What Could National Health Care Reform Mean for California?

As Congress considers major overhaul of the country’s health care system, various interest groups — industries, consumers, local and state governments — are beginning to assess what reform might mean for them.

California has one of the largest totals of uninsured in the country (estimates range from 6.4 million to almost seven million), so any expansion of coverage at the federal level would probably be good for the state. The spread of health information technology is also welcomed by most Californians.

What other elements of the state’s financing and delivery of health care might be affected by national reform? What parts of the state’s health system might end up being compromised or enhanced by federal action?

California Healthline sought answers from several corners including federal and state government, health care providers and consumers. Two responded:

• Mitchell Katz, M.D., Director of Health, San Francisco Department of Public Health
• Erica Murray, Vice President, California Association of Public Hospitals and Health Systems

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Local Providers Should Be Focus

Mitchell Katz, M.D. Director of Health, San Francisco Department of Public Health

With 6.4 million uninsured persons, California has much to gain from a federal plan that would expand coverage for the uninsured.  Providing uninsured persons with coverage would result in improved health status, higher use of preventive measures (e.g. pap smears, mammograms), decreased emergency room use, and perhaps most importantly greater peace of mind for the working uninsured who know that a serious medical illness could bankrupt them. 

A federal plan that guaranteed issue by health insurers would also benefit uninsured persons who can afford coverage but cannot currently obtain it.

Although covering the uninsured would be of tremendous help to the state of California, there is a risk that the federal government will pay for the reforms in part by decreasing Medicaid reimbursements. 

The already insufficient reimbursement rates result in low provider participation.  The result is that beneficiaries have insurance, but no access because no doctor will see them. 

Federal reform efforts may also tap federal dollars currently used to support the care of uninsured persons at the local level, such as Disproportionate Share Dollars (DSH).  Although it is entirely appropriate for these dollars to be used to insure individuals, there is a problem if the dollars are taken but insurance is not universal.  In this instance, county safety-net systems would still have the burden of caring for the uninsured, but would no longer have the resources to do so.

San Francisco’s experience with Healthy San Francisco is instructive with regard to how health reform could work at both the federal and state levels. 

It provides comprehensive, affordable health care to uninsured adults.  It emphasizes primary and preventive care by ensuring that all participants select their own primary care medical home.  It is truly universal in that no one is ineligible due to pre-existing medical conditions, immigration status or employment status. 

Initial cost data indicate that this public option is currently less expensive than purchasing health insurance for uninsured residents and therefore might make it possible to expand access to care to a greater number of people. 

Service data also appear to indicate that the program has resulted in decreased hospital emergency department use.

As California and the nation contemplate health care reform, it is important to recognize where care is provided — at the local-level and that these delivery systems must be preserved and enhanced to ensure expanded coverage.

 

Reform Must Provide Coverage and Access

Erica Murray Vice President, California Association of Public Hospitals and Health Systems

National health care reform holds great promise for California. If crafted thoughtfully, its passage could result in millions more residents receiving health care coverage and becoming healthier as a result.

But coverage alone won’t suffice — reform must also ensure actual access to medical services through a delivery system that can provide high-quality health care to patients when and where they need it.

Such an endeavor won’t be easy, but with comprehensive reform, we can see the ranks of the state’s 6.6 million uninsured greatly diminished and the health of our residents improve. As part of this effort, we must ensure that the safety net — upon which so many rely for trauma, physician training, primary and specialty care — is supported and strengthened. 

And we must address the myriad of serious health issues — such as obesity, Type 2 diabetes and high blood pressure — that is taking a tremendous toll on our health care system and causing untold misery for millions of people.

California’s 19 public hospital systems see every day the toll of the health care crisis and its disproportionate impact on low-income, uninsured and vulnerable people. Two-thirds of our members’ patients are either uninsured or Medi-Cal beneficiaries. These patients tend to be sicker and have multiple, complex medical concerns.

Public hospital systems have been working hard to provide coordinated systems of care for patients. This work has been especially vigorous in public hospital outpatient clinics, also called medical homes, where patients receive primary and preventive services from a team of providers who help them manage their chronic conditions such as diabetes, hypertension and asthma.

These interventions help prevent costly emergency room visits and inpatient stays.  Medical home provider teams also help to ensure that patients are offered timely medical appointments, given proper medications, and receive follow-through with appropriate care.

These kinds of delivery system reforms lead to improved health outcomes and increased access to services; they must be a part of any health care reform measure passed if we are to succeed in reaching our goal of a healthier California and a healthier country. 

The good news is that the building blocks already exist within local public hospital systems, where necessity breeds innovation. 

We stand ready to work with our elected officials and the Obama administration to expand coverage and access and strengthen the safety-net system. We must achieve these goals; inaction is simply not an option.