND USE TAX THE
CORPORATION TAX ALL THOSE BABIES
FOR THE MOST PART THAT IS WHAT.
ON THE PROCEEDS OF TAXES.
ARE MADE UP BY THERE ARE OTHER
REVENUES THEY GET FACTORED IN
OKAY SO YOU HAVE PROCEEDS OF
TAXES YOU NEXT STEP WITHIN THE
SECOND BOX ON THE BOTTOM IS TO
DECIDE. WHICH APPROPRIATIONS
FROM PROCEEDS OF TAXES ARE
SUBJECT TO THIS LIMIT BECAUSE
NOT ALL APPROPRIATIONS ARE.
BASED ON PROP FOR AN PROP ONE
ELEVEN THE STATE GETS TO TAKE A
LOT OF APPROPRIATIONS OFF THE
TOP YOU DON'T COUNT REVENUES
THAT YOU TRANSFER TO LOCAL
GOVERNMENTS IN THE FORM OF
FINANCIAL ASSISTANCE THAT COUNTS
TOWARD THEIR OWN GANG LIMITS.
YOU DON'T HAVE ANYTHING WE'RE
DOING IN CALIFORNIA BECAUSE THE
FEDERAL GOVERNMENT SAID WE HAD
TO OUR COURT SAID WE HAD TO.
YOU DON'T HAVE DEBT SERVICE.
SO THOSE ARE THE THREE MAJOR
ONES THERE ARE OTHER ONES THAT
I'M I I'M NOT GOING TO GET INTO
BUT THE IDEA IS BEGAN LIMIT
APPLIES TO CERTAIN
APPROPRIATIONS. FROM TAX
PROCEEDS EACH YEAR SO THEN WHAT
DO YOU DO YOU GO TO STEP THREE
BACK UP TO THE TOP NOW ON THE
RIGHT. AND ESSENTIALLY YOU
COMPARE YOUR LIMIT. TO THE EX TO
THE EXPENDITURES OR THE
APPROPRIATIONS THAT ARE SUBJECT
TO THE LIMIT AND WHAT IS THE
CONSTITUTION SAY HERE. IT SAYS
THAT IF.
YOUR EXPENDITURES ARE YOUR
APPROPRIATIONS REACH YOUR LIMIT.
ANY REVENUES REMAINING OVER THAT
TWO YEAR PERIOD ARE CONSIDERED
EXCESS REVENUES
THE CONSTITUTION SAYS WHAT DO
YOU DO WITH EXCESS REVENUES
COMING DOWN A STEP FOR.
HALF OF THEM GO TO PROP NINETY
EIGHT IN THE FORM OF ADDITIONAL
SPENDING AND HALF OF THEM GO
BACK TO THE VOTERS TO TAX PAYER
OR TO TO TAXPAYERS AS REBATES.
THE LEGISLATURE HAD THE OPTION
OF TAKING SOME OF THESE REVENUES
AND SAY WELL WAIT A MINUTE MAYBE
WE DON'T WANT TO DO THAT EXACTLY
WE'RE GONNA SPEND SOME OF THEM
FOR NON. A REP FOR.
APPROPRIATIONS THAT ARE EXEMPT
FROM BEGAN LIMIT RIGHT AS I
MENTIONED THAT NOT ALL
APPROPRIATIONS APPLY RIGHT TO
BEGIN LIMIT SO THERE ARE SOME
THINGS YOU MAY BE ABLE TO SPEND
SOME OF THOSE REVENUES ARE BUT
THE HOPE FOR THE MOST PART. THE
AUTOMATIC ANSWER THE
CONSTITUTION GIVES IS IF WE
SPEND UP TO OUR LIMIT. A COUPLE
YEARS IN A ROW.
ANY REVENUES BEYOND THAT LIMIT.
FROM PROCEEDS TO TAXES GO BACK
TO THE TAXPAYERS AND GO TO PROP
NINETY EIGHT IN THE FORM OF
ADDITIONAL SPENDING.
SO WHY DID I TELL YOU ALL THAT.
IF YOU THINK ABOUT IT.
RAISING REVENUES TO PAY FOR
UNIVERSAL COVERAGE OUR EXPANDED
COVERAGE IN CALIFORNIA.
WOULD BE CONSIDERED PROCEEDS OF
TAXES.
AND WOULD GO TO SERVICE SAYS
HEALTH CARE.
THAT ARE NOT SPECIFICALLY
EXCLUDED FROM AGAIN LIMIT.
THESE ARE ALL EXPENDITURES OR
APPROPRIATIONS THAT WOULD BE
COUNTED FOR THE GANG LIMIT NOW
RIGHT NOW WE HAVE ACCORDING TO
GOVERNOR BROWN'S DEPARTMENT
FINANCE WE HAVE ABOUT TWELVE
BILLION DOLLARS IN WHAT'S CALLED
ROOM. UNDERNEATH THE LIMITIN
OTHER WORDS WE'RE NOT AT THE
LIMIT WERE BELOW THE LIMIT FOR
THE APPROPRIATIONS THAT MATTER.
WE HAVE TWELVE BILLION DOLLARS
IN ROOM WHAT IF WE DECIDED TO DO
SINGLE PAYER IN CALIFORNIA AND
WE SOMEHOW GOT A TWO HUNDRED UP
ABOUT TWO HUNDRED BILLION DOLLAR
TAX INCREASE THROUGH THE
CALIFORNIA LEGISLATURE.
AND APPROPRIATE A TWO HUNDRED
BILLION DOLLARS TOWARD A SINGLE
PAYER SYSTEM
I'M WHAT YOU CAN SEE HAPPENING
IS YOU WOULD BY DEFINITION BE
EXCEEDING AGAIN LIMIT BECAUSE
YOU ONLY HAVE ABOUT TWELVE
BILLION DOLLARS IN ROOM. SO
ANYTHING THAT GOES BEYOND ANY
APPROPRIATIONS FROM PROCEEDS OF
TAXES THAT GO BEYOND TWELVE
BILLION AT THIS POINT AND THE
NUMBER MAY MOVE AROUND A LITTLE
BIT. WOULD BE CONSIDERED ACCESS
REVENUES AND WOULD HAVE TO BUY
ACCORDING TO THE CONSTITUTION.
GO BACK TO THE TAXPAYERS AND GO
TO ADDITIONAL PROPOSITION NINETY
EIGHT SPENDING AND COULD NOT BE
USED FOR THE PURPOSE FOR WHICH
THE REVENUES WERE RAISED. IN
OTHER WORDS UNIVERSAL COVERAGE
SO.
KEN THE LEGISLATURE IF IT WANTED
TO ADDRESS THIS ISSUE.
AND IT'S A SIMILAR ANSWER TO
WHAT I GAVE BEFORE I'M PROP
NINETY EIGHT CALIFORNIA VOTERS
ARE USED TO SEEING. A REQUEST TO
AMEND OUR STATE CONSTITUTION IT
HAPPENS EVERY TWO YEARS IT'S
GONNA HAPPEN AGAIN THIS YEAR THE
LEGISLATURE COULD ADVANCE A
CONSTITUTIONAL AMENDMENT. UP
THAT NOT ONLY PASSED VOTERS TO
RAISE THE TAXES NECESSARY TO
FUND THE SYSTEM THAT EXCLUDES
THE REVENUES SPECIFICALLY FROM
THE PROP NINETY EIGHT GUARANTEE
IF IT WANTED TO DO SO BUT COULD
ALSO ASK VOTERS TO REVISED AGAIN
LIMIT IN SUCH A WAY.
THAT THESE NEW EXPENDITURES
THESE NEW APPROPRIATIONS WOULD
NOT BELOW PASSED AGAIN LIMIT.
AND BE COUNTED SORT OF AS
EXCESS REVENUES NOT BEING ABLE
TO BE USED ESSENTIALLY FOR
UNIVERSAL COVERAGE.
SO HOPEFULLY THAT WAS I I TRIED
TO MAKE THAT AS CLEAR AS I COULD
HOPEFULLY IT WAS YOU KNOW IT WAS
CLEAR ENOUGH I'M I'M HAPPY TO
TAKE QUESTIONS FIRST I WANTED TO
GIVE YOU JUST A FEW CAN
CONCLUDING THOUGHTS.
IT'S THAT THAT THE FIRST KEY
POINT TO KEEP THAT THE KEEP IN
MIND HERE IS THAT.
EFFORTS TO ITS AT THE PRICE AS
A PROP NINETY EIGHT AND AGAIN
LIMIT BOTH CONSTRAIN THE
LEGISLATURE'S ABILITY.
TO SORT OF ENACT MAJOR NEW.
PROGRAM EXPENDITURES THIS ISN'T
SOMETHING THAT APPLIES JUST TO
UNIVERSAL COVERAGE WERE TALKING
ABOUT IT IN THE CONTEXT OF
UNIVERSAL COVERAGE HERE BUT IF
THE STATE WANTED TO MAKE
SUBSTANTIAL INVESTMENT IN HIGHER
EDUCATION THE YOU SEE IN THE CS
YOU. ARE IN AFFORDABLE CHILDCARE
ON IN A RANGE OF PROGRAMS AND
SERVICES IT WOULD STILL BE
DEALING. WITH THESE TYPES OF
ISSUES I'M BRINGING THEM UP
SPECIFICALLY BECAUSE WE'RE
TALKING ABOUT IT IN THE CONTEXT
OF UNIVERSAL COVERAGE.
I ALSO WANTED TO NOTE THAT SOME
ADVOCATES SPECIFICALLY SOME MAP
I'M PROPONENTS OF SENATE BILL
FIVE SIXTY TWO. HAVE ASSERTED
THAT THE LEGISLATURE COULD
ADDRESS THESE CONSTITUTIONAL
CONSTRAINTS LEGISLATIVELY I'M
WITHOUT GOING TO THE VOTERS
WITHOUT CONSULTING THE VOTERS
AND BASED ON OUR ANALYSIS OF YOU
KNOW GOOD WORK THE LA HOW HAS
DONE OF OUR READ OF THE STATE
CONSTITUTION.
OUR RESPONSE TO THAT IS
ESSENTIALLY IT SEEMS VERY
UNLIKELY THAT THE LEGISLATURE
COULD ADDRESS THE PROBLEM POSED
BY THE CAMERAMAN.
LEGISLATIVELY WITHOUT GOING TO
THE VOTERS.
AND THAT GOING AROUND PROP
NINETY EIGHT COULD TRIGGER A
LAWSUIT JUST BASED ON THESE
VARYING INTERPRETATIONS PALM
WHICH WOULD PUT. UNIVERSAL
COVERAGE ANY NEW PROGRAMS AND
SERVICES PUT ON CLICK PUT IN
PLACE ON A VERY SHAKY LEGAL
FOUNDATION WHICH IS PROBABLY NOT
WHERE THE LEGISLATURE WOULD WANT
TO BE WHEN IT'S ATTEMPTING UP TO
PROVIDE. A RANGE OF ROBUST OF
SERVICES IN THE HEALTH CARE AND
ARENA TO CALIFORNIA AND SO.
JUST THE BOTTOM LINE HERE.
IF IT ASKING CALIFORNIA VOTERS
TO REMOVE THESE CONSTRAINTS
WOULD PROBABLY BE A BETTER WAY
FORWARD AND I'LL CONCLUDE THEIR
THANK YOU.
I THINK IT'S OKAY WOULD LIKE TO.
YOU DON'T TIRE FAN ALL OF THAT
IF YOU'RE GOOD WITH THAT SO.
OUR NEXT AND I AM SORRY I AM.
BEN BEN JOHNSON IS GOING TO
SPEAK TO US A. BEEN IS A.
OF FISCAL POLICY IN THEM
ANALYST WITH THE LEGISLATIVE
ANALYST'S OFFICE BEEN PLEASE.
THANK YOU.
YEAH SO A BEN JOHNSON AT THE LA
AUTO.
AND TO BRIEFLY TOUCH ON MY
AGENDA OUR ARE ACTUALLY HERE I
HAVE A HANDOUT THAT I BELIEVE
WAS DISTRIBUTED YOUR PACKETS AND
IT'LL FORM THE BASIS OF MY
REMARKS.
BRIEFLY GO OVER MY OUR OUR
AGENDA HERE TODAY OF FIRST IN
OPEN BY TOUCHING BRIEFLY ON
HEALTH CARE COVERAGE AND
EXPENDITURES UNDER THE EXISTING
SYSTEM. IN THE STATE THEN
PRESENT.
ARE ELIA ANALYSIS OF A PUBLICLY
FINANCED STATEWIDE HEALTH CARE
PROGRAM. AND THEN FINALLY
CONCLUDE ACTUALLY MY PORTION OF
THEIR MUCH OF OUR REMARKS
WITHOUT BY INTRODUCING
ASSORTMENT OF POLICY APPROACHES
TO EXTENDING COVERAGE TO THE
REMAINING HONORS ON IN SHARED.
THROUGH THE EXISTING HEALTH
CARE SYSTEM THEN I'LL TURN IT
OVER TO MY COLLEAGUE BRIAN
MILLER TO DISCUSS VARIOUS
FINANCING CONSIDERATIONS AND
OPTIONS.
SO TURNING TO PAGE ONE OF THE
HAND OUT.
WOULD JUST THEM INITIALLY NOTE
THAT NINETY THREE PERCENT.
WELL WHICH OF A QUICKER.
GREAT TURNING TO PAGE ONE.
AT NINETY THREE PERCENT OF
CALIFORNIANS.
WE ESTIMATE ARE CURRENTLY
INSURED AND THIS MARKS AN
INCREASE FROM ABOUT EIGHTY THREE
PERCENT OF CALIFORNIANS WHO HAVE
HEALTH INSURANCE.
IN TWENTY THIRTEEN CHANGES THAT
ARE LARGELY RELATED WE THINK TO
THE AFFORDABLE CARE ACT.
I MEAN ACTUALLY FLIP AHEAD TO
THE FIGURE ON PAGE TWO HERE.
TO BREAK BRIEFLY DESCRIBE WHERE
CALIFORNIANS OBTAIN THEIR
COVERAGE
SO JUMPING DOWN ACTUALLY TO THE
BOTTOM.
WE ESTIMATE THAT THE LARGEST
PORTION OF CALIFORNIANS PROBABLY
A LITTLE OVER FIFTEEN MILLION.
INDIVIDUALS OBTAIN COVERAGE
THROUGH THEIR EMPLOYERS OR
THROUGH EMPLOYER SPONSORED
INSURANCE.
ANOTHER AN ADDITIONAL THIRTEEN
TO FOURTEEN MILLION OBTAIN
COVERAGE THROUGH MEDICAID OUT
THE STATE'S MEDICAID PROGRAM FOR
LOW INCOME RESIDENTS AND THEN
FOUR TO FIVE MILLION OBTAIN
COVERAGE THROUGH MEDICARE WHICH
IS FOR THE ELDERLY AND.
AND CERTAIN DISABLED
POPULATIONS.
FINALLY THE INDIVIDUAL MARKET.
PROVIDES COVERAGE TO TWO TO
THREE MILLION CALIFORNIANS AND
THEN WE LEFT AFTER SOME SMALLER
INSURANCE PROGRAMS WITH A
RESIDUAL UNINSURED POPULATION OF
ABOUT THREE MILLION PEOPLE WHICH
I WILL. GO INTO NEXT
TO DESCRIBE A LITTLE FURTHER.
SO THERE ABOUT THREE MILLION
REMAINING UNINSURED AND WE WOULD
DIVIDE THESE INDIVIDUALS AND TO.
PROBABLY TWO CATEGORIES THE
FIRST WHICH ACCOUNTS FOR LESS
THAN TO MILLION OF THEIR
REMAINING AND THEN SHARED ARE
UNDOCUMENTED ENCOURAGE
IMMIGRANTS THE MAJORITY OF WHOM
ARE LOW INCOME. LOW INCOME SO
THAT THEY WOULD.
QUALIFY FOR MEDI CAL OR SUB
FEDERAL HEALTH INSURANCE
SUBSIDIES THROUGH COVERED
CALIFORNIA IF THEY HAD
DOCUMENTED IMMIGRATION STATUS.
THE SECOND CATEGORY COMPRISING A
LITTLE MORE THAN MILLION
INDIVIDUALS ACROSS THE STATE.
COMPRISES CITIZENS AND
IMMIGRANTS WITH DOCUMENTED
STATUS.
AND WE ESTIMATE THAT ABOUT TWO
THIRDS OF THESE SHARON SUBSIDIES
THROUGH
COVERED CALIFORNIA.
BUT THEY'VE ELECTED NOT TO
ENROLL THE REMAINING THIRD OF
THE REMAINING ANY CHAIRED OUR
RESIDENTS THAT WE ESTIMATE HAVE
INCOMES TOO HIGH TO QUALIFY FOR
FEDERAL INSURANCE SUBSIDIES TO
RECOVER CALIFORNIA. CLOSER
INDIVIDUALS WHO ARE IN ABOUT
FOUR HUNDRED PERCENT OF THE
FEDERAL POVERTY LINE WHICH FOR A
FAMILY FOR WOULD BE.
ABOUT A HUNDRED THOUSAND
DOLLARS.
NEXT I'M GONNA TOUCH JOHN
STATEWIDE HEALTHCARE
EXPENDITURES HERE STILL BONTA AT
THE BOTTOM OF PAGE THREE. WE
ESTIMATE THAT THERE FOR THERE'S
FOUR HUNDRED BILLION DOLLARS IN
TOTAL HEALTHCARE SPENDING IN
CALIFORNIA IN THE FISCAL YEAR
TWENTY SEVENTEEN EIGHTEEN AND
THIS IS FROM ALL PUBLIC AND
PRIVATE SOURCES SO IT INCLUDES.
I NUMBER OF DIFFERENT PROGRAMS
ARE SOURCES THAT OUT TOUCH ON.
HERE VERY SHORTLY.
FOR ON BEEN TERMS OF PER CAPITA
EXPENDITURES THIS COMES TO ABOUT
TEN THOUSAND DOLLARS PER PERSON.
FIGURED CHIU HERE BREAKS DOWN
THE EXPENDITURES BY PAYER OR
PAYER TYPE AND AS WE CAN SEE
EMPLOYER SPONSORED INSURANCE
THAT COVERS THE MOST INDIVIDUALS
AND IT WROTE WE THINK IT
ACCOUNTS FOR MOST THIS.
THE HIGHEST PROPORTION OF
SPENDING.
IN TERMS OF SPECS MANAGERS
ACROSS THE STATE AT BETWEEN
HUNDRED HUNDRED FIFTY BILLION
ARE YEAH SOME AND MEDIAN
ESTIMATE OF HUNDRED TWENTY FIVE
HUNDRED AND THIRTY BILLION
DOLLARS.
IN TWENTY SEVENTEEN EIGHTEEN
THE NEXT.
LARGEST SOURCE OF.
HEALTHCARE SPENDING IN THE
STATE IS MEDI CAL AT.
ABOUT A HUNDRED BILLION DOLLARS
AND THEN MEDICARE AT ABOUT
SEVENTY FIVE BILLION DOLLARS.
YOU HAVE ALSO SEE OTHER THAN.
IN TERMS OF PREMIUMS THERE IS A
PORTION THAT IS SOME FORM OF OUT
OF POCKET EXPENDITURES AND THE
BACK COMPRISES COPAYS AND
DEDUCTIBLES THAT PEOPLE
INDIVIDUALS PAY WHEN THEY VISIT
THE DOCTOR.
TURNING TO PAGE FIVE.
WE ESTIMATE THAT ABOUT TWO
HUNDRED BILLION DOLLARS IN TOTAL
HEALTHCARE SPENDING IN THE STATE
COMES FROM PUBLIC AS OPPOSED TO
PRIVATE SOURCES WITH THE MAJOR
PROGRAMS MEDI CAL MEDICARE AND
THE FEDERAL HEALTH INSURANCE
SUBSIDIES THAT ARE AVAILABLE
THROUGH COVERED CALIFORNIA.
REALLY COMPRISING THE BULK OF
PUBLIC SPENDING. THERE IS ALSO
AN INDIRECT FORM OF PUBLIC
SUPPORT FOR.
HEALTHCARE INSURANCE AND THAT
IS THE TAX EXCLUSION OF EMPLOYER
SPONSORED HEALTH INSURANCE
FEDERAL AND STATE GOVERNMENTS
EXCLUDE.
FROM INCOME TAXES INCOMES THAT
EMPLOYEES RECEIVE IN THE FORM
OF.
INSURANCE BENEFITS AND WE
ESTIMATE THIS BENEFIT TO BE
WORTH BETWEEN FORTY AND FIFTY
BILLION DOLLARS IN FOREGONE
REVENUE.
TO THE FEDERAL AND STATE
GOVERNMENT ABOUT SEVENTY FIVE
PERCENT OF WHICH.
IS IN IS IN TERMS OF FOREGONE
REVENUE TO THE FEDERAL
GOVERNMENT.
ALL TOLD FEDERAL SPENDING
ACCOUNTS FOR ABOUT THREE FOURTHS
OF THE TWO HUNDRED BILLION
DOLLARS IN.
IN TOTAL PUBLIC SPENDING ON
MEDICARE OUT FORM IT.
FEDERAL SPENDING COMPRISE A
LARGE PORTION MEDI CAL HOUGHTON
YOU KNOW ALL OF MEDICARE THAT'S
NOT INCLUDE THAT'S NOT INCURRED
BY THE INDIVIDUAL PARTICIPANTS
OF THE PROGRAM.
AND AS WELL AS THE FEDERAL
HEALTH INSURANCE SUBSIDIES TO
COVER CALIFORNIA AND THEN THE
STATE AND LOCAL GOVERNMENTS THEY
PROVIDE THE REMAINING FIFTY
BILLION DOLLARS MEDI CAL BEING.
I THINK SIGNIFICANTLY THE
LARGEST SOURCE THEIR.
AND THEN THE MAJOR PRIVATE
SOURCES OF HEALTH CARE SPUR OF
PRIVATE HEALTHCARE SPENDING IN
THE STATE ARE EMPLOYER SPONSORED
INSURANCE PREMIUMS INDIVIDUAL
MARKET PREMIUMS NET OF ANY OF
FEDERAL SUBSIDIES THAT
INDIVIDUALS PAY. AND THE OUT OF
POCKET EXPENSES WHICH WE
ESTIMATE OF BETWEEN THIRTY FIVE
OR TWENTY FIVE AND THIRTY FIVE
BILLION DOLLARS IN COSTS IN THE
STATE A IN THE FORM OF COPAYS
AND DEDUCTIBLES ANOTHER HEALTH
CARE COSTS. NOT PAID BY INSURERS
AND AND THIS THIS FIGURE
EXCLUDES ANY PREMIUMS THAT
INDIVIDUALS WOULD PAY.
NOW I'M GONNA TURN AWAY FROM
DESCRIBING HEALTH CARE COVERAGE
IN EXPENDITURES UNDER OUR
EXISTING SYSTEM AND TALK ABOUT
OUR ANALYSIS OF A PUBLICLY
FINANCED HEALTH CARE PROGRAM.
IN TWENTY SEVENTEEN THE L. ILIO
ANALYZE THE COST OF A STATEWIDE
PUBLICLY FINANCE HEALTHCARE
PROGRAM THAT WOULD REPLACE THE
EXISTING MULTI PAYER HEALTHCARE
SYSTEM.
THEY WERE GENERALLY PROVIDE
EXCLUSIVE FINANCING OF
HEALTHCARE SERVICES ACROSS THE
STATE AND WOULD NOT DIRECTLY
OPERATE HOSPITALS WERE EMPLOYED
THE WORK FIRST BUT INSTEAD
PRIMARILY BE FOCUSED WITHOUT
FOCUSED ON FINANCING THE
HEALTHCARE SERVICES THAT ARE
CURRENT.
WE JUST NOTE SO WE'LL GO
THROUGH OUR ESTIMATES BUT A
PROGRAM STRUCTURED DIFFERENTLY
THE ONE THAN THE ONE THAT WE
ANALYZE AND TWENTY SEVENTEEN
COULD COST TENS OF BILLIONS OF
DOLLARS MORE OR TENS OF BILLIONS
OF DOLLARS LESS THAN. THE ONE
THAT WE ANALYZED
IN ANALYZING THE DATA PROGRAM WE
MADE UP.
SAID OF MAJOR ASSUMPTIONS
INCLUDING THAT IT WOULD COVER
NEARLY ALL CALIFORNIANS BY
INCORPORATING THE EXISTING
FEDERAL AND STATE FUNDING
STREAMS REDIRECTING THOSE TO BE
ABLE TO PAY FOR. A A SINGLE
STATEWIDE PUBLICLY FINANCED
PROGRAM SUCH AS MEDICARE AND
MEDICAID WHICH PREVIOUS SPEAKERS
DESCRIBED SOME OF THE CHALLENGES
OF.
.
AND WE ASSUME THAT THE SYSTEM
WOULD BE A FEE FOR SERVICE
DELIVERY SYSTEM WHERE INDIVIDUAL
SERVICES THAT AND GOT US THE
SERVICES THAT INDIVIDUALS.
UTILIZE WOULD BE SEPARATELY
PAID FOR ON THEIR OWN AND THAT
THE SYSTEM WOULD PAY.
PROVIDER RATES THAT ARE
COMPARABLE TO WHAT MEDICARE PAYS
WHICH ARE LITTLE ALONE WHAT WE
THINK HIGHER THAN WHAT MEDI CAL
PAYS IN FEE FOR SERVICE.
BUT NOT NECESSARILY AS HIGH AS
THE COMMERCIAL RATES THAT.
PRIVATE INSURERS TEND TO PAY.
WITH THE SYSTEM THAT WE ALSO
THAT WE ANALYZED OUGHT WOULD
OFFER A COMPREHENSIVE PACKAGE OF
BENEFITS INCLUDING CERTAIN
BENEFITS THAT ARE NOT OFFERED
THROUGH TRADITIONAL HEALTH
INSURANCE PROJECT PRODUCTS IN
THROUGH EMPLOYER SPONSORED
INSURANCE FOR EXAMPLE. SUCH AS
LONG TERM CARE BENEFITS DENTAL
INVENTED VISION BENEFITS.
AND THEN FINALLY WE ASSUME THAT
THIS PROGRAM WOULD HAVE NO COST
SHARING THAT BAD THERE'D BE NO
CO PAYS OR DEDUCTIBLES FOR THE
INDIVIDUALS ARE FOR INDIVIDUAL
SERVICES THAT.
THE STATE RESIDENTS UTILIZE.
WE ESTIMATED THAT THIS COST
WOULD.
THIS PROGRAM WOULD COST ABOUT
FOUR HUNDRED BILLION DOLLARS ON
IN TWENTY SEVENTEEN EIGHTEEN
TERMS BUT WE WOULD NOTE THAT
THERE IS SIGNIFICANT UNCERTAINTY
SURROUNDING THAT ESTIMATE.
GIVEN THAT IT WOULD BE SUCH A A
LARGE TRANSFORMATION AND HOW THE
STATE DELIVERS HEALTHCARE
SERVICES.
WE SOON THE HEALTH CARE SERVICES
A SUCH AS DOCTORS VISITS
SERVICES THE HOSPITAL IN
PHARMACEUTICALS.
WOULD REALLY COMPRISE THE TO
THE BULK OF SPENDING IN THE
PROGRAM THAT ADMINISTRATIVE OUR
STATE OPERATIONS SPENDING WHAT
ACCOUNT FOR LESS THAN TEN
PERCENT OF TOTAL PROGRAM
EXPENDITURES.
WE ALSO ASSUMED THAT THE TWO
HUNDRED BILLION DOLLARS IN TOTAL
PUBLIC SPENDING COULD
BEREDIRECTED TO FUND THE
PROGRAM.
AND JUST NOTE THAT THERE IS
UNCERTAINTY AS WAS PREVIOUSLY
DISCUSSED ON WHETHER IN FACT NOT
WHETHER OR NOT THAT COULD BE THE
CASE.
THIS LEAVES ABOUT TWO HUNDRED
BILLION DOLLARS IN ADDITIONAL
STATE REVENUE THAT WOULD BE
NEEDED TO FULLY FUND THE PROGRAM
HOPE.
.
I AND THIS REVENUE WOULD LIKELY
HAVE TO BE REYES THROUGH THE
STATE'S TAX SYSTEM.
TO CONCLUDE MY PORTION.
IF THE LA OWES REMARKS I'M
GONNA TURN TO A SET OF PROPOSALS
THAT DOUR REALLY POLICY
APPROACHES THAT WE'VE BEEN ASKED
BY THE COMMITTEE DISCUSS. TO
EXTEND COVERAGE TO THE REMAINING
AND THEN SHARED.
THROUGH REALLY THE EXISTING
HEALTH CARE SYSTEM.
CERTAIN APPROACHES WOULD BE
DESIGNED TO TARGET THIS FIRST
GROUP ARE UNINSURED LOW INCOME
DOT AND I UNDOCUMENTED
IMMIGRANTS PA WHO WE ESTIMATE
ARE ABOVE ABOUT ALMOST TWO
THIRDS OF THE REMAINING ON AND
SHARE.
WE DEFINE AGAIN LOW INCOME AS
THOSE INDIVIDUALS WHO ARE
EARNING LESS THAN FOUR HUNDRED
PERCENT OF THE FEDERAL POVERTY
LINE THE CUT OFF FOR FEDERAL
HEALTH INSURANCE SUBSIDIES TO
COVERED CALIFORNIA.
FIRST POLICY APPROACH WOULD BE
OUT TO EXTEND FULL SCOPE MEDICAL
COVERAGE FOR INCOME ELIGIBLE
UNDOCUMENTED IMMIGRANT ADULTS
THAT IS IMMIGRANT ADULTS EARNING
LESS THAN MY ONE HUNDRED AND
THIRTY PER A PERCENT GENERALLY
OF THE FEDERAL POVERTY LEVEL.
AND THIS TRANSLATES INTO ABOUT
THIRTY FOUR THOUSAND DOLLARS FOR
A FAMILY OF FOUR.
MORE AND PREVIOUSLY A COUPLE OF
YEARS AGO THE STATE ACTUALLY
EXTENDED A FULL SCOPE MEDICAL
COVERAGE TO CHILDREN
UNDOCUMENTED IMMIGRANT CHILDREN
UP TO AGE NINETEEN.
BUT ADULTS REMAIN ONLY ELIGIBLE
FOR WHAT IS KNOWN AS RESTRICTED
SCOPE MEDICAID OUR.
IN WHICH MEDI CAL PAYS FOR THE
EMERGENCY AND PREGNANCY RELATED
SERVICES BUT IT WOULDN'T FUNDS
NIGHT OF THE.
THE PREVENTIVE VISITS ARE OTHER
OTHER TYPES OF SERVICES THAT
MEDI CAL COVERS.
WE ESTIMATE WE ESTIMATE THAT
THIS APPROACH COULD EXTEND
COVERAGE TO ABOUT A MILLION
ADDITIONAL UNDOCUMENTED
IMMIGRANTS ACROSS THE STATE MOST
OF WHOM ARE WE DO ESTIMATE ARE
ALREADY ENROLLED IN RESTRICTED
SCOPE MEDI CAL.
THE SECOND APPROACH TO.
TARGET.
REMAINING UNINSURED
UNDOCUMENTED IMMIGRANTS.
WOULD BE TO PROVIDE HEALTH
INSURANCE IN DIVIDEND OF VISUAL
MARKET HEALTH INSURANCE
SUBSIDIES.
FOR.
INCOME I SAID OF INCOME ELIGIBLE
UNDOCUMENTED IMMIGRANTS IF THIS
WERE MODELED AFTER THE FEDERAL
HEALTH INSURANCE SUBSIDIES FOR
EXAMPLE THIS WOULD.
THIS WOULD PROVIDE STATE FUNDED
TAX CREDITS TO UNDOCUMENTED
IMMIGRANTS EARNING BETWEEN ONE
HUNDRED AND THIRTY EIGHT PERCENT
AND FOUR HUNDRED PERCENT OF THE
FEDERAL POVERTY LEVEL. AND WE
ESTIMATE THAT THIS COULD HELP AN
ESTIMATED THREE HUNDRED TO FIVE
HUNDRED THOUSAND AND UNINSURED
UNDOCUMENTED IMMIGRANTS OBTAIN
COVERAGE.
ONE WAY TO MODEL IT WOULD BE TO
THESE TAX CREDITS WOULD BE TO.
MODEL THEM AFTER THE FEDERAL
TAX CREDITS WHICH LIMIT PREMIUMS
THAT INDIVIDUALS PAY TO A
CERTAIN PERCENTAGE OF THEIR
INCOME.
NEXT TO HER I'LL TURN TO.
POLICY APPROACHES THAT COULD
TARGET THE OTHER REMAINING
UNINSURED SO PRIMARILY STATE REP
CITIZENS AND AND IMMIGRANTS WITH
DOCUMENTS STATUS.
.
ONE APPROACH HERE WOULD BE TO
OFFER STATE WRAPAROUND TAX
CREDITS IN THE INDIVIDUAL MARKET
UP FOR INDIVIDUALS.
WITH IT WITH INCOMES THAT ARE
TOO HIGH TO QUALIFY FOR MEDICAID
ALSO ABOVE ONE HUNDRED AND
THIRTY EIGHT PERCENT.
THESE PROTESTS PROPOSAL SORT OF
OR THE SET OF PROPOSALS COULD
POTENTIALLY HELP AROUND ONE
MILLION UNINSURED.
CALIFORNIANS OBTAIN COVERAGE
NOW THERE TO.
COMPLEMENTARY BUT SEPARATE.
SORT OF.
APPROACHES UNDER THIS MORE
GENERAL APPROACH ONE WOULD BE TO
OFFER STATE FUNDED HEALTH
INSURANCE SUBSIDIES FOR
INDIVIDUALS WHO ACTUALLY EARN
MORE THAN THE CUT OFF FOR
FEDERAL ELIGIBILITY SO. COULD BE
STRUCTURED TO FOR EXAMPLE.
PROVIDE STATE TAX CREDITS FOR
INDIVIDUALS EARNING.
BETWEEN FOUR HUNDRED PERCENT IN
FIVE HUNDRED PERCENT OF THE
FEDERAL POVERTY LINE.
BUT COULD BE MODELED IN A SORT
OF SIMILAR FASHION WHERE.
THESE INDIVIDUALS.
TAKE HOMES OR NOT SORT OF
PREMIUM PAY.
WOULD BE LIMITED TO A CERTAIN
AMOUNT OF THEIR INCOME OR A
CERTAIN PERCENTAGE OF THEIR
INCOME.
THE STATE COULD ALSO.
OFFER STATE SUBSIDIES THAT.
ACTUALLY JUST COMPLEMENT THE
FEDERAL SUBSIDIES FOR
INDIVIDUALS WHO ARE CURRENTLY
ELIGIBLE FOR FEDERAL HEALTH
INSURANCE SUBSIDIES AND WHAT
THESE COULD DO IS THEY COULD
LOWER THE PERCENTAGE OF INCOME
THAT INDIVIDUALS PAY.
FOR PREMIUMS ON THE INSURANCE
ON THE INDIVIDUAL MARKET ABOUT
FOR EXAMPLE SOMEBODY WHO'S ON
WHO EARNS ABOUT FOUR HUNDRED
PERCENT OF THE FEDERAL POVERTY
LINE LIMITED TO TEN PERCENT OF
THEIR INCOME IN TERMS OF THE
PREMIUMS THEY PAY. A STATE TAX
CREDIT COULD FOR EXAMPLE LOWER
LOWER THAT PERCENTAGE TO MAYBE
EIGHT PERCENT OF THEIR INCOME.
AND THEN I'LL FINALLY TOUCH ON A
STATE INDIVIDUAL MANDATE STATE
INDIVIDUAL MANDATE WOULD DO
CRIER RESIDENTS STATE RESIDENTS
TO MAINTAIN HEALTH INSURANCE
COVERAGE OR OTHERWISE PAY A
PENALTY SIMILAR TO THE ACA'S
INDIVIDUAL MANDATE.
BUT WHICH WAS.
RECENTLY THE PENALTY OF WHICH
WAS RECENTLY SET TO ZERO IN THE
MOST RECENT FEDERAL TAX BILL.
BEGINNING IN TWENTY NINETEEN.
THE BENEFIT OF A STATE TAX
CREDIT IT WOULD COULD THAT COULD
REPLACE THE EXPIRING FEDERAL
MANDATE PENALTY WOULD BE THAT IT
COULD.
PROVIDE AN INCENTIVE FOR
INDIVIDUALS ESPECIALLY THE
RELATIVELY YOUNG AND HEALTHY A
TO MAIN HATE MAINTAIN HEALTH
CARE COVERAGE.
TO GIVE SOME CONTEXT ON THE
PENALTIES THAT WERE PAID BY
CALIFORNIA RESIDENTS ARE.
UNDER THE FEDERAL MANDATE.
ALMOST EIGHT HUNDRED THOUSAND
CALIFORNIANS PAID THE FEDERAL
INDIVIDUAL MANDATE PENALTY IN
TWENTY FIFTEEN AT A TOTAL
PENALTY AMOUNT OF THREE HUNDRED
AND EIGHTY MILLION DOLLARS.
AND THAT CONCLUDES MY PORTION.
OF OUR REMARKS HAPPY TO TAKE
QUESTIONS BUT I'LL TURN OVER TO
RYAN MILLER.
AND RYAN MILLER FROM THE LA NOW.
.
BEFORE WE DIVE INTO SOME OF THE.
FRONT FINANCING OPTIONS THAT
WE'VE PREPARED I WANTED TO HIT A
COUPLE OF INTRODUCTORY POINTS.
FIRST WHILE WHILE WE WALK
THROUGH VARIOUS TAXES WE
PROVIDED ESTIMATES OF WHAT RATES
WOULD BE NECESSARY TO RAISE AN
ADDITIONAL. TEN BILLION DOLLARS
ON THE LOW END AND TWO HUNDRED
BILLION DOLLARS ON THE HIGH END.
AND WE WE PICKED THOSE NUMBERS
BECAUSE THEY REPRESENT.
MANY OF THE PROPOSALS BEING
THROWN AROUND.
.
SOME OF THE PROPOSALS THAT.
MISTER JOHNSON DISCUSSED IN
KIND OF THE SEVERAL BILLION
DOLLAR RANGE AND MORE
SUBSTANTIAL CHANGES TO THE
HEALTHCARE SYSTEM IN THE. TWO
HUNDRED BILLION DOLLAR RANGE.
AS MISTER GRAVES MENTIONED.
TAX INCREASES GENERALLY REQUIRE
A TWO THIRDS VOTE OF THE
LEGISLATURE.
HOWEVER IN SOME CASES.
CHANGES WOULD REQUIRE GOING TO
THE VOTERS
I GENERALLY SPEAKING MODIFYING
THE PROPERTY TAX FOR EXAMPLE.
WOULD REQUIRE AMENDING THE
CONSTITUTION AND A AND A
STATEWIDE VOTE.
AND I WANTED ALSO HAD ON.
FEDERAL TAX CHANGES THAT WERE
RECENTLY MADE.
ITS IT THE THE THE THE FEDERAL
BILL IS VERY COMPLEX THERE'S A
LOT OF.
PROVISIONS THAT WERE WORKING
FOR A LOT OF THE FRANCHISE TAX
BOARD IS TAKING A LOOK AT THE
EFFECTS.
.
BUT ONE OF THE PROVISIONS THAT
SEEMS.
PARTICULARLY NOTABLE FOR THIS
CONVERSATION IS THE.
BUT IS THE CAP ON THE STATE AND
LOCAL TAX DEDUCTIONS.
I'M SURE THAT YOU'VE HEARD OF
IT.
.
I TAXPAYERS CAN DEDUCT UP TO TEN
THOUSAND DOLLARS OF EITHER
PERSONAL INCOME TAX OR SALES TAX
PLUS PROPERTY TAXES.
SO WHERE AS LAST YEAR.
MANY OF THE OPTIONS WILL
DISCUSS.
WOULD HAVE ALLOWED A TAXPAYERS
TO DEDUCT THE INCREASE ON THEIR
FEDERAL TAX BILLS.
MANY TAXPAYERS.
NO LONGER WOULD HAVE THAT
OPTION.
.
SO.
FIRST WE'LL DISCUSS THE PERSONAL
INCOME TAX THE PERSONAL INCOME
TAXES THE MAIN STATE TAX.
PROVIDES.
ROUGHLY SEVENTY PERCENT OF THE
STATE'S GENERAL FUND.
IT'S LEVIED ON.
HOUSEHOLD INCOME LIKE WAGES AND
SALARIES RETIREMENT INCOME
BUSINESS INCOME.
I AND THE STATE ASSESSES.
MARGINAL RATES THAT RANGE FROM
ONE PERCENT TO TWELVE POINT
THREE PERCENT. AND THEY INCREASE
WITH INCREASES IN INCOME.
AS WE KNOW THE HAND OUT THERE
IS ALSO A ONE PERCENT SURCHARGE.
FROM PROPOSITION SIXTY THREE
RELATED TO MENTAL HEALTH.
BUT WE GENERALLY DON'T I HAVE
THOSE REFLECTED IN OUR.
ESTIMATES AND TABLES HERE.
SO THE TWO MAIN WAYS THAT YOU
CAN INCREASE PERSONAL INCOME TAX
REVENUE.
ARE TO EITHER INCREASE RATES
AND OR.
ELIMINATE OR MODIFY TAX
EXPENDITURES LIKE THE MORTGAGE
INTEREST DEDUCTION.
FOR THIS HAND OUT WE LOOKED AT
WHAT TYPES OF RATE INCREASES
WOULD BE NECESSARY.
.
TO RAISE OTHER TENANT TO HONOR
BILLION DOLLARS IN LOOK AND
ASSUMING THAT.
THERE WOULD BE AT ACROSS THE
BOARD.
INCREASE IN ALL RATES NOW.
YOU KNOW YOU WOULD HAVE OPTIONS
TO SORT OF CONCENTRATE THAT TAX
INCREASE ON DIFFERENT PARTS OF
THE INCOME DISTRIBUTION.
BUT AGAIN WE WE KIND OF LOOKED
AT A. AN ACROSS THE BOARD
OPTION.
.
SIR ALL KNOW THAT.
THAT THE HANDOUTS THAT THEN THE
COMMITTEE HAVE.
ARE UPDATED TO REFLECT THE A
PROBLEM THAT WE FOUND IN IN
THEIR TABLE.
EARLIER THIS MORNING BUT
ANYBODY WHO HAD PICKED UP THE
HAND OUT FROM OUTSIDE THE ROOM.
CAN FIND THE CORRECTED VERSION
ON OUR WEBSITE.
.
SO WE ESTIMATE THAT IT THAT IT
INCREASE REQUIRED FOR TEN
BILLION DOLLARS WOULD REQUIRE A
TEN PERCENT
INCREASE IN RATES ACROSS THE
BOARD SO FOR EXAMPLE. I THE TOP
TWELVE POINT THREE PERCENT RATE
WOULD HAVE TO INCREASE TO
THIRTEEN POINT FIVE PERCENT.
.
I DON'T IN ORDER TO RAISE TWO
HUNDRED BILLION DOLLARS HOWEVER
THE RATES WOULD HAVE TO BE ABOUT
THREE TIMES HIGHER.
I AM IS REFLECTED ON THE TABLE
THE CORRECTED VERSION THAT IS.
THE TOP MARGINAL RATE ON THE
TWO HUNDRED BILLION DOLLAR
OPTION WOULD BE.
ABOUT THIRTY SIX PERCENT.
AND TO PROVIDE A LITTLE BIT OF
CONTEXT THERE.
WHEN COMBINED WITH THE NEW TOP
FEDERAL RATE.
IN THE IN THE RECENT FEDERAL.
BILL.
THAT WOULD RESULT IN A COMBINED
STATE AND FEDERAL RATED OVER
SEVENTY PERCENT.
THIS SEEMS LIKE A GOOD TIME TO
MENTION.
THAT SOME OF THESE OPTIONS
WOULD WOULD HAVE LARGE TAXPAYER
BEHAVIORAL RESPONSES IN IN FOR
EXAMPLE HERE.
ONE CAN IMAGINE THAT WITH.
COMBINED RATE OF OVER SEVENTY
PERCENT THERE WOULD LIKELY BE
MANY PEOPLE.
FINDING ANOTHER PLACE TO LIVE.
AND AND I MENTION THAT AS WELL
BECAUSE WE HAVE PRODUCED.
STATIC ESTIMATES THE DON'T
ASSUME.
CHANGES IN THE ECONOMY CHANGES
AND HOW TAXPAYERS RESPOND.
AND SO PARTICULARLY AT THE HIGH
END OF OF WHAT WE'RE TALKING
ABOUT THIS PRESENTATION.
THERE WOULD BE HUGE UNCERTAINTY.
RESULTING FROM FROM THESE
FACTORS.
AND IT'S QUITE POSSIBLE THAT
THE AMOUNT OF REVENUE THAT WOULD
BE RAISED IF YOU DID UP PURSUE
SOME OF THESE OPTIONS WOULD.
WOULD.
VERY FROM THESE ESTIMATES BY
MANY TENS OF BILLIONS OF
DOLLARS.
SO NEXT WILL DESCRIBE THE
PROPERTY TAX AND IT'S THE MAIN
LOCAL TAX SOURCE.
.
THE.
THE PROPOSITION THIRTEEN.
MAILED A NUMBER OF CHANGES TO
THE PROPERTY TAX IT CAPS THE.
PROPERTY TAX RATE AT ONE
PERCENT.
AND ALSO.
AFFECTS HOW.
HOW ASSESSED VALUES CAN GROW?
IT LIMITS.
GROWTH NEXT BEEN ASSESSED
VALUES TO THE GREATER INFLATION
AND TWO PERCENT AND SO. THAT
KIND OF USMOVES OUT THE TAX
BASE.
.
SO FOR OPTIONS FOR ATTACKS THAT
THE PARTY TAX YOU CAN EITHER
INCREASE THE TAX RATE OR YOU CAN
MAKE CHANGES TO THAT ASSESSMENT
SYSTEM FOR EXAMPLE SOME HAVE UP
PROPOSED A SPLIT ROLE WHEREBY. A
RESIDENTIAL PROPERTIES ARE
CONTINUING TO BE TAXED AT THE IN
THE UNDER THE CURRENT SYSTEM THE
COMMERCIAL PROPERTIES WILL BE
TAXED AT MARKET VALUES.
.
FOR THIS.
HEARING HOWEVER WE LOOKED AT.
JUST AN INCREASE IN TAX RATES
WITHOUT A CHANGE IN THE TAX BASE
OR IN THE ASSESSMENT SYSTEM.
NOW WE ESTIMATED THAT A POINT
TWO PERCENT INCREASE WOULD BE
NEEDED FOR AN ADDITIONAL TEN
BILLION DOLLARS WHICH WOULD
BRING THE STATEWIDE AVERAGE.
TAX RATE TO.
I BELIEVE ONE POINT THREE
PERCENT.
BUT IT BUT A TWO HUNDRED
BILLION DOLLAR INCREASE ON THE
OTHER HAND WOULD REQUIRE AN
INCREASE OF THREE POINT SEVEN
PERCENT WHICH WOULD BRING THE
AVERAGE RATES ALMOST FIVE
PERCENT.
NEXT.
IS THE SALES AND USE TAX.
THIS IS ATAXES COLLECTED BY
THE STATE AND IS DISTRIBUTED TO
THE STATE AND LOCAL GOVERNMENTS.
THE STATEWIDE AVERAGE RATE IS
CURRENTLY EIGHT POINT FIVE
PERCENT THE LOCAL GOVERNMENTS
CAN.
CHOOSE TO ADD ON RATES.
SO THAT TELLS TAX CAN VARY
CONSIDERABLY IN SOME PARTS OF
THE STATE.
.
NOW IN THE SALES TAX.
ANOTHER OPTION THAT YOU CAN
CONSIDER IS TO CHANGE THE TAX
BASE FOR EXAMPLE.
SOME PEOPLE HAVE TALKED ABOUT
EXTENDING THE SALES TAX
SERVICES.
WE ALSO NOTE.
THAT. THAT THE SALES TAX COULD
ALSO BE EXTENDED TO.
BE APPLIED TO A CANDY SNACK
FOODS AND BOTTLED WATER BUT THAT
WOULD BE ANOTHER OPTION THAT
REQUIRE GOING THE VOTERS BECAUSE
THERE'S A SPECIFIC. PROVISION IN
THE CONSTITUTION ABOUT THAT.
.
SO WE AGAIN.
MADE NO.
ASSUME NO CHANGE IN THE TAX
BASE.
AND JUST LOOK AT WHAT KINDS OF
RATES WOULD BE NEEDED TO RAISE
THE ADDITIONAL AYE REVENUE.
FOR TEN BILLION DOLLARS WE
ESTIMATE THAT IT WOULD REQUIRE
AN ADDITIONAL ONE POINT FOUR
PERCENT. AND THAT WOULD BRING
THE STATEWIDE AVERAGE SALES TAX
RATE TO ABOUT TEN PERCENT.
THAT ON THE OTHER HAND.
TWO HUNDRED BILLION DOLLARS
WOULD REQUIRE AN INCREASE OF
ROUGHLY TWENTY EIGHT PERCENTAGE
POINTS.
I WHICH WOULD BRING THE AVERAGE
SALES TAX RATE TO ABOUT THIRTY
SEVEN PERCENT.
ANOTHER OPTION.
THAT WE INCLUDE IS IS A PAYROLL
TAX ON THE STATE HAS A FEW SMALL
PAYROLL TAXES FOR EXAMPLE THAT
ARE LEVIED FOR. REALLY DONE
EMPLOYMENT ASSURANCE.
THE FEDERAL GOVERNMENT ALSO
LEVEES PAYROLL TAXES FOR EXAMPLE
FOR SOCIAL SECURITY AND THEY
LOVE IT UP TO A CERTAIN AMOUNT.
I BELIEVE IN. AND.
TWENTY SEVENTEEN IT WAS A
HUNDRED AND TWENTY THOUSAND FOUR
HUNDRED.
BUT THE STATE COULD CHOOSE TO
APPLY IT TO ALL INCOME IT
DOESN'T ACTUALLY HAVE TO HAVE A
CAP.
ON THE STATE WOULD BE ABLE TO
MAKE CHOICES ABOUT WHAT RATE TO
CHARGE IN COULD CONCEIVABLY
CHARGE DIFFERENT RATES.
DIFFERENT INCOME LEVELS.
WE ESTIMATED THAT AN INCREASE
OF TEN BILLION DOLLARS WOULD
REQUIRE PAYROLL TAX RATE OF ZERO
POINT EIGHT PERCENT.
AND THAT IS INCREASE OF TWO
HUNDRED BILLION DOLLARS WOULD
REQUIRE RATE OF ROUGHLY FIFTEEN
PERCENT.
FINALLY AN OPTION THAT WE
INCLUDED.
HAS BEEN MENTIONED BY.
SOME RESEARCHERS.
GROSS RECEIPTS TAX.
A GROSS RECEIPTS TAXES A LITTLE
BIT SIMILAR TO A SALES TAX ITS
ITS ASSESSED ON ALL BUSINESS
SALES ENDING AND INCLUDES GOODS
AND SERVICES.
BUT WHEREAS THE SALES TAX IS
COLLECTED AT THE RETAIL LEVEL
YOU KNOW LIKE AT A STORE.
THE GROSS RECEIPTS TAX IS
COLLECTED AT ALL STAGES OF
PRODUCTION.
AND SO YOU COULD IMAGINE FOR
EXAMPLE.
A CAR MANUFACTURER THAT IS.
SOURCING SEAT BELTS AND BRAKE
PADS AND ALL KINDS OF PARTS IN
ASSEMBLING A CAR THERE THEIR
SOURCING THESE PRODUCTS FROM
OTHER COMPANIES.
AT EACH STAGE OF THAT PROCESS
WHEN THEY PREPARE THE SEAT BELTS
AND OTHER PARTS THE GROSS
RECEIPTS TAX WOULD BE ASSESSED
EVERY SINGLE TIME.
AND THIS CAUSES SOME.
POTENTIALLY NEGATIVE ECONOMIC
EFFECTS BECAUSE IT WOULD PROVIDE
AN INCENTIVE FOR FIRMS.
TO.
STAR INSTEAD TO PRODUCE ALL OF
THOSE MATERIALS THEMSELVES SO AS
TO AVOID THE TAX NEXT
PARTICULARLY A PROBLEM WITH A
LARGER TAX RATE.
WE ESTIMATED THAT A GROSS
RECEIPTS TAX OF ZERO POINT TWO
FIVE PERCENT WOULD BE NECESSARY
TO RAISE THE TEN BILLION
DOLLARS.
BUT IN ORDER TO RAISE TWO
HUNDRED BILLION DOLLARS WE
ESTIMATED THAT WOULD HAVE TO BE
ROUGHLY FIVE PERCENT.
SO IN THE END OF THE.
PRESENTATION HERE WE HAD ON A
NUMBER OF.
CONSIDERATIONS TWO WAY.
.
AS YOU CONSIDER VARIOUS
PROPOSALS.
.
I'M NOT GOING TO COVER EVERYONE
BUT I DID WANT TO MENTION.
NEAR THE BOTTOM OF PAGE
SEVENTEEN HERE.
REVENUE VOLATILITY AND WHICH
HAS BEEN A BIG HOT ISSUE IN THE
STATE BUDGET FOR THE LAST TWENTY
YEARS OR SO.
.
AS YOU PROBABLY KNOW WITH THE
GENERAL FUND OF THE GENERAL FUND
RELYING SO MUCH IN THE PERSONAL
INCOME TAX WHICH IS A HIGHLY
VOLATILE SOURCE.
HAS MADE BUDGETING CHALLENGING
BECAUSE REVENUES CAN CAN KIND OF
BOOM AND BUST.
AND IN THE PAST.
THE STATE HAS COMMITTED TO AN
UNSUSTAINABLE LEVEL OF SPENDING
AND THAT'S.
PART OF THE REASON THAT THE
STATE HAD.
SUCH SIGNIFICANT BUDGET
PROBLEMS IN THE TWO THOUSANDS.
PROPOSITION TWO THAT WERE OF
THAT WAS APPROVED BY VOTERS IN
TWENTY FOURTEEN ESTABLISH A
RAINY DAY FUND.
WITH.
WITH A TARGET OF TEN PERCENT OF
GENERAL FUND TAXES.
AND THE THE POINT OF THE RAINY
DAY FUND WAS TO.
ON THE ONE HAND KEEP SPENDING
LOWER BECAUSE YOU'RE TAKING SOME
OF WHAT COULD OTHERWISE BE SENT
AND YOU'RE PUTTING IN THE
RADIATOR FINE BUT ALSO HAVE
RESOURCES AVAILABLE SO THAT
WHEN.
WHEN THERE'S AN ECONOMIC
DOWNTURN IN THE STATE BUDGET IS
FACING BUDGET PROBLEMS YOU CAN
DRAW ON THAT RAINY DAY FUND TO
TO AVOID SPENDING CUTS AND TAX
INCREASES AND OTHER ACTIONS.
NOW IN THE CONTEXT OF.
OF OTHER HEALTH CARE.
AUGMENTATION.
.
YOU. THE THE VARIOUS OPTIONS
THAT WE MENTION HERE WOULD WOULD
VARY CONSIDERABLY IN TERMS OF
REVENUE VOLATILITY FOR EXAMPLE.
.
A A PERSONAL INCOME TAX US ROUTE
BY RATE INCREASE THAT'S FOLKS
AND HIGH INCOME TAXPAYERS WOULD
BE VERY VOLATILE.
AND AND GENERALLY SPEAKING.
ALL THINGS EQUAL WOULD REQUIRE
A LARGER BUDGET RESERVE.
THAN SAY PROBABLY A PAYROLL TAX
WHICH IS LIKE WE DON WAGES AND
SALARIES WHICH IS A RELATIVELY.
STABLE I INCOME SOURCE.
SO SO THOSE THOSE TWO.
CONSIDERATIONS REALLY SHOULD BE
THOUGHT OF TOGETHER TO THE TO IN
GENERAL TO THE EXTENT THAT THE
THAT A PROPOSAL RELIES ON A MORE
VOLATILE REVENUE SOURCE.
YOU HAVE A GREATER NEED FOR A
BUDGET RESERVE AND THERE IS
REALLY NO ONE RIGHT NUMBER.
FOR WHAT IT TARGET SHOULD BE.
AS THE LEGISLATIVE ANALYST'S
DISCUSSED.
IN THE OVERVIEW OF THE BUDGET
HEARING IT FROM THE ASSEMBLY
BUDGET COMMITTEE.
TO SOME EXTENT IT RISE.
RELY A LOT DEPENDS ON THE SORT
OF RISK TOLERANCE YOU HAVE.
BUT ESPECIALLY IN A PROGRAM OF.
IT IF THE LEGISLATURE CONSIDERS
MAJOR CHANGES TO THE HEALTHCARE
SYSTEM.
.
THIS YOU KNOW STABILITY AND
PROVIDING SERVICES BOB IS
DESIRABLE AND SO LARGER BUDGET
RESERVE WILL HAVE THE
LEGISLATURE REALIZE THAT.
SO THAT CONCLUDES.
MY REMARKS AND.
WHERE MY HABIT ANSWER QUESTIONS
IF YOU HAVE THEM?
THREE QUESTIONS MISCHIEF.
I THINK IT'S CHAIR IT BRIGITTE.
ALL THE PRESENTATIONS TODAY
ARMED. THREE CATEGORIES OF
QUESTIONS AROUND THE IMPACT OF
TRUMP TAX PLAN. UP THROUGH THE
COST OF SOME THE OPTIONS YOU
LAID OUT AND THEN.
SOME OF THE ESTIMATES YOU PAT
AROUND A WATER PUBLICLY FINANCED
SINGLE PAYER SYSTEM MIGHT LOOK
LIKE SPEAKING FIRST AROUND THE
IMPACT OF THE TRUMP TAX PLAN I.
I APPRECIATE THE VARIOUS TAX
OPTIONS THAT YOU HAVE LAID OUT
HERE. UP OBVIOUSLY THESE WERE IN
CONSIDERATION I THINK LAST YEAR
WHEN.
THIS WAS AND AND DISCUSSION IN
THE SENATE. OF BUT SINCE THEN
WE'VE OBVIOUSLY HAD A VERY
SIGNIFICANT.
FEDERAL.
SAID OF CHANGES OF OUR TAX
POLICY AND.
YOU ALLUDED TO SOMEONE ELSE'S
THAT YOU'RE STARTING ARE ON WHAT
IT WOULD TAKE TO BRING BACK SOME
OF THE REVENUES BUT GIVEN THE
SIGNIFICANT CUTS AT THE FEDERAL
LEVEL OF CERTAIN.
TAXES.
IS THE LA O. ARE YOU GUYS
ANALYZING WHAT IT MIGHT TAKE TO
US FOR US TO REVERSE SOME OF
THAT TO BRING IN STATE REVENUES.
ARE IN A WAY THAT MIGHT BE TAX
REVENUE NEUTRAL OR TAX MUTUAL
TO.
AT SOME OF THE CORPORATIONS OR
THE WEALTHY YOUR.
CALIFORNIANS THAT HAVE JUST
SEEN SIGNIFICANT TAX CUTS AND
WHAT DO THOSE NUMBERS LOOK LIKE.
ENSURE WE HAVE NOT PRODUCED ANY
ANALYSIS LIKE THAT.
AS I MENTIONED THE FRANCHISE TAX
BOARD IS CURRENTLY WORKING
THROUGH.
THE MANY PROVISIONS OF THE
FEDERAL TAX BILL ON AND SOME OF
THEM ESPECIALLY ON THE BUSINESS
TAX SIDE ARE QUITE COMPLICATED.
FOR EXAMPLE THERE'S A NEW LOVE
A DEDUCTION OF.
PASSED THROUGH INCOME FROM
BUSINESSES TO INDIVIDUALS AND.
I THINK THERE'S A LOT OF
UNCERTAINTY RIGHT NOW IN TERMS
OF WHAT THAT'S GOING TO MEAN FOR
THE STATE.
.
SO.
IT WE COULD OR IS HE LEN GONNA
LOOK AT THIS HEARD IS THIS
REALLY ENHANCE OF FOR THE
FRANCHISE TAX BOARD AT THIS
POINT.
WELL I I BELIEVE FTP IS PLANNING
TO PRESENTER A PORTS OF THE
LEGISLATURE IN APRIL ABOUT
CONFORMITY ISSUES.
AND THE ADMINISTRATION HAS.
NOTED THAT IT PLANS TO TRY TO
REFLECT THE REVENUE IMPACTS IN
ITS MAY REVISION.
WE'LL OF COURSE SPEECH TRYING
TO ESTIMATE THOSE AFFECTS AS
PART OF OUR FUTURE WILL FUTURE I
REVENUE ESTIMATING EFFORTS.
BUT ULTIMATELY IT'S GOING TO BE
AT LEAST ANOTHER YEAR BEFORE. WE
START TO GET ANY DATA ON THE ONE
HAND.
ABOUT HOW MUCH I INCOME HAS BEEN
SHIFTED FROM YEAR TO YEAR
BECAUSE OF SOME OF THE
INCENTIVES THAT TAXPAYERS SPACE.
BUT MOREOVER IT'S UNDERSTAND
KIND OF THE ONGOING AFFECTS
IT'S REALLY GOING TO TAKE A FEW
YEARS TO GET ENOUGH DATA TO HAVE
A GOOD SENSE OF THAT.
SO I GUESS IN SHORT IT WOULD BE
DIFFICULT TO ESTIMATE.
SOME OF THOSE A FAX.
IN ORDER TO.
TO LOOK AT.
WHAT SORT OF?
OFFSETTING MEASURES THE STATE
COULD TAKE.
AND I WOULD JUST SAY THIS IS FOR
COLLEAGUES I'M CERTAINLY
INTERESTED IN AND TRYING TO
THINK ABOUT HOW OUR STATE COULD.
REVERSE SOME OF WHAT I THINK OF
AS THE.
NOT NOT PARTICULAR HELPFUL
POLICY DECISIONS MADE BY
CONGRESS THAT HER GIVING
SIGNIFICANT TAX BREAKS TO
CORPORATIONS AND AND THE
WEALTHIEST AMERICANS.
EN AND I'D BE VERY INTERESTED
IN THINKING ABOUT WHAT TYPE OF
TAX OPTIONS WOULD HELP TO.
TO TO ADDRESS THAT WHEN YOU ARE
SLASHING CORPORATE TAX RATE OR
IMPACTING SALTS OR.
OR INCREASING QUALIFIED
BUSINESS INCOME OF THESE ALL
SEEM TO ME BE THINGS THAT WE
NEED TO BE LOOKING AT AS A WAY
TO POTENTIALLY FUND. NEW
PROGRAMS THAT WE MAY WANT TO
CONSIDER PARTICULAR IN THE AREA
OF HEALTHCARE.
FROM MY SECOND SET OF QUESTIONS
I WAS. LOOKING AT THE DIFFERENT
OPTIONS THAT.
I THINK THAT THE MISTER.
THE MISTER JOHNSON YOU WERE
PRESENTED AROUND.
HOW WE TARGET VARIOUS STE ON
UNINSURED POPULATIONS AND I BOTH
IN THE UNDOCUMENTED IMMIGRANTS?
CATEGORY AS WELL AS WITH A LOT
WITH WITH ON IT OTHER UNDER AND
UNINSURED CALIFORNIANS DO ANY
COST ESTIMATES ON WHAT THESE
DIFFERENT OPTIONS WOULD. ENTAIL
I'M THAT IS SOMETHING THAT THE
OFFICE IS WORKING ON AND IN
TERMS OF THE.
LET ME GO THROUGH THE
INDIVIDUAL ITEMS THEN TERMS OF
THE EXTENDING MEDICAL COVERAGE.
FULL SCOPE.
TO UNDOCUMENTED IMMIGRANTS WHO
WOULD BE OTHERWISE ELIGIBLE BUT
FOR THEIR UNDOCUMENTED STATUS WE
DO THINK THAT THAT WOULD LIKELY
COST IN THE LOW AND THE SEVERAL
BILLIONS OF DOLLARS THAT WE'RE
STILL WORKING ON REFINING THOSE
ESTIMATES BUT THOSE ARE SORT OF
OUR PRELIMINARY. GENERAL NUMBERS
IN TERMS OF PROVIDE EXTENDING
INSURANCE TO UNDOCUMENTED
IMMIGRANTS THROUGH SUCH A THING
AS A.
AS.
HEALTH INSURANCE SUBSIDY
PERHAPS TO COVERED CALIFORNIA OF
THAT WAS POSSIBLE WELL WE HAVE
SOME PRELIMINARY ESTIMATES THAT
OF THAT AS WELL AND WE THINK
THAT WOULD BE. IN THE LOW
BILLIONS OF DOLLARS.
BUT WE ARE NOT SURE SALES EVER
BILLIONS VERSUS LOW BILLIONS SO
SEVERAL BILLIONS ON THE MEDI CAL
SIGNED FOR THE.
FOR THE UNDOCUMENTED ADULTS WHO.
WHO ARE REALLY BELOW ONE
HUNDRED AND THIRTY EIGHT PERCENT
OF THE FEDERAL POVERTY LEVEL AND
THEN FOR IN FRONT DOCUMENTED
IMMIGRANTS WHO ARE OVER ONE
THIRTY EIGHT BUT?
ABOUT FOUR HUNDRED.
PERCENT OF THE FEDERAL POVERTY
LINE THAT WOULD BE.
THAT THE LOW BILLION TAKE AND I
AND I KNOW YOU CAN HEAR SIZE.
IN MY MIND SEVERAL BILLION LOW
BILLION SOUNDS AROUND THE SAME.
SINCE I WAS ABSOLUTELY HIGHER
ESTIMATE ON THE MEDI CAL SIGNED
IN ON THE THAN ON THE.
COVER ART ON THE HEALTH
INSURANCE SUBSIDY SIDE AND THEN
HOW ABOUT TARGETING OTHER
REMAINING ON A SHARED THOSE WE
ARE LOOKING INTO BUT WE DO NOT
HAVE ANY ESTIMATES THAT WE CAN
CHAT THE SOCKET WHEN YOU EXPECT
HAVE THAT'S.
OR WE ARE GOING TO BE WORKING
ON THEM OVER THE SPRING AND WE
HOPE TO BE ABLE TO.
PROVIDE LEGISLATURE WITH SOME
TECHNICAL ASSISTANCE ON THOSE.
AT THAT AT THAT POINT OKAY AND
THEN MY MY LHASA QUESTIONS HAVE
TO DO WITH SOME OF THE COMMENTS
HE MADE AROUND WHAT A PUBLICLY
FINANCES TIM WOULD WOULD COST
AND. THERE'S BEEN A LOT THAT'S
BEEN MADE OF THE FOUR HUNDRED
BILLION DOLLAR NUMBER AND. AS A
READ ON PAGE EIGHT YOU ESTIMATE
FOR HER BILLION DOLLARS IN TOTAL
COSTS TO RUN A PUBLICLY FINANCED
HEALTH CARE PROGRAM.
NOW WHAT'S INTERESTING TO ME IS
THAT AS.
EXACTLY HOW MUCH
WE USE HAVE SPENT IN TWO
THOUSAND SEVENTEEN TO TWO
THOUSAND EIGHTEEN. ARE ON HEALTH
EXPENDITURES RIGHT SO THAT
NUMBER IS NOT COINCIDENTAL IT'S
IT'S MEANT TO BE THE SAME.
OR DID YOU CALCULATE A
DIFFERENT WE CALCULATED IT QUITE
A BIT DIFFERENTLY.
SO WE WE. WE CHECKED OUR NUMBER
AGAINST EXISTING HEALTH CARE
EXPENDITURES TO SEE IF IT WAS IN
THE BALLPARK OR SOMETHING AROUND
WHAT OUR EXPECTATIONS WOULD BE.
HOWEVER OUR APPROACH WAS REALLY
TO.
LOOK AT HEALTHCARE EXPENDITURES
FROM THE MOST SORT OF ANALOGOUS
PROGRAM THAT WE COULD THINK OF
TO.
THE ONE THAT WE'RE ANALYZING IN
THIS WAS AND SO WE USED MEDI CAL
AS A SORT OF BASE LEVEL.
BASE LEVEL POGRAM BY WHICH WE
COULD.
TEND TO SEE WHAT WHAT WOULD
HAPPEN IF ADDITIONAL PEOPLE
ENROLLED IN MEDICAID OUT AND THE
SORT OF COVERAGE.
YOU KNOW THE POPULATION TIED
THE TYPES OF POPULATIONS THAT
WERE ENROLLED CHANGE THE RATES
CHANGE FROM THE RATES THAT MEDI
CAL PAY TO THE RATES THAT
MEDICARE PAY.
TO CHANGE THEM TO TO CHANGE THE
ASSUMPTIONS TO A MORE.
BROADER SET OF COVERED BENEFITS.
AND SO ON AND SO WE REALLY
CONSTRUCTED IT FROM THE GROUND
UP USING SORT OF MEDI CAL PER
CAPITA EXPENDITURES THAT COMES
WITH ITS OWN CAVEATS WHICH I'M
HAPPY TO GO INTO.
AND THEN BUILT THAT ESTIMATE
FROM THE GROUND UP BILL TO
SEPARATE ESTIMATE IN TERMS OF
WATER THE ADMINISTRATIVE
EXPENDITURES OF OF MEDI CAL AS
WELL AS OTHER SO AS MEDICARE AND
OTHER SORT OF STATE
ADMINISTERED.
HEALTHCARE SYSTEMS AND SO.
BY AND LARGE WE JUST ABOUT A
WEEK CAME AT IT FROM A DIFFERENT
DIRECTION BUT SETTLED ON A
SIMILAR NUMBER TWO EXISTING
HEALTHCARE EXPENDITURES IN THE
STATE. OKAY WELL THAT ON IT DO
YOU HAVE MORE DATA ON AND IF
THERE IS A WAY TO TAKE
THAT FOUR HUNDRED BILLION AND
SET UP A PUBLICLY FINANCED
ESTIMATE OBVIOUSLY THERE ARE A
LOT OF.
CHALLENGES WITH THAT BUT IF
THERE'S A WAY TO DO IT IT WOULD
NOT COST US ANY MORE THAN WHAT
WORK CURRENTLY SPENDING TODAY
RIGHT.
IT IS NOT A TO THE THAT ADDED
REVENUE THAT IS NEEDED.
IS NOT ON TOP OF THE ADDITIONAL
HEALTHCARE SPENDING IN THE
ECONOMY SO LARGELY WHAT IT WOULD
BE.
ENACTING SUCH A PUBLICLY
FINANCED PROGRAM WOULD INVOLVED
TRANSFERRING EXISTING PRIVATE
HEALTHCARE SPENDING AYE INTO OF
PUBLICLY FINANCED.
STATE RUN SYSTEM CONSUMMATE
SURE HAVE THEIR CLEAR AND THEN.
THE OTHER THING I WAS CURIOUS
ABOUT THE FACT THAT THE NUMBERS
WERE THE SAME.
AGAIN MAYBE COINCIDENTLY THE.
IS.
THERE DON'T SEEM TO BE ANY
SAVINGS
FROM WHAT ONE WOULD THINK WOULD
BE THE. THEY STREAMLINED
ADMINISTRATIVE.
OF NATURE OF A PUBLICLY FINANCE
SYSTEM RATHER THAN HAVING
MULTIPLE.
PAYERS.
AND AND THE COMPLEXITY OF THE
PUBLIC HEALTH SYSTEM OR THE
HEALTH CARE SYSTEM WE HAVE TODAY
IT WOULD JUST BE ONE PAIR. OF
BUT THERE DON'T SEEM TO BE ANY
SAVINGS FROM THAT DID YOU ASSUME
THAT IN YOUR MOM ó WE ASSUMED.
WE ASSUMED.
OR WE CREATED SEPARATE SORT OF
ESTIMATES OF THE ADMINISTRATIVE
COSTS OF SUCH A PROGRAM AND I I
THINK THIS WOULD BE.
THAT ESTIMATE WOULD BE LESS
THAN IN THE EXISTING MULTI PAYER
SYSTEM UP FOR EXAMPLE TO THE
TUNE.
WHAT BECAUSE WE OFTEN HEAR THAT
ADMINISTRATIVE COSTS?
PARTS OF THE SYSTEM OR TWENTY TO
THIRTY PERCENT BUT.
WE'RE NOT SEEN THOSE SAVINGS
UNRESTORED TO HEAR IT FOR OUR
ESTIMATE WE ASSUME TOTAL
ADMINISTRATIVE EXPENDITURES
WOULD BE LESS THAN TEN PERCENT
SO.
WE DID I WE WE MODELED SOME
SAVINGS ON THE ADMINISTRATIVE
SIDE IF YOU INCLUDE THE SAVING
SAY THAT.
IN THE EXISTING HEALTHCARE
SYSTEM THAT IS REALLY
DISTRIBUTED ACROSS SAY THE STATE
ADMINISTRATING.
ADMINISTRATING ENTITIES SUCH AS
AN MEDI CAL AND THE
ADMINISTRATIVE ACTIVITIES THAT
ARE OCCURRING.
IN THAT COMMERCIAL HEALTH
INSURANCE PLANS AND SO FORTH.
SO IN OTHER WORDS SAY YOU'RE
SEEN SOME ADMINISTRATIVE SAVINGS
DUE TO THE STREAMLINING BUT
YOU'RE ASSUMING THAT IN A PUBLIC
FINANCE SYSTEM MORE PEOPLE WOULD
BE COVERED. IS THAT HOW IT ALL
BALANCES OUT MOVIE GET MORE
INDIVIDUALS WOULD BE WOULD BE
COVERED THERE BE A MORE
COMPREHENSIVE SET OF BENEFITS.
THAT ARE COVERED THROUGH THE
INSURANCE SYSTEM AND THEN I I AN
ADDITIONAL.
AND THEN AND AND THAT LACK OF
SAY ANY COST SHARING AS IS IN
THE EXISTING HEALTH CARE SYSTEM
RIGHT AYE IT'S A SORT OF
TRANSFER FROM. THE COPAYS AND
DEDUCTIBLES THAT WE PAY AS
INDIVIDUALS WHO ARE UTILIZING
THE SYSTEM AN INSTEAD WE WOULD
NEED THAT FUNDING TO BE IN THE
FORM OF TAX REVENUES WHICH HELPS
TO.
AYE WHICH INCREASES THE AMOUNT
OF REVENUES THAT WOULD BE NEEDED
TO FUND THE PROGRAM.
OKAY SOME I LOVE TO SEE THE
UNDERLYING ASSUMPTIONS.
WHAT YOU USED TO GET TO THAT
FORMER BILLION DOLLAR NUMBER
IT'S IT IS AMAZINGLY
COINCIDENTAL THAT IT IS SO
EXACTLY WHAT WE SPEND TODAY SO?
ON PAT AND I KNOW YOU'RE
BASICALLY SENATE WAS COMPLETELY
COINCIDENTAL BUT.
JUST LOVE LOVE TO SEE THAT AND
THEN A FINAL QUESTION I KNOW
THERE'S BEEN A LOT OF.
BACK AND FORTH ABOUT THE
ASSUMPTIONS OF WATER BUT. A
PUBLICLY FINANCED HEALTHCARE
SYSTEM WOULD WOULD COST AND THE
SO CALLED POLLEN STUDY THAT WAS
OUT THERE THAT SUGGESTS THAT.
THESE NUMBERS ARE ARE TENS OF
BILLIONS OF DOLLARS LAST YEAR
ANY COMMENT ON. THAT PARTICULAR
STUDY AND.
ANY ANALYSIS OF HOW YOUR
ASSUMPTIONS DIFFER FROM THAT
STUDY.
YEAH AND AND JUST IN THAT WE WE
WE DID WORK WITH THAT DOCTOR
POLLAND A LITTLE BIT AND AND
COMING UP WITH OUR ESTIMATE AND
WE'RE HAPPY TO SHARE MANY OF THE
ASSUMPTIONS THAT WE ARE USING IN
OUR ESTIMATE OF WHAT DOES. THIS
PUBLICLY FINANCED HEALTH CARE
PROGRAM WOULD COST AND THERE
WERE A COUPLE SORT OF THINGS AND
LATER WELL AREAS WHERE WE DIDN'T
AGREE. ON THE SAY ON THE COST
SIDE THE.
PERRY ANALYSIS TO THE POLLEN
ANALYSIS ASSUMED A SET OF
SAVINGS AS A RESULT OF.
DECREASED UTILIZATION OF SAY
UNNECESSARY MA MEDICAL SERVICES
OF REDUCED FRAUD AND SO FORTH
THAT WE DIDN'T NECESSARILY.
SEE AS BEING AS BEING A SORT OF
NECESSARY OUTCOME FROM THE
LEGISLATION THAT WE WERE
ANALYZING SO THERE WAS A
DIFFERENCE BETWEEN US AND AND
THE POLLEN ANALYSIS THERE IS
ALSO A DIFFERENCE ON.
THE REVENUES AVAILABLE SIDE.
WHEREAS THE POLLEN ANALYSIS
ASSUMES THAT THE STATE COULD USE
OF THE AS THE TAX BENEFIT DUE TO
THE EXCLUSION OF EMPLOYER
SPONSORED INSURANCE TO FUND THE
PROGRAM WE DIDN'T IDENTIFY AWAY
THAT THE STATE COULD ACTUALLY.
OBTAIN THAT FUNDING AND USE IT
TO FUND THE PROGRAM AND SO THERE
WERE DIFFERENCES BOTH ON THE
TOTAL COST SIDE AND ON THE
AMOUNT OF AVAILABLE FUNDING SIDE
THAT NETTED OUT TO A DIFFERENCE.
IN TERMS OF HOW MUCH ADDITIONAL
FUNDING WE THOUGHT WOULD BE
NEEDED.
GREAT THANK YOU APPRECIATE THAT
AND AND AGAIN I'D LOVE TO SEE
THE INFORMATION WHEN YOU HAVE
IT.
THANKS.
UP THANK YOU THANK YOU VERY MUCH
FOR THE INFORMATION WELL IF THE
LEGISLATURE DECIDED
TO PUT A MEASURE BEFORE THE
VOTERS IT IT COULD GO RELATIVELY
QUICKLY I MEAN I KNOW YOU'RE
AWARE THAT THE LEGISLATURE HAS.
CAN SPEED UP THE PROCESS CAN
MAKE IT HAPPEN WITHIN A MATTER
OF MONTHS.
IF IT WERE UP TO.
ORGANIZATIONS OUTSIDE OF THE
LEGISLATURE TO PUT A MEASURE ON
THE BALLOT. THEN YOU'RE TALKING
PROBABLY AT LEAST A YEAR
SIGNATURE GATHERING. YOU KNOW
GATHERING UP THE MONEY NOT OF IT
IS CHEAP MILLIONS OF DOLLARS TO
GATHER SIGNATURES MILLIONS OF
DOLLARS POTENTIAL DEFIED A
BALLOT. A CAMPAIGN.
SO I AT A MINIMUM A YEAR.
YOU ALSO SAID IT.
YOUR ANNOUNCES THAT IT PRIME
MAKES MORE SENSE TO GO TO THE
VOTERS RATHER THAN RELY ON THE
LEGISLATURE TO APPROVE SOME OF
THESE POTENTIAL CHANGES LIKE.
THE UP TO PROP NINETY EIGHT OR
THE GANG LIMIT.
WITH THAT BIGGER PICTURE.
.
WITH THE ORIGINAL POLICY GOALS
OF THESE INITIATIVE SAY ABOUT
THE APPROPRIATE ROLES OF VOTERS
VERSUS.
THE LEGISLATURE.
SAY THAT CAN CAN YOU REPEAT THE
LAST PART OF QUESTION.
WHAT TO THE ORIGINAL POLICY
GOALS OF THOSE INITIATIVES?
SAY ABOUT THE APPROPRIATE ROLES
OF FOR VOTERS VERSUS THE AND
LEGISLATURE.
WELL IT'S HARD IT THAT'S A
TOUGH ONE TO ANSWER BECAUSE.
WE HAVE A PROCESS IN CALIFORNIA
THAT MAKES THE CONSTITUTION
RELATIVELY EASY.
TO AMEND SO ON THAT. WHEN THE
VOTERS AMEND THE CONSTITUTION.
THEY MAY THINK THAT THEY'RE
VOTING FOR ON AN ISSUE FOR THE
VERY LAST TIME.
BUT OUR PROCESS BY DEFINITION.
IS OPEN TO CHANGE AND YOU KNOW
SOME PEOPLE WOULD ARGUE PERHAPS
WE SHOULD NOT BE LIVING WITH THE
STATE APPROPRIATIONS LIMIT
THAT'S BASED ON. YOU KNOW.
SPENDING WHEN I WAS BACK IN THAT
JUNIOR HIGH OR SOMETHING SO YOU
KNOW WE'RE GOING FORTY YEARS
BACK IN TIME OR SELL DO WE
REALLY WANT TO TIE OURSELVES UP
IN KNOTS SO.
I THINK THERE'S ALWAYS A
PRESUMPTION THAT EITHER THE
LEGISLATURE OR THE VOTERS
THEMSELVES. CAN GO BACK TO THE
BALLOT AND RE VISIT DECISIONS
THAT WERE MADE IN PRIOR YEARS
NONE OF THIS IS WRITTEN IN
STONE.
IT SIMPLY REQUIRES FIFTY
PERCENT PLUS ONE TO AMEND OUR
CONSTITUTION OUT WHICH IS WHY IT
HAPPEN SO FREQUENTLY.
IS IT BECAUSE THAT HELP FORGET
THAT'S THAT'S OKAY VERY HOPEFUL
SO HONORED FOR OUR FOLKS EMILIO.
DO YOU HAVE AN ESTIMATE OF OF
WHAT CURRENT EMPLOYER PAYMENTS
FOR HEALTH INSURANCE ARE AS A.
AS A PERCENTAGE OR FRACTIONAL
PAYROLL.
AS A.
PERCENTAGE OF PAYROLL.
WELL I SORT OF MEDIAN ESTIMATE
OF EMPLOYER SPONSORED PREMIUM SO
SHARE BOTH BY EMPLOYERS AND
EMPLOYEES IS. ABOUT A HUNDRED
AND THIRTY BILLION DOLLARS.
WE ESTIMATE TOTAL WAGES AND
SALARIES IN THE STATE TO BE
ABOUT ONE POINT THREE TRILLION
DOLLARS SO IT'S ABOUT. TEN
PERCENT OF.
WAGES AND SALARIES THAT IS PAID
ON.
ENSURE EMPLOYER SPONSORED
BENEFITS AS A WHOLE INDIA HERE
YOU GREATLY SAID THAT.
SOME OF THE EMPLOYER BENEFITS
TAX BENEFITS FOR PROVIDING
INSURANCE.
THERE'S THERE'S NO WAY FOR US TO
REALLY RECAPTURE THAT FROM THE
FEDERAL GOVERNMENT I GUESS. WE
DIDN'T IDENTIFY NECESSARILY AWAY
TO BE A TO BE ABLE TO REALLY
CAPTURE THAT. AS REVENUES TO BE
ABLE TO FINANCE THE PROGRAM.
IT'S IT POTENTIALLY DEPENDING
ON AYE AYE MY COLLEAGUE RYAN
MILLER COULD TOUCH AND MORE IT
POTENTIALLY COULD BE SORT OF
IMPLICIT AND.
IN IN DIFFERENT WAYS THAT WE
FUND THE PROGRAM GOING FORWARD
I'M I DON'T KNOW IF YOU WANT
TOUCH ON THE PAPER.
THOSE TAXES.
.
WELL IT'S CERTAINLY A
CONSIDERATION BECAUSE AS I
MENTIONED.
WITH THE SALES TAX PROCLAIMS
PROPERTY TAX.
OVER THE NEW FEDERAL LAW HAS A
TEN THOUSAND LIKE CAPS OF FOR
MANY TAXPAYERS.
THERE WOULDN'T BE SORT OF A
FEDERAL OFFSET TO THE TAX
INCREASE HERE.
I BELIEVE HOWEVER THAT.
EMPLOYER.
PAYROLL TAX PAYMENTS.
CONTINUE TO BE DEDUCTIBLE ON
THE FEDERAL LEVEL HOWEVER AND SO
IF IF THE LEGISLATURE PURSUED
THAT OPTION.
THERE WOULD BE A SOURCE OF
FEDERAL TAX BENEFIT.
BUT IN TERMS OF THE STATE BEING
ABLE TO COLLECT LIKE REVENUE
THAT IS.
I AT REDUCED REVENUE FROM THE
FEDERAL GOVERNMENT I THINK
THAT'S WHAT MY COLLEAGUE WAS
SAYING WHERE WE DON'T REALLY
KNOW HOW THAT WOULD.
THAT THE FEDERAL GOVERNMENT
COULD DECIDE TO BLOCK GRANTED
BUT WE DIDN'T FEEL THAT THAT WAS
AN ASSUMPTION THAT WE COULD MAKE
IN ESTIMATING THE COST OF THE
PROGRAM.
WELL THANK YOU VERY MUCH ALL
THREE OF YOU REALLY APPRECIATE
CRESCENTA.
EXPERIMENTS.
AT THIS POINT WE'D LIKE TO GO
AHEAD AND MOVE TO PUBLIC
COMMENT.
LIKE TO. ASK THAT YOU LIMIT
YOUR COMMENTS TO TWO MINUTES
PIECE AND.
WE HAVE TWO MICROPHONES SET UP
SO.
PLEASE WHOEVER.
I THINK YOU WERE I THINK YOUR
FIRST OVER HERE.
PLEASE.
HI MY NAME IS KEITH MCALLEN I'M
WITH PHYSICIANS FOR A NATIONAL
HEALTH PROGRAM HEALTHY
CALIFORNIA CAMPAIGN HEALTH CARE
FOR ALL. I'M GONNA SAY THIS
QUICKLY BECAUSE I HAVE TO GET MY
DAUGHTER TO BASKETBALL PRACTICE
ENOUGH I DON'T UP I'M GONNA NEED
HEALTH CARE WHICH I CAN AFFORD.
THE LAW PROFESSOR FROM MISSOURI.
STATED.
A COUPLE OF TIMES THAT THE
DETAILS THAT NOBODY KNOWS BUT
THEY LEARN QUICKLY WHEN THEY
HAVE TO I KEPT WAITING THE WHOLE
TIME FOR HER TALK TO GIVE THE
DETAILS OF WHAT OF. PRECISELY
WHAT THAT IS HERE'S WHAT SHE WAS
TALKING ABOUT EMPLOYEE SPONSORED
PROGRAMS THAT ARE SELF FUNDED
HAVE NO RECOURSE IN THE COURTS
WHEN RIGHT FULL BENEFITS ARE
DENIED BY GATEKEEPERS SO SAID
THE SUPREME COURT. SO WHAT DOES
THAT MEAN SOMEONE GOES INTO THE
E. ARE THEY HAVE A LITTLE BITTY
BRAIN BLEED THEY NEED AN MRI
DENIED VIBES REFLEXIVELY.
A THE PERSON THEN DIES.
SO WHAT ARE THEY HAVE A RIGHT TO
AT THAT POINT WHAT THEY HAVE A
RIGHT TO IT THAT. IS THE COST OF
THE MRI THAT WAS DENIED.
SO REGARDING THAT POINT.
THREE THINGS PLEASE.
INSURANCE COMPANIES ARE GAMING
THE SYSTEM DENY DENY DENY FOR
DOLLARS.
A.
PLEASE KEEP THIS IN MIND WHEN
THE EARNEST UNDERWRITERS STAND
BEFORE YOU AND TELL YOU THAT
THEY'RE A BEAUTIFUL PART OF THE
COMMUNITY.
.
THIS ALSO GOES BACK TO WHAT BILL
CLINTON SAID IN TWENTY SIXTEEN
WITH HIS GAFFE OF IT'S THE
CRAZIEST THING. WE MAKE THE
ASSUMPTION HERE THAT EVERYONE
THAT HAS EMPLOYEE BASED
INSURANCE IS DOING JUST FINE CAN
WE WE CAN'T TOUCH THAT. IT'S NOT
TRUE.
IT ALSO GOES TO WHAT ASSEMBLY
MEMBER FRIEDMAN SAID.
YEAH BACK IN LOS ANGELES.
THAT.
WHAT IF THE ANTS ARE IS THAT WE
CALIFORNIA HAVE TO GET IT THE
FIGHT WITH THE FEDERAL
GOVERNMENT TO GET ANYTHING DONE
SHE'S RIGHT SHE'S RIGHT SHE'S
RIGHT? THANK YOU.
OUR I'M HENRY ABRAMS I'M A
PHYSICIAN.
WITH PHYSICIANS FOR A NATIONAL
HEALTH PROGRAM.
A COUPLE POINTS AND ONE IS THAT
THE WORD COVERAGE HAS BEEN USED
A LOT BUT.
BY I THINK THAT IT WAS ASSEMBLY
MEMBER ARE WALDRON WHOM MADE THE
POINT. THAT WE ARE REALLY
TALKINGABOUT ACCESS AND I THINK
THAT WHEN WE TALK ABOUT COVERAGE
THAT IS NOT IN ANY WAY. A CLOSE
TO THE INDIVIDUAL WHO'S COVERED
RECEIVING. A TIMELY APPROPRIATE
HIGH QUALITY IS COMPREHENSIVE
AND AFFORDABLE CARE I THINK ALL
OF THOSE THINGS NEED TO BE KEPT
IN THE FOREFRONT. AND THEY'RE
ALL INTERLINKED AND THAT'S WHY
PHYSICIANS FOR A NATIONAL HEALTH
PROGRAM ARE STRONG ADVOCATES FOR
A SINGLE PAYER PROGRAM BECAUSE
THAT IS THE POLICY. THAT LINKS
THOSE ESSENTIAL ELEMENTS WITHOUT
WHICH WE DON'T REALLY. PRODUCE
MEANINGFUL REFORM.
THE SECOND THING IS THAT I THINK
WHEN DOCTOR POLLAND HAS AN
OPPORTUNITY TO TESTIFY ON
WEDNESDAY. ON MY HOPE THE
COMMITTEE MEMBERS WILL KEEP AN
OPEN MIND. ABOUT.
WHAT I CONSIDER TO BE SOME GAPS
IN THE LA JOH ANALYSIS WHEN ONE
ELIMINATES PROFIT SEEKING
COMMERCIAL?
INVESTOR OWNED HEALTH INSURANCE
AND AND HEALTH CARE PROVIDERS.
AND CAPTURES THE MAXIMUM SAVINGS
FROM COORDINATED.
.
DASH SIMPLIFIED CARE MY I THINK
THAT THE COST OF THE PROGRAM
WILL COME DOWN A LOT FROM THE
FOUR HUNDRED BILLION DOLLARS.
AND THE THIRD THING IS THAT I
HOPE THE COMMITTEE BUT HASN'T
GOTTEN LOST IN THE ENORMOUS
WEEDS AND DETAILS THAT THEY'VE
HEARD.
THAT SEEM TO BE OBSTACLES.
IN THE FOR GROUND.
TO GETTING TO UNIVERSAL COVERAGE
BUT KEEP YOUR EYES ON THE PRIZE
THE PRIZE IS UNIVERSAL COVERAGE.
ONLY A PUBLICLY FINANCED
PUBLICLY ADMINISTERED NONPROFIT
HEALTH CARE PROGRAM.
I CAN ACHIEVE THAT AND I I
REALLY.
FEAR THAT THE THE COMMITTEE
WILL GET BOGGED DOWN. AND.
SHE AS AN OBSTACLE.
THAT WE HAVE A DYSFUNCTIONAL
BROKEN HEALTHCARE SYSTEM AND SO
IT'S NO SURPRISE THAT WE HAVE A
DYSFUNCTIONAL AND BROKEN LEGAL
AND ADMINISTRATIVE SYSTEM. THAT.
PREVENTION US FROM GETTING
ACCESS TO THE MONEY THAT THE
FEDERAL GOVERNMENT IS CUSTODIAN
FOR BUT IT'S OUR MONEY AND
CALIFORNIA NEEDS TO CLAIM IT.
THOUGH I'M JEFF CARTAGIA.
ADVOCATES. OF.
CAR.
DOG FIGHT.
OTHER REPRESENTATIONS
TWO CHAIRMAN WOULD I WILL SAY.
ABSTAINING IS NOT A NEUTRAL
VOTE.
BUT FOR A YEAR YOU GUYS HAVE
BEEN PUSHING.
AND WHERE IS SINGLE PAYER
IT'S BEEN AROUND HERE A LONG
TIME BEING ASKED OR WHICH.
YOU PRESENTED EVERYTHING.
DOESN'T HAVE TO DO WITH HOW IN
THE WORLD KEN'S SINGLE PAYER.
WORK.
I HOPE WEDNESDAY'S WILL BE
BETTER AND BE MORE ON POINT
ABOUT HOW THE SINGLE PAYER
BECAUSE OUR CURRENT MEDICAL
SYSTEM.
HE NOT DOING ITS JOB.
I THINK YOU AYE I'M BRIAN STOMP
OF FROM THE BOTTLE.
CALIFORNIA I'M RETIRED SMALL
BUSINESS.
OWNER.
I'VE ATTENDED THREE IF YOU'RE
HEARINGS AND THE I THINK YOU'RE
DOING A GOOD JOB ASSESSING THE
THE NEED. FOR A SINGLE PAYER
SYSTEM. AND.
THE COMPLEXITY OF GETTING THERE.
SOME PEOPLE HAVE SUGGESTED THAT
THIS IS A WAY TO PARK THIS THING
GET NOTHING DONE.
I'M COMING AROUND TO THE
THOUGHT THAT.
PERHAPS.
YOU PEOPLE ARE.
EXPOSING A LOT OF THE PROBLEMS
AND SOME OF THE SOLUTIONS. AND
ARE GIVING THIS.
A FAIR HEARING BUT OF COURSE
THE NEXT STEP IS TO GET OUT OUT
THERE AND DO SOMETHING WITH IT.
UNITED STATES IS SPENDING OVER
SEVENTEEN PERCENT OF US GDP. ON
HEALTH CARE AMOUNTING TO NINETY
FIVE HUNDRED DOLLARS A PERSON
THAT'S OVER THREE TRILLION
DOLLARS THAT WE SPEND ON. OTHER
HEALTHCARE IN THIS COUNTRY.
IF WE HAD THE FIFTY FIVE
HUNDRED DOLLAR PER PERSON
WITH A SINGLE PAYER SYSTEM AND
WE SAVED THE FOUR THOUSAND
DOLLARS PER PERSON.
WE WOULD HAVE A SAVED A MILLION
AND A ONE I'M STORY. A ONE AND A
QUARTER TRILLION DOLLARS A YEAR
ONE A QUARTER TRILLION DOLLARS A
YEAR. WE ONLY SPENT THREE AND A
HALF PERCENT OF OUR GDP.
ON DEFENSE.
AND WE SPEND MORE THAN THE NEXT
SEVEN COUNTRIES IN THE WORLD. ON
DEFENSE
SO THIS IS A HUGE PROBLEM IN
YOU.
INDIVIDUALS ARE IN CALIFORNIA
ARE DOING A VERY IMPORTANT A
JOB.
NOT ONLY IN REDUCING OUR
OUTLANDISH HEALTH CARE COSTS.
BUT IN PROVIDING A BETTER
HEALTH.
AND I HOPE BECAUSE THESE
POSITIONS OF MENTION. I THAT YOU
NEVER CONFUSE INSURANCE.
WITH HEALTH CARE INSURANCE IS
NOT HEALTH CARE INSURANCE IS A
WAY TO MAKE MONEY.
IT'S A GOOD WAY TO MAKE MONEY IF
A PERSON CAN'T AFFORD THE RISK
THE NEED INSURANCE.
CALIFORNIA CAN AFFORD THE RISK.
THANK YOU AND I HOPE THAT.
WERE SUCCESSFUL IN GETTING
SINGLE PAYER.
MONDALE FOUNTAIN WITH ENACT
UNIVERSAL HEALTH CARE FOR
CALIFORNIA.
THANKS AGAIN FOR THESE HEARINGS.
AND I'VE FIRST OFF I JUST WANT
TO CONGRATULATE THE ASSEMBLY ON
PASSING THE WHISTLEBLOWER
PROTECTIONS I'M BELIEVE THAT'S
WHAT I SAW ON THE FLOOR.
NEVIS ALMOST UNANIMOUS.
IT WAS.
I THINK THAT'S AMAZING WHEN
EVERYBODY CAN COME TOGETHER.
TO.
TO PASADENA PROTECTS PEOPLE.
LIKE THE WAY YOU GUYS DID.
I THINK THAT'S KIND OF
ANALOGOUS TO WE'RE TRYING TO DO
HERE.
ALSO.
ALTHOUGH SHE ISN'T IN THE ROOM.
ASSEMBLY MEMBER FRIEDMAN.
SHE'S HELPED OUT A LOT AND I
KNOW THAT.
SHE PUSHED.
TO GET THE CONSTITUTIONAL.
ISSUES OF RAISED.
AND.
THANK YOU DOCTOR WOULDN'T AND
WELL DOCTOR RANDALL IS NOT HERE
RIGHT NOW.
BUT.
THANKS ALL OF YOU AND I WILL
SEE YOU ON WEDNESDAY.
HELLO CRISCO IN FROM THE
CALIFORNIA IMMIGRANT POLICY
CENTER WE ARE A STATEWIDE
IMMIGRANT RIGHTS ORGANIZATION
THAT ADVANCES AND SUPPORTS AYE
IMMIGRATION HEALTH POLICIES.
JUST WANTED TO THANK THE
COMMITTEE ARE FOR HOLDING THAT
TODAY'S HEARING ON
IMPLEMENTATION OF CHALLENGES AS
IT RELATES TO UNIVERSAL COVERAGE
OUR CONSIDERATIONS.
AND JUST WANTED TO REITERATE
THE IMPORTANCE OF SOME OF OUR
WHAT THE LA A DISCUSSES IT
RELATES TO THE.
COVERING THE UNINSURED
POPULATION I'M I KNOW MY
COLLEAGUE WILL SPEAK MORE TO
THIS AYE ON WEDNESDAY BUT JUST
WANT TO REITERATE.
SOME OF THE ONE OF THE POINTS
THAT FIFTY PERCENT OF THOSE WHO
REMAIN ON THE SHIRT IN THE STATE
ARE UNDOCUMENTED AND SO.
WE DO LOOK FORWARD TO.
SPEAKING ABOUT WAYS IN AND ONE
OF THEM BEING THE HEALTH FOR OUR
PROPOSAL.
THAT WOULD EXPAND ACCESS TO
FULL SCOPE MEDICAL TO THE
UNDOCUMENTED POPULATION IN
DISCUSSING HOW THAT CAN BE ONE
OF THE WAYS IN WHICH WE LOWER
THE UNINSURED RATE HERE IN THE
STATE OF CALIFORNIA. THANK YOU
VERY MUCH.
HAVE THEIR EYES STEPHANIE BERGER
PRESIDENT OF THE CALIFORNIA
ASSOCIATION OF HEALTH
UNDERWRITERS ARE TWENTY FIVE
HUNDRED MEMBERS ARE EXTREMELY
PROUD OF THE WORK AS LEADING IN
ROLLERS IN COVERED CALIFORNIA.
COUPLED WITH THEIR ENROLLMENTS
IN MEDICARE MEDICAL AND OTHER
PROGRAMS OUR MEMBERS ARE
ENSURING CALIFORNIA CONTINUES TO
LEAD WITH THE MOST SUCCESSFUL
EXCHANGE IN THE NATION.
WE KNOW THAT THERE'S A LOT MORE
HARD WORK AHEAD OF US.
WE REMAIN COMMITTED TO
PARTNERING WITH THIS COMMITTEE
AND ALL STAKEHOLDERS TO ENSURE
THAT THE REMAINING SIX POINT
EIGHT PERCENT OF CALIFORNIANS
THAT HAVE NOT YET BEEN SHIRT
ACHIEVE THE RIGHT TO CHOICE AND
QUALITY HEALTHCARE. THINK YOU.
GOOD EVENING MISTER CHAIR
NUMBERS TAM LA WITH HEALTHAXIS
CALIFORNIA IS ONE OF THANK YOU
FOR HOLDING AND THIS HEARING
TODAY AND IT.
OF THEM WONDERFUL PRESENTERS
HAVE GIVEN US A LOT OF OF REALLY
GOOD INFORMATION AND FOOD FOR
THOUGHT ABOUT LOVE THE
SIGNIFICANT CHALLENGES THAT.
THIS LEGISLATURE.
AND POLICY MAKERS NEED TO
GRAPPLE WITH AS WE LOOK FOR A
PATH TOWARD A UNIVERSAL COVERAGE
AND PARTICULARLY THE OF THE
FEDERAL HURDLES THAT EXISTS
WITH.
BOTH LIKE FEDERAL FINANCING AND
FEDERAL LAWS AND WAIVERS.
I THINK.
IT'LL LAST WEEK ON THE THIRTY
FIRST UNCOVERED CALIFORNIA
CLOSED ITS OPEN WORLD AND OPEN A
ROAD PERIOD AND WE SAW A LOT
MORE PEOPLE SIGNED UP FOR
COVERAGE.
AND WHAT THIS IS REALLY GREAT
NEWS.
PARTICULARLY.
GIVEN ALL OF THE CONFUSION THAT
HAS BEEN SOWED OVER THE LAST
YEAR AT THE FEDERAL LEVEL ABOUT
THE.
.
OF AFFORDABLE CARE ACT AND IT'S
A VERY EXISTENCE.
WE AT HEALTH ACCESS HAVE A LOT
OF IDEAS ON HOW CALIFORNIA CAN'T
GET UNIVERSAL COVERAGE AND WE
LOOK FORWARD TO SHARING THOSE
WITH THE COMMITTEE ON WEDNESDAY
THANK YOU.
AYMERIC LEAN XIN ON THE CO
DIRECTOROF THE BUSINESS
ALLIANCE FOR HEALTHY CALIFORNIA
A BUSINESS ORGANIZATION OF THREE
HUNDRED MEMBERS AND GROWING.
THAT SUPPORTS THE SINGLE PAYER
SOLUTION. WHAT STRIKES ME IS THE
FACT THAT?
WE'RE TALKING ABOUT.
THE MONEY ALREADY BEING IN THE
SYSTEM
YOU FORGETTING IT OBEYED ABOUT
WHICH THE COSTS AND SINGLE PAYER
LET'S JUST SAY YOU HAVE FOUR
HUNDRED BILLION DOLLARS HERE
YOUR FOUR HUNDRED BILLION
DOLLARS THERE WITH A MUCH BETTER
SYSTEM. IN PLACE THE MONEY'S
THERE SO WE SHOULD BE CREATIVE
ENOUGH TO FIGURE OUT HOW TO GET
IT INTO THE RIGHT PLACE.
FOR ME AS A BUSINESS PERSON.
HEALTHCARE HEALTH INSURANCE
IS TAX
OKAY WE EVER THINK ABOUT THAT
ASPECT I KNOW SEMANTICALLY AND
IN WEBSTER'S DICTIONARY IT WON'T
BE THAT WAY. BUT IN REALITY WHAT
COMES OUT OF MY POCKET TO PAY
FOR EMPLOYEES IS A TAX.
I SAME TIME NOT ONLY GOT TO
SPEND THE MONEY BUT I HAVE TO
SPEND ALL THE TIME WORRYING
ABOUT GETTING IT FOR MY
EMPLOYEES.
IT SEEMS LIKE WE REALLY NEED A
SIMPLIFICATION IN THE SYSTEM AND
BY THE WAY I THINK WE ALL SAW
THE HEADLINES LAST WEEK ABOUT
THE NEW FORMATION OF A COMPANY.
A NONPROFIT COMPANY.
BY JEFF BEZOS WARREN BUFFETT AND
JAMIE DIMON.
BECAUSE OF THE FRUSTRATION LEVEL
WITH OUR SYSTEM THAT'S BROKEN.
I THINK BUSINESS
WILL COME AROUND UNDERSTANDING
THAT THEY'RE GOING TO PAY
SOMETHING FOR HEALTH CARE
WHETHER IT'S A PAYROLL TAX WORK
OR HEALTH INSURANCE.
WE GOT A LOOK AT WHAT'S
REASONABLE AND WHAT WAS GONNA
REALLY COST.
WHO'S GOING TO BENEFIT AND THINK
ABOUT THE FUTURE.
BECAUSE I BELIEVE UNDER SINGLE
PAYER SYSTEM WILL BEER CONTAIN
COSTS A LOT BETTER THEIR
SKYROCKETING LOOK AT PROBLEM
WE'RE HAVING WITH PENSION FUNDS
NOW.
PART BECAUSE OF RISING HEALTH
INSURANCE COSTS THANK YOU.
I MY NAME IS DON BACKROOM FROM
SINGLE PAYER NOW. LA I QUESTION
THE LA OWES ASSUMPTION OF TEN
PERCENT OVERHEAD TO RUN THE
SYSTEM. MEDICARE DOESN'T
NATIONALLY FOR TWO TO THREE
PERCENT MEDICAID DOESN'T FOR
FIVE PERCENT THAT'S BECAUSE THEY
DO MEANS TESTING. OR THEY HAVE
TO HIRE SOME SOCIAL WORKERS TO
LOOK AT YOUR BANK ACCOUNTS NOW
ME HOME JONES.
SO I QUESTION THAT ASSUMPTION A
WHOLE LOT. BOMB TODAY'S
DISCUSSION. WAS ABOUT HOW TO GET
MEDICARE MONEY INTO THE SYSTEM.
WAIVERS IS NOT THE ONLY WAY TO
DO IT.
NOT JUST MENTAL NEW IDEA WE HAD
THIS IN THE NINETEEN NINETY FOUR
INITIATIVE IN CALIFORNIA.
WHERE DOCTORS COULD SEND THEIR
MEDICARE BILLS TO?
TO THE COMMISSIONER.
ALL THE CALIFORNIA HEALTH CARE
SYSTEM OR WHATEVER GOVERNING BUT
WE HAVE IT. AND THEN THEY WOULD
BUNDLES UP. AND BILL THEM DO
THAT THE FUNCTION OF BILLING
THEM TO THE FEDERAL GOVERNMENT.
THAT WAS FEVER SERVICE HAD THE
FEVER SERVICE IN BELUM ONE BY
ONE BUT THEY WOULD BILL THAT THE
FEDERAL GOVERNMENT. FOR EVERY
OPERATION THAT YOU'RE A
PROCEDURE THAT A DOCTOR HOSPITAL
VISITS ANOTHER WAY OF GETTING
THE MEDICARE MONEY INTO THE
SYSTEM.
I ALSO FOUGHT IT WAS INTERESTING
THAT THE KANSAS PROFESSOR.
.
THAT'S A LOT OF TIME ONE MINUTE.
.
I ALSO WAS VERY ANDERSON SHE
SAID THAT FIFTY TO SIXTY TO
SEVENTY PERCENT. OF BUSINESSES.
ARM.
MAYBE ARE INVOLVED WITH
THEORISTS OF THING. THAT MEANS
THAT WE PASSED A TAX IN THE
STATE FOR HEALTH CARE.
THEY COULDN'T CLAIM WE WERE
TARGETING ANY ONE OF THEM.
THAT MUCH BUSINESS IN CALIFORNIA
WHO PROVIDES HEALTH CARE IS.
ARM.
WHAT WE'RE NOT TARGETING AND
WE'RE JUST IT'S AND OVERALL TAX
FOR EVERYTHING THAT WE DO FOR?
EVERYTHING IN THE STATE THANK
YOU.
HI FOLKS I'M PAUL ROCKED AB I'M.
LONG TERM NURSE PRACTITIONER
INSTEAD OF CALIFORNIA ALSO
MEMBER OF P. IN HP.
AND I WANT TO REMIND ALL OF YOU
IN TERMS OF COMMITMENT VALUE
HERE. THAT IN THE EIGHT MONTHS
THAT SENATE BILL FIVE SIXTY TWO
HAS NOT HAD ANY ACTION OR BEEN
FILLED IN IN ANY WAY.
THOUSANDS OF CALIFORNIANS HAVE
DIED.
AS A RESULT OF NO ACCESS TO
HEALTH CARE FOR NOT BEING ABLE
TO AFFORD INSURANCE.
AND LOOKING AT THIS IN TERMS OF
THE UNINSURED.
SIGNIFICANTLY UNDER ESTIMATES
THE CONSEQUENCES TO PEOPLE IN
TERMS OF MORBIDITY.
THE UNDER INSURED AND THIS STATE
OF SOMETHING THAT I CAN'T EVEN
FIND ON THE INTERNET. THE
NUMBERS OF THOSE PEOPLE THERE
ARE MILLIONS AND MILLIONS AND
MILLIONS OF PEOPLE BEING
AFFECTED. BY THE SYSTEM THAT WE
HAVE IT'S VERY CLEAR THAT THE
COMMITMENT HERE HAS TO BE A
FIGHT AWAY. SO I HAVE A
COMMITMENT TO FIND A WAY.
THROUGH THE COMPLICATIONS THAT
WE'RE HEARING ABOUT TODAY IN
TERMS OF FINANCING AND IT'S
THEIR.
THANK YOU.
VERY MUCH.
ANYONE ELSE.
SEEING NO ONE WORLD GO AHEAD.
BEFORE WE CLOSE I JUST WANNA
ANNOUNCE THAT. THERE IS AN
ADDITIONAL HEARING IT'S ON
WEDNESDAY BEGINS HERE AT TEN AM
AND WE'LL BE HEARING. A VARIETY
OF PROPOSALS ABOUT.
HOW WE GET TO UNIVERSAL
HEALTHCARE?
SO.
WE WILL WE WILL LIKELY HAVE A
AT LUNCH BREAK IN THE MIDDLE OF
THAT SOME AT SOME POINT. BUT
THERE WILL BE A COUPLE OF PANELS
IN THE FIRST WILL BEGIN AT TEN
AM ON ON WEDNESDAY MORNING SO
THANK YOU VERY MUCH FOR BEING
HERE. AND I'LL SEE SOME OF YOU
ON WEDNESDAY I SUSPECT.
MEETING ADJOURNED