The Dec. 1 edition of The Weekly highlight's the first half of an interview with E. Richard Brown, the founder and director of the UCLA Center for Health Policy Research and a professor at the UCLA School of Public Health. His recent work focuses on health insurance coverage and the effect of public policy, managed care and other market conditions on health care access, especially with regard to underserved populations.
In the interview, Brown discussed recent legislative efforts to expand health insurance coverage in California, the politics of extending health care coverage to undocumented immigrants and the implications of eliminating some coverage mandates for health plans.
Audio of the complete interview with Dr. Brown is available online. The Dec. 8 edition of The Weekly will feature the second half of the interview.
Q: [Gov. Schwarzenegger] has shown some interest in the plan passed in Massachusetts to provide universal coverage in that state, and it's reported that his advisers are looking at many different options for health care reform in [California]. Do you think it's going to be possible to cover the uninsured or more of the uninsured in this state without raising taxes, which has also been one of [the governor's] promises?
BROWN: I think it's going to be next to impossible for the governor to realize the goals that he has set out without either raising taxes or making employers who are currently not spending very much on their employees' health care to at least begin to spend something that approaches the average of what other employers who are providing health benefits to their employees are spending. California simply doesn't have the kind of conditions that Massachusetts had when they enacted their program. We have a far higher uninsured population. Our uninsured population is greater than the population of Massachusetts itself. Massachusetts had a $1 billion fund sitting there and available for this purpose that had been used to pay for uncompensated hospital care. California doesn't have that. They have a higher proportion of employers who offer health insurance and a higher proportion of employees who are covered through employment-based coverage than California does. And California has more undocumented immigrants, making it more challenging for them to get covered, either through their employer, in some cases, but certainly through federally sponsored programs.
Q: Last year there was a proposal by state Sen. Sheila Kuehl [D-Los Angeles] for universal coverage. The governor vetoed it. It may be reintroduced this year. He'll probably veto it again. [In] a recent interview, [Kuehl] mentioned the possibility [of] managed competition as a way to deal with some of the problems in the state. What's your take on that possibility?
BROWN: Well, I'm not sure what she means by managed competition but certainly one option that California could use is to expand our existing public programs, mainly the Healthy Families program that current covers low- and moderate-income children, and the Medi-Cal program, which covers many of those children in that group, as well as their parents, in some cases, and many other adults. Those programs can be expanded, as they have been in a number of other states, and we could get federal matching funds to help California pay for this expansion. Those plans are increasingly relying on the contracting with private health insurers to cover their beneficiaries. And perhaps she means taking that as a model and paying health plans to take uninsured, currently uninsured Californians as enrollees in a similar fashion, with a sliding fee scale and substantial government subsidies. I think that that is an effective way to expand coverage, bringing in some federal funds to help California with this enormous problem.
Q: So if it was your call, ... what would your solution look like? Have you formulated anything?
BROWN: Well, a colleague of mine, Rick Kronick, and I, had a few years ago developed a proposal that had been introduced by Sen. Jackie Speier [D-San Mateo] in 2002 into the Senate. And that proposal would utilize these public programs in California to offer a vehicle for subsidizing coverage for workers and nonworkers in the state who are currently uninsured. But we also proposed, and I think this is important, to require that employers step up to the plate, those who are not currently covering their employees or who are paying very miniscule contributions for their employees' coverage and making more significant contributions based on a percentage of payroll, which would make it affordable to every employer in the state. It did require some modest increase in revenues to help pay for it, but it was a workable system and one that I think still merits a lot of attention and consideration.
Q: A possibility that had been floated from the governor's office, as his panel of advisers look at ways to increase coverage but also reduce cost, is the possible repeal of existing rules that require HMO's to cover treatments for such things like mental illness, birth control [and] cancer screenings. ... What do you think of that proposal?
BROWN: I don't think it's an effective way to cut costs. I don't think it's an effective way to control spending. I think it is an effective way to have a cheap program that, frankly, a lot of people won't want to enroll in because it's not going to buy them very much coverage. And we see that being marketed by a number of health insurers today around the country. And, you know, while the take-up rates for those kinds of high-deductible health plans with very limited benefits has been growing somewhat, it's still a very small percentage of the insurance market. There's not a lot of interest on the part of employers, and there's not a lot of interest on the part of employees in enrolling in those plans. And, I think the evidence is that they will, on the average, leave most working Californians paying considerably more in health care expenditures than they do today, and, in many cases, actually pushing them over the edge into bankruptcy and certainly into financial distress. I think it's not a good way to go.
Q: Earlier you had mentioned California's large immigrant population. That's sort of the elephant in the room that nobody has really addressed directly. What's the best way, do you think, to deal with that issue?
BROWN: Well, first of all, I think we need to recognize that their children are overwhelmingly children who are born here in this country and are U.S. citizens. They are going to school. They are destined to become the workers of tomorrow. And we ought to be very concerned about making sure that they get the health care that they need to become adequately developed and healthy, working and contributing adults to our society, our economy, and to their families. I think it's in California's interest to do that.
I also think that even for adults who are here and are undocumented immigrants, we do need to recognize that they're parts of our communities. They work in our restaurants. They work in our supermarkets. They work in a variety of places in which they come into contact with everybody else. And germs and viruses don't seem to stop in a given community simply because that community may have predominantly people who are not here legally, or many such people. So I think it's in our interest to assure that all residents of California have coverage and access to basic health care that they need to be functioning and healthy members of our communities and societies.
That said, I think that many undocumented immigrants currently do actually get health insurance through employment, and many more could do that. We could also provide health care to all children in our state, and make that a state commitment, as the governor has indicated he supports. So I think there are ways to address this problem, but we do need to recognize that it is something that needs to be a part of our plan.
Q: Earlier you mentioned state programs, such as Medi-Cal. There was an article recently in the Sacramento Bee that talked about understaffing and all the red tape, that it makes it difficult for doctors to ... take care of Medi-Cal patients. There are some statistics that supposedly Medi-Cal has about 46 primary care doctors for every 100,000 patients. The standard for Medicaid, the federal program, is about 60 to 80 doctors per 100,000 patients. It seems like there are not enough doctors right now to take care of the patients that are in the Medi-Cal system, and if Medi-Cal is expanded to include, let's say, more kids, is the system going to be able to handle that?
BROWN: Well, I think part of any agreement that expands the Medi-Cal program must recognize that the state needs to pay an adequate reimbursement rate for doctors, for hospitals, for health plans that are caring for the enrollees in the Medi-Cal program. It can't be done on the cheap and be done well. We do need to streamline these programs. California spends very little per Medi-Cal enrolled compared to the rest of the country. And I think California needs to recognize that it can't go on being the bargain basement of society and have an effective, adequately funded health care system because, in the end, we do pay for that. We pay for it with people walking around with chronic illnesses or not being able to walk at all and becoming more dependent on other institutions in our state, the welfare system, criminal justice system and others really, in part, because they are not able to get adequate health care to deal with chronic illnesses that they have or that they may be developing.
The Dec. 8 edition of The Weekly will feature the second half of the interview with Dr. Brown, including his thoughts on funding health care reform efforts and what the health care system in California will look like in a year.