CAL CARE

PROPOSERS

Spelman, for Health Care for All-California.

What is the main objective of this proposal?

To provide health insurance for all state residents. The delivery of most health care will provided privately, as it is now.

What population will be covered; what is the timeline?

All persons who have resided in California for 3 or more months and who plan to remain a resident of the state.

What medical and hospital services will be covered?

All services, except as noted below. The general benchmark is a combination of the Kaiser Permanente large group standard benefit package and additional services currently available to Medi-Medi (persons having both Medicare and Medi-Cal) enrollees (limited long-term care, hospice, home health, vision, and dental services). The basic benefit package includes hospice, home health, vision, some dental and mental health and durable medical equipment.

What medical services are not covered?

Initially, there will be limited coverage of long-term care. Also, coverage will be expanded to include complementary and alternative medicine, as the budget permits. Non-covered services: non-formulary drugs and equipment, and cosmetic surgery.

What kind of choice does a participant have?

The individual consumer can choose the kind of health care delivery system (integrated or non-integrated). If the consumer chooses a non-integrated system, the consumer can choose any provider.

What are the costs to participants?

A small payroll tax will replace co-pays, deductibles and insurance programs. For almost everyone the health tax will be less than what is presently paid for health care.

Does the program have a benefit limit?

There is no cap on individual or family expenditures. Because a single-payer plan saves so much in administrative costs, the benefits are extremely generous. There will be an annual global budget, and some less essential services might have to be postponed if there is a budgetary short-fall. There will be no exclusion of coverage for "pre-existing illnesses".

Can a participant loose insurance?

Only if the insured moves out of California.

Where does the money to run the plan come from?

The money to run the system comes from a combination of a payroll tax and the folding in of current state and federal revenues for health care programs (Medicare, Medi-Cal, VA, Indian Health Services, etc.). The payroll tax would be shared by the employee and employer and would also apply to the self-employed. Other tax sources may be added, if needed (for example: tobacco tax, non-salary income tax, sales tax).

How will costs be controlled?

Costs are controlled not at the level of individual, but rather of the system. The main sources of cost control include the administrative efficiency inherit in a single payer system, enforceable global budgets, system-wide planning, coordination of capital expenditures, aggressive purchasing policies, and improved access to primary and preventive care (people stay healthier and get care early in their illness).

Will there be administrative coordination? What is the administrative structure for the program?

There will be a health care commission to oversee the system and a single state agency with local brances in each county to administer the system. There will be an elected commissioner and 10 commissioners (some appointed and some elected, including elected consumer advocates). There will be close coordination

between the commission and the state and local agencies. However, local agencies have a great deal of autonomy under Cal Care. The percent of administrative costs is expected to be similar to Medicare (2%) or Kaiser Permanente (5%).

How will participants have input into the system?

Healthcare consumers will have input at the local level through each county’s Offices of Consumer Advocate. At the state level, consumers vote for the health commissioner and consumer advocates. Providers will be represented by professional organizations that will negotiate fees with the commission.

How will providers be paid?

Providers can choose to work in settings that pay by fee for service, capitation, or salary. Except for federal, state and county health clinics, providers will not be salaried by the state.

What will be the role of insurance companies?

Insurance companies will offer insurance policies for individuals who are tourists or who are awaiting eligibility, and for services not provided by Cal Care. Through public-private partnerships overseen by the Commission, insurance companies may provide various administrative services. Current employees of private insurance companies will have the option of seeking employment with Cal Care and will be offered retraining if necessary.

How will quality of care be assured?

The main mechanism of assuring quality of care is that the competition for patients will be based on quality of services rather than on the lowest bid for contracted services. Providers who provide quality service will attract more patients and higher income. Quality will be assured by the establishment and monitoring of standards of care and by the monitoring of selected health indicators.

Is there a provision for supporting professional education and health research?

There will be state oversight of research funded by the state health fund. There will also be incentives to influence the number and type of physicians produced by state medical schools.

Will state and/or federal action be required to enact the plan? 

The plan will need to be introduced either by a ballot measure (which would require a majority vote) or by a 2/3^rd’s vote of the Legislature. Federal waivers would be required to fold in existing plans such as Medi-Cal, Medicare, and retirees’ health benefits.

What are other unique aspects of the plan?

There will be a displaced worker program for insurance company employees who lose their job as a result of this plan. There will be an emphasis on information systems to streamline enrollment, healthcare delivery, and reimbursement.

STEPPING UP TO UNIVERSAL COVERAGE

PROPOSERS

Brown & Kronick

What is the main of objective of this proposal?

To achieving universal coverage in two stages. Stage 1 will combine current public health insurance programs (i.e., MediCal, Healthy Families and Access for Infants and Mothers) into Healthy California for the first three years. MediCal aid categories will not be integrated. Coverage would expand to families earning up to 150% of poverty once a federal waiver is obtained. Stage 2, Healthy California (HC), will be available for all legal California residents.

What population will be covered, and what is the timeline for being covered?

Low-income populations, expanding up to 150% of the federal poverty level (FPL, which was $17,650 for a family of 4 in 2001) in the first three years, for stage one. In stage two, after the first three years, all legal California residents will be covered through a "pay or play" approach. Those covered by Medicare, CHAMPUS and employer-sponsored insurance will be able to enroll at no cost.

What medical and hospital services will be covered?

A state standard for benefit packages (SSBP), which uses Healthy Families benefits as a benchmark, will be established and utilized for both stages. Services covered include physician services, preventive care, prescription drugs, hospital, emergency health care services, medical transportation, diagnostic services, durable medical equipment, mental health, alcohol & drug abuse, physical-occupational-speech therapy, home health care, skilled nursing care, vision, dental, acupuncture, chiropractic, biofeedback, and elective abortion. MediCal enrollees will receive a supplementary benefits package called Healthy California+Plus

What medical services are not covered?

Not specified.

What kind of choice does a participant have?

HC will provide a mix of health care choices — it will contract with HMOs and possibly with provider offices. In addition to the HMO package, HC will offer a Preferred Provider Option (PPO) with an extensive network and limited utilization controls.

What are the costs to participants?

MediCal enrollees will not be charged co pays that exceed those currently allowed by the MediCal no-share-of-cost program. Co-pays are required for other enrollees. HMO benefits will be standardized across plans and premiums may vary. In each geographic region, HC must fully pay for the cost of the least expensive plans that cover at least 1/3 of the region’s population. If enrollees choose to join a more expensive plan, the enrollee pays the difference. HC's contribution will be adjusted based on the characteristics (age, health status) of enrollees of each plan. For individuals who choose a PPO option, deductibles and co-payments will be approximately 5 to 10% above the average HMO premium.

Does the program have a benefit limit

Not specified.

Can a participant loose insurance?

If enrollees of HC receive coverage through their employer, they are required to inform HC of this and they will not be covered by HC.

Where does the money to run the plan come from

Financing for HC comes from three sources. 1. Maximizing federal matching funds for Medi-Cal and Healthy Families; 2. Premium payments made by employers and employees; and 3. Premium payments made by the self-employed and unearned income and who are not continuously covered by qualifying employer sponsored coverage, Medicare or CHAMPUS during the tax year. 4. Taxes will be levied on tobacco, spirits, diesel fuel in stage one.

How will costs be controlled?

Not mentioned.

Will there be administrative coordination? What is the administrative structure for the program?

Stage 1 of HC will be administered by the Major Risk Medical Insurance Board (MRMIB), which will contract with HMOs and contract directly for services. MRMIB will be responsible for all aspects of implementation. During the first three years, MRMIB will develop their administrative capacity to implement stage 2.

How will participants have input into the system?

See Section on Quality of Care.

How will providers be paid?

Not specified.

What will be the role of insurance companies?

Insurance companies will offer the health plans.

How will quality of care be assured?

MRMIB will establish an Office of Quality Assessment with an advisory board, which will have the authority to collect relevant data from all health plans and providers receiving funding through the HC program. Consumer satisfaction surveys will be reported on an annual basis and other measures will be examined. No mention of grievance procedures or lawsuits.

Is there a provision for supporting professional education and health research?

No

Will state and/or federal action be required to enact the plan? 

Yes. California will fully draw down its S-CHIP allotment. A federal waiver will be needed.

What are other unique aspects of the plan?

The MRMIB will assure that culturally competent services are accessible and that safety net providers are enabled to participate in the HC program. Eligibility will be determined through various friendly formats.

THE MANAGED CARE EXPANSION PROGRAM

PROPOSERS

Brownstein, Zimmerman, Lum, Auerhahn, Muller, Elliott, for Working Partnerships USA

What is the main of objective of this proposal?

To provide affordable health insurance to all California citizens or legal immigrants with incomes equal to, or less than, 400% of the Federal Poverty Level. Builds upon current Medi-Cal system, using managed care.

What population will be covered, and what is the timeline for being covered?

The participants are limited to those who have been uninsured for more than six months, who do not have access to health insurance through their job, and who do not qualify or any other public insurance program, and who meet the income requirements.

15 year phase-in, starting with the lowest income group.

What medical and hospital services will be covered?

Similar to the Healthy Families benefit package for both children and adults. Comprehensive coverage will include: inpatient, outpatient, medical and surgical services; prescription drugs; x-ray services; speech therapies; mental health; dental and vision care.

What medical services are not covered?

There is no mention of long term care, substance abuse treatment, alternative-complementary treatment, nor durable medical equipment.

What kind of choice does a participant have?

Participants will be encouraged to enroll in managed care plans or county operated health systems such as already are being offered in many counties. In rural areas, fee for service providers may be used.

What are the costs to participants?

Premium payments on a sliding scale. Co-payments will range from $5 to $10 monthly for all services, with an annual maximum of $250. Prescription drug co-payments range from $0 to $5 and are included in the annual cap. As employees’ incomes increase, their share of the cost of the insurance premium increases.

Does the program have a benefit limit?

None is mentioned.

Can a participant loose insurance?

No such possibility is mentioned — but, if income level is exceeded, presumably coverage would be lost.

Where does the money to run the plan come from?

25% will come from co-payments and payroll taxes and

the other 75% from state general funds, with revenue sources to be decided by the legislature; suggested sources are sales tax and 10% or 11% tax (depending on income) on high incomes.

How will costs be controlled?

A very long phase-in period. Premiums to be negotiated, and there will be a sliding scale, dependent on participant income (from $50/year to 2.5% of annual household income. Also, there will be economies of scale by enrolling all participants in a limited number of plans.

Will there be administrative coordination? What is the administrative structure for the program?

There is no estimate of administrative costs. "Decentralization, with local authorities responsible for implementation in each county, will promote community involvement and community control while still insuring state oversight, as well as helping to establish mutually supportive relationships with a county's safety net institutions. Exclusive reliance on public sector organizations will also tend to support safety net and traditional providers."

How will participants have input into the system?

The county plans will be responsible for member communication and grievances, and local authorities are supposed to promote community involvement.

How will providers be paid?

Providers and provider groups will contract with public sector managed care plans. Reimbursement will usually be capitation and occasionally fee-for-service (rural areas).

What will be the role of insurance companies?

To insure coverage to those who are too affluent to qualify for this plan and to provide employment-based insurance.

How will quality of care be assured?

Relying on traditional safety-net providers, who are not profit-driven, will ensure quality. In addition, "county plans will be responsible for member communication and grievances."

Is there a provision for supporting professional education and health research?

No

Will state and/or federal action be required to enact the plan? 

New state taxes would have to be levied.

What are other unique aspects of the plan?

Based upon the premise that universal care is not politically feasible, but a system which moves steadily toward universal care is feasible. This plan preserves and strengthens existing safety net providers.

THE CALIFORNIA HEALTH SERVICE PLAN

PROPOSERS

Shaffer

What is the main of objective of this proposal?

To establish a publicly funded, single payer program that will provide universal and comprehensive coverage for all Californians.

What population will be covered, and what is the timeline for being covered?

All residents with primary residence in California for 6 continuous months, newborns delivered in CA and newborns whose parents are CA residents.

What medical and hospital services will be covered?

Preventative, primary, acute, home health care, dental, vision, prescription drugs. Acupuncture & chiropractic care are covered if practitioners operate within group practices as delineated by the proposal. Other complementary services covered upon referral from primary care provider. Durable medical equipment is not mentioned but seems to be implicitly covered based on goals of plan.

What medical services are not covered?

Long term care not included initially but would be coordinated with existing Medi-Cal & Medicare benefits.

What kind of choice does a participant have?

Primary care physicians, non-specialist clinicians and specialists will work in group practices. Each user of services will have access to group practices and can choose their primary care provider. Specialists can be accessed through group practices or hospitals. Community clinics and health centers will also be available to participants.

What are the costs to participants?

There are no co-payments or deductibles in this plan. However the proposal mentions a willingness to consider a modest co-payment scheme if modelers for the project deem it necessary.

Does the program have a benefit limit?

No benefit limit is mentioned in the plan.

Can a participant lose insurance?

As long as the participant is a CA resident s/he can’t lose insurance because the structure of the system is single payer, state-run, comprehensive and universal.

Where does the money to run the plan come from?

The state establishes regular sources of funding for the Health Service. Current public and private contributions to health care services would be consolidated and contributed to a California Health Services Trust Fund. The balance would be derived from an increase in corporate tax, tobacco tax and an aggregate payroll tax.

How will costs be controlled?

California Health Service (CHS) would set and enforce annual Health Service budgets for specific categories of services with separate funds for capital, research and training. CHS will act as a group purchaser of prescription drugs. Formulary and generic drugs will be encouraged subject to override by prescribing clinician. Costs are controlled on the provider side by creating a salaried work force of health care providers and on the patients’ side by emphasizing public health, prevention and socioeconomic causes of disease.

Will there be administrative coordination? What is the administrative structure for the program?

Three departments of equal standing overseen by California Health and Human Services Agency (HHS): California Health Service (delivery of most primary care, hospital and home health services), Department of Public Health (DPH) (improve public health.), Office of Statewide Health Planning and Development (collects and analyzes data on health services and supports strategic planning by CHS and DPH.).

How will participants have input into the system?

Patient advisory boards will be elected at the community level. Community boards will nominate members of the state advisory board, who will be selected and appointed by the Secretary of HHS. Boards will provide patient perspectives on organizational, access and quality issues and will educate and communicate with patients.

How will providers be paid?

All providers will be salaried. California Health Service will finance the premises and equipment for each group practice. Providers cannot offer covered services privately.

What will be the role of insurance companies?

None.

How will quality of care be assured?

A clinician-led Quality Improvement Initiative will maintain standardized, evidence based guidelines as a framework for standards of care and will educate providers. Patient advisory groups will help oversee quality of care, outreach and cultural competence of services.

Is there a provision for supporting professional education and health research?

CHS would finance medical education. Doctors would be salaried state employees whose education was paid for by the state.

There would be an annual budget for research.

Will state and/or federal action be required to enact the plan? 

The state will be the key player and payer in establishing this plan and legislation to enact the plan is needed.

What are other unique aspects of the plan?

A major focus on serving underserved populations through directing the location of new medical school graduates to needy areas and away from "overdoctored" areas. Public health initiatives are emphasized. 2 year transition period.

CAL-HEALTH

PROPOSERS

Based on Assembly Bill 32 (AB 32).

What is the main of objective of this proposal?

1. To expand health insurance coverage through the Medi-Cal program (for family incomes at or below 133 % of the federal poverty level (FPL, which was $17,650 for a family of 4 in 2001) and through the Healthy Families program (for family incomes at or below 250 % of the FPL).
1. To develop standard uniform benefits packages (SUBP) that can be offered by commercial carriers to persons with incomes above 250 percent of poverty and small firms.

What population will be covered, and what is the timeline for being covered?

Low income families - Medi-Cal and Healthy Families for those with family incomes at or below 250 % of FPL. Develops SUBPs that can be offered in the private market for families with higher income. No timeline is stated.

What medical and hospital services will be covered?

Health care coverage as mandated by the Healthy Families program or Medi-Cal, depending on income level. Persons over 250% of FPL who purchase private coverage with the SUBP will have coverage for hospitalization, outpatient visits, preventive care, ambulance services, dialysis care, maternity care, mental health care, emergency and out-of-area care, family planning, hospice care, health education, imaging, lab tests and special procedures, reconstructive surgery, and transplants. In addition, coverage with limits will be offered for physical, occupational and speech therapy, multidisciplinary rehabilitation, and home health care.

What medical services are not covered?

No drugs or long term care

What kind of choice does a participant have?

Whatever Medi-Cal or Healthy Families provides.

What are the costs to participants?

Whatever Medi-Cal or Healthy Families requires. A standard uniform benefit package (SUBP) from private carriers will be 10-20% less than the HMO products available in California's individual market

Does the program have a benefit limit?

Whatever the Medi-Cal or Healthy Families program limits are. For the SUBPs there will be limited coverage for physical, occupational and speech therapy, multidisciplinary rehabilitation, and home health care.

Can a participant loose insurance?

If income rises above Medi-Cal or Healthy Families income limits, would need to obtain insurance through employer or by purchasing coverage.

Where does the money to run the plan come from?

Financing will come from both the state and federal governments. This option takes advantage of federal funds made available to the state, but not utilized due to Medi-Cal and Healthy Family eligibles who are not enrolled in those programs.

How will costs be controlled?

Not stated.

Will there be administrative coordination? What is the administrative structure for the program?

The program will be run under Cal HHS.

How will participants have input into the system?

Not stated

How will providers be paid?

As currently done for Medi-Cal and Healthy Families programs

What will be the role of insurance companies?

To offer plans for the SUPBs (for those above 250% of FPL)

How will quality of care be assured?

CalHHS controls quality of care

Is there a provision for supporting professional education and health research?

No

Will state and/or federal action be required to enact the plan? 

A Federal waiver will be required for the expansion of the Medi-Cal program and of the Healthy Families program This will require the creation of the Cal-Health program, housed in the California Health and Human Services Agency.

What are other unique aspects of the plan?

CHOICE

PROPOSERS

Schauffler

What is the main of objective of this proposal?

Increase affordable, comprehensive coverage for all non-elderly workers and their families.

What population will be covered, and what is the timeline for being covered?

1. Workers and their families.

2. Workers and families with health insurance which lacks affordability, continuity & sufficient choice.

(This plan excludes the homeless, non-working Californians, and those 65 and older who are not in Medicare or Medi-Cal.)

What medical and hospital services will be covered?

Preventive, hospital, outpatient, drugs, ambulance, mental health, alcohol and drug dependence treatment, durable medical equipment,

Emergency care, out-of-area care, family planning, hospice, vision, hearing care, home health, physical, occupational & speech therapy, skilled nursing facility.

What medical services are not covered?

No dental or long term care.

What kind of choice does a participant have?

Participant in CHOICE may choose: 1) statewide network of health care professionals and facilities, including safety net providers; the primary care physician is accountable for preventive care and disease management. Referral authorization is not required OR 2) Non-profit health plans

What are the costs to participants?

Co-payments: For those earning less than 150% of the federal poverty level, none for preventive services or outpatient services; for enrollees whose coverage is financed in part by the state’s share of Medi-Cal or Healthy Families there will be co-pays according to those programs. Workers earning more than 150% of the federal poverty level will be charged co-pays for outpatient and ER visits and drugs.

Does the program have a benefit limit?

No benefit limit.

Can a participant loose insurance?

No

Where does the money to run the plan come from?

The state’s share of funds for Medi-Cal, Healthy Families, subsidy for "high risk" enrollees & previously uninsured, and the Federal share of Medi-Cal & Healthy Families. Employees will pay a progressive annual premium, no more than 2% of wages up to $84,000, and employers will pay a marginal tax rate that increases with size of workforce. (The state will continue to fund indigent care of persons not eligible for CHOICE)

How will costs be controlled?

Not clear. CHOICE pays physicians on a "competitive, discounted fee-for-service basis" and pays hospitals on a DRG basis. There will be competitive bidding for drugs. There is no control on capital costs. It is not clear how the Managed Risk Med. Insurance Board (MRMIB), which administers CHOICE, will be involved in planning.

Will there be administrative coordination? What is the administrative structure for the program?

MRMIB will administer CHOICE and coordinate with the CA Department of Health Services to enroll Healthy. Families & Medi-Cal eligibles; regulate providers; assess quality; report data; develop media campaigns and community outreach.

The % for administrative costs is not stated.

How will participants have input into the system?

No structure for participant input.

How will providers be paid?

MRMIB will centralize claims processing and pay providers either by fee-for-service or by risk-adjusted capitation.

What will be the role of insurance companies?

CHOICE does not automatically replace existing coverage (public or private). A reduction in persons covered by for-profit PPO and IPA/network HMO model is anticipated. The health insurance market will have to compete with the CHOICE program and/or provide supplemental products for coverage that exceed the CHOICE benefit package.

How will quality of care be assured?

Physicians will be required to report both quality and cost and to participate in quality studies. There is provision for patient education and preventive services. CHOICE contracts only with hospital providers whose facilities meet or exceed evidence-based standards for high-cost procedures .There will be economic incentives for patients to participate in self-care programs.

Is there a provision for supporting professional education and health research?

No provision for supporting profession education. Health research may be supported by quality studies (see above).

Will state and/or federal action be required to enact the plan? 

State legislative action is needed to create CHOICE program, but no Federal waivers afd required (if state’s request to extend eligibility to parents of children eligible for Healthy Families program is approved). No ERISA waiver required.

What are other unique aspects of the plan?

NAFTA Social Integration Fund. Agreements could be broadened to take into account public health and medical care issues for families from Mexico who live and work in the U.S. A portion of the NAFTA Social Integration Fund would be used to subsidize the cots of coverage in the CHOICE program for Mexicans working in CA.

THE CURRENT SYSTEM

PROPOSERS

Not applicable

What is the main of objective of this proposal?

There is no overall objective. The result is a haphazard uncoordinated patchwork of health care coverage, where the ability to pay and the health care market determines who will receive what care.

Public insurance and public and charity care exists for low income workers, but the "safety net" has many holes. Public insurance exists for most people over 65 years of age. Private health insurance coverage may be provided through employment, and may be subsidized; private policies are available on the open market, but are expensive and they do not cover people with pre-existing conditions.

What population will be covered, and what is the timeline for being covered?

Those with access to employer sponsored private insurance are mostly full-time workers for large employers. Public programs are available for the poor, working poor, disabled, and retired but many are ineligible for these programs and cannot afford to pay for healthcare or health insurance. Limited emergency services for all.

What medical and hospital services will be covered?

Varies with coverage from very limited (catastrophic coverage) to generous. Each insurance plan sets limits on what services will be covered. The following services are frequently not covered: services for pre-existing illness, certain chronic conditions, mental illness, infertility, vision, hearing, preventive services (annual physical, screening tests and counseling), long-term and hospice care, chiropractic care, and selective surgery (hernias, cataracts, gallbladder, joint replacement, etc.)

What medical services are not covered?

Varies with coverage. Many services are not covered, as noted above. Other than Medi-Cal, long term care is unusual. Drugs usually not covered.

What kind of choice does a participant have?

Varies by income level, employer offerings and cost of insurance. Most workers are forced into managed care plans where they have limited choice of providers and their care is managed by gate-keepers.

What are the costs to participants?

Varies with coverage. Most employers require employee to pay part of the premium; many require co-pays or deductibles for visits or medications. Often, there is a cap on total annual or lifetime services.

Does the program have a benefit limit?

Varies with coverage. Often there is a benefit limit either in the form of a maximum cost or a maximum number of visits for one type of illness (mental health, diabetes, etc.)

Can a participant loose insurance

Yes, with loss of employment (temporary COBRA extension is federally mandated but is often unaffordable).

Yes, if income decreases, for those who purchase insurance directly.

Yes, if the insured develops some kinds of chronic health conditions

Where does the money to run the plan come from

Federal, state and county funds for low-income groups.

Premiums paid by employers and employees or by individuals.

Co-pays and deductibles paid by insured individuals

How will costs be controlled?

Costs are not controlled; cost control is attempted by withholding or excluding services, requiring co-pays and deductibles, and demanding discounted fees from contracted providers. There is no system-wide planning or allocation of resources.

Will there be administrative coordination? What is the administrative structure for the program?

There is no overall administrative coordination. Each private and public program has its own administrative system. Individual health plans mostly focus on the business aspect of the plan rather than on the health services provided — they are more concerned about what they will pay for rather than how services will be provided.

How will participants have input into the system?

Health care consumers only have input through "satisfaction surveys" and grievance proceedings, which do not always allow for independent and timely review of their case. Physicians are losing their ability to make decide proper treatment for their patients.

How will providers be paid?

Fee for service, capitation or salary.

What will be the role of insurance companies?

They originally were simply fiscal intermediaries with little control over the provision of care, but more recently, they have used their control over large panels of patients (the employees of large companies) to control the delivery of health care by doctors and hospitals.

How will quality of care be assured?

Some state regulation. Managed care organizations have a grievance policy. Lawsuits are generally allowed.

Is there a provision for supporting professional education and health research?

Yes, limited. Predominantly federal funds. Health plans try not to pay indirectly for health education and research although they benefit from those activities, resulting in financial stress for professional education.

Will state and/or federal action be required to enact the plan? 

Not applicable

What are other unique aspects of the plan?

A non-system with significant administrative costs stemming from multiple insurers engaged in eligibility review, premium collection, marketing and public relations, micromanagement of individual cases, etc. Millions of uninsured persons. Many uninsured services (long-term care, family planning, mental health, etc.). Lack of choice. Undue emphasis on high-tech services with insufficient attention to primary and preventive services.

CALIFORNIA PACADVANTAGE PREMIUM PROGRAM (CPPP)

PROPOSERS

Horton

What is the main of objective of this proposal?

To expand employer-sponsored insurance by helping small businesses overcome obstacles to providing health care coverage for their low-income employees. To ensure that policies will be affordable to eligible low-income employees.

What population will be covered, and what is the timeline for being covered?

Low-income employees (and their families) of small businesses in CA. The companies must have 2-50 employees, and the majority of employees must reside in CA. Employers must not have offered any equivalent health insurance coverage in the last 6 months. A certain % of the employees must be covered under this program, depending on the percent of the premium that the employer pays.

Employees must not be eligible for any other kind of health insurance program sponsored by the state and/or Federal government (for example, Medi-Cal, Medicare, Healthy Families, Access for Infants and Mothers, Medicare, etc.) Employees must work at least 20 hours/week and their income must be less than 350% of the Federal Poverty Level. Employees must have been uninsured for the last 6 months.

What medical and hospital services will be covered?

Employers are encouraged to purchase policies through the work through PacAdvantage program, which offers more than a dozen different products available in various parts of the state. Coverage must be similar to that available to federal or CALPERS employees, or through large commercial HMOs, so plans would generally cover prevention and treatment, hospital care and laboratory tests, some mental health and durable medical equipment. Insurance coverage for chiropractic, acupuncture, dental and vision can be purchased for additional cost.

What medical services are not covered?

Not explicitly stated, but probably would not cover prescription drugs or long term care.

What kind of choice does a participant have?

Choice of plan to be determined by the employer, and that would determine whether there would be a required primary care provider, and/or gatekeeping.

What are the costs to participants?

Employees pay a portion of the premium, on a sliding scale depending on their income (from 10-40% of the premium). Participant costs (premium, co pays, deductibles) vary, depending on the plan offered by the employer. Co-payments can range from $5 per office visit to 50% of the cost, and deductibles can range from $0 to $3,000 per family annually.

Does the program have a benefit limit?

Some plans have lifetime maximum benefits, others do not.

Can a participant loose insurance?

Yes, if employee changes employment or loses eligibility for

PacAdvantage or if the employer stops offering the plan.

Where does the money to run the plan come from

From a Trust Fund that receives state funding through an increase in tobacco tax, and possibly donations from for-profit and non-profit entities. The amount of the tobacco tax is not defined.

Another possible funding sources could be the Federal Government, through a 1115 waiver, but this route is not being recommended.

How will costs be controlled?

Copays, deductibles and lifetime caps paid by the participants diminish insurance premiums. There is no other type of cost control mentioned.

Will there be administrative coordination? What is the administrative structure for the program?

PBGH will be responsible for the administration of PacAdvantage; administrative costs will be funded by a 1.5% premium surcharge paid by participating employers. A new, separate entity may be created to serve administrative infrastructure.

How will participants have input into the system?

They will not, other than usual channels available through the coverage plan selected.

How will providers be paid?

This depends on the insurance policy. The providers could be paid fee for service, capitation or salary.

What will be the role of insurance companies?

Insurance companies are an essential part of the PacAdvantage program — they sell the insurance policies that will be offered.

How will quality of care be assured?

Employers will be encouraged to work with PacAdvantage.

Grievances and appeals processes are left to the individual plans.

Is there a provision for supporting professional education and health research?

None

Will state and/or federal action be required to enact the plan? 

Funding for PacAdvantage will primarily rely upon state funding and will be secured before enacting program. The Managed Risk Medical Insurance Board (MRMIB) will set policy and this needs to be implemented.

What are other unique aspects of the plan?

Employer and non-profit approach of offering health insurance may be appealing to California’s immigrant families unlikely to approach government agencies. Builds upon the tradition of employer sponsored health insurance. Does not offer universal health coverage.

DRAFT SINGLE PAYER OPTION

PROPOSERS

Kahn and others.

What is the main of objective of this proposal?

To provide all CA residents with comprehensive health services in a single-payer system.

What population will be covered, and what is the timeline for being covered?

All CA residents of more than 3 months are covered, including "undocumented" who can prove residence. There is a 3 year residence requirement for certain services, like Long Term Care. Simple enrollment process. Phased in over several years.

What medical and hospital services will be covered?

Comprehensive services: inpatient and outpatient care; testing; durable medical equipment; podiatry; chiropractic; transportation for emergency care and for disabled; rehabilitation; prescription medication based upon formulary; institutional and residential care; home health, hospice and long term care; wide range of mental health services; substance abuse treatment; if funding permits: dental benefits and vision care.

What medical services are not covered?

Room and board portion of long term care, except for very low income persons; therapies determined to be ineffective; and cosmetic surgery.

What kind of choice does a participant have?

Fee for service, capitated or salaried. There is choice of provider and no gatekeepers

What are the costs to participants?

No co-payments unless they are determined to be needed.

No deductibles.

Does the program have a benefit limit?

No benefit limit.

Can a participant loose insurance?

Not as long as they reside in CA.

Where does the money to run the plan come from?

Folding in a variety of federal, state and local programs; retirement-associated health plans (if they elect to be included); 8% payroll tax on employers (very small firms exempted); personal income tax of 2.5% on taxable income, not less than $50 per household; state income tax surcharge of 2.5% on taxable income over $250,000

How will costs be controlled?

Global budget (which shall not increase faster than the state gross domestic budget) for entire system; regional budgets for fee-for-service and capitated systems, for integrated health delivery systems, and for facilities in the fee-for-service system. In addition, capital spending greater than $750,00 requires approval by Commissioner. Budgets are negotiated annually, and surpluses are used to develop new programs or are returned to Health Security System. Budget increases are possible if justified by increased utilization of services. There will be close monitoring and regular projections of costs, to minimize administrative costs and identify unnecessary/wasteful care. If there are cost over-runs: coverage of elective services, vision and low-priority dental care can be limited.

Will there be administrative coordination? What is the administrative structure for the program

There will be an elected state health commissioner, and a State Board (elected and appointed members), regional Boards (elected and appointed members), and other advisory groups.

After one year of implementation, administrative costs must be less than 4% of total funds appropriated for the health system.

How will participants have input into the system?

Election of commissioner and some members of state and regional boards. State and regional boards have consumer representatives.

How will providers be paid?

Individual practitioners can be paid (1) negotiated fee-for-service rates, with limits on high income OR (2) risk adjusted capitated OR (3)salaried from globally budgeted facility. Integrated Health Delivery Systems will be paid by capitation, negotiated regionally and risk-adjusted. Health facilities will be paid by capitation or global budgets, assuming risk (with risk adjustment applied)

What will be the role of insurance companies?

No role for insurance companies

How will quality of care be assured

Providers compete for consumers based on quality and service

Existing systems monitor quality

Improved data collection and analysis of outcomes

Is there a provision for supporting professional education and health research?

Not discussed.

Will state and/or federal action be required to enact the plan? 

Needs state legislative action. Need to persuade federal government to fold in those who are currently covered by federal programs. ERISA waiver probably not required.

What are other unique aspects of the plan?

Health care costs would be shifted to smaller employers and to wealthier families. Low income and working class individuals would pay the least and those not currently covered by public insurance would save the most money.

INSURE THE UNINSURED PROJECT (ITUP)

PROPOSERS

Wulsin, Long, Ahmed, Hickey & Frates

What is the main of objective of this proposal?

Increase the insurance coverage of low income workers and their families by improving affordability of health insurance.

What population will be covered, and what is the timeline for being covered?

Employed individuals and families up to 200% of the Federal Poverty Level (FPL, which was $17,650 for a family of 4 in 2001). Working undocumented individuals and families are covered. Timeline not stated

What medical and hospital services will be covered?

For those below the FPL, coverage equivalent to current Medi-Cal benefits.

For those with higher incomes, coverage equivalent to current Healthy Families managed care benefits (which are less than Medi-Cal, and with higher co pay)

All plans must cover: medical, hospital, radiological services, emergency care, home health care, hospice services and prescription coverage.

Plans will not be subject to the CA basic benefit mandates.

What medical services are not covered?

Depends on income level, see above.

Allows a 12-month exclusion for pre-existing conditions for insurance not purchased through employer.

What kind of choice does a participant have?

Managed care organizations for the lowest income groups; managed care or fee for service for higher income groups.

What are the costs to participants?

Co-pays (amount not stated) for all but the lowest income enrollees. Employees would receive a tax credit to purchase insurance (as high as 90% of cost for the lowest income groups, and then decreasing as income increased).

Does the program have a benefit limit?

Yes, for income above $35,000/individual and $70,000/family.

Can a participant loose insurance?

Its not clear if insurers could cancel enrollment if income rises above $35,000/individual or $70,000/family.

Where does the money to run the plan come from

Use existing state and local health funding sources to purchase insurance rather than provide care; Increase federal funding through §1115 Medicaid waiver; tax credits for employer and employees. If needed, tax on providers and health plans or increase in state sales tax on services (and decrease in tax on

How will costs be controlled?

Not discussed.

Will there be administrative coordination? What is the administrative structure for the program?

This plan will consolidate a series of state and county programs and funding streams. Many state agencies will be responsible for parts of the program, depending on participants’ income and/or the types of programs being offered

How will participants have input into the system?

They will not have input.

How will providers be paid?

As at present —capitation, fee for service, or salaried

What will be the role of insurance companies?

Insurers will market and offer plans — guaranteed issue, guaranteed renewable, with rate adjustments.

How will quality of care be assured?

Not stated — probably continues existing programs

Is there a provision for supporting professional education and health research?

No

Will state and/or federal action be required to enact the plan? 

Need a §1115 Medicaid waiver from the federal governments — several states have already been able to obtain.

What are other unique aspects of the plan?

Major goal is to simplify health insurance programs for low income individuals and families; this is seen as a starting point for future state health care reform.