Defending Against This Season’s Deadly Flu: 5 Things To Know Now

January 11, 2018 by · Leave a Comment 

Aja C. Holmes planned to go to work last week, but her flu symptoms — a cough, fever and severe body aches that worsened overnight — had other ideas.

“It felt like somebody took a bat and beat my body up and down,” said Holmes, 39, who works as a residential life director at California State University-Sacramento. “I couldn’t get out of bed.”

The nation is having a Terrible, Horrible, No Good, Very Bad flu season.

Flu is widespread in 46 states, including California, according to the latest reports to the U.S. Centers for Disease Control and Prevention (CDC).

Nationally, as of mid-December, at least 106 people had died from the infectious disease. At least 27 Californians younger than 65 had died as of Friday, seven of them during the week before Christmas. And states across the country are reporting higher-than-average flu-related hospitalizations and emergency room visits.

In California, flu struck surprisingly early and hard this season. The state’s warmer temperatures typically mean people are less confined indoors and result in a later flu season compared with other regions. Health experts aren’t sure why this season is different.

“We’re seeing the worst of it right now,” said Dr. Randy Bergen, a pediatrician who is leading Kaiser Permanente-Northern California’s anti-flu effort. “We’re really in historic territory, and I just don’t know when it’s going to stop.” (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Here are five things you should know about this flu season:

  1. It’s shaping up to be one of the worst in recent years.

The H3N2 influenza A subtype that appears to be most prevalent this year is particularly nasty, with more severe symptoms including fever and body aches. Australia, which U.S. public health officials follow closely in their flu forecasting in part because their winter is our summer, reported a record-high number of confirmed flu cases in 2017. Another influenza B virus subtype also is circulating, “and that’s no fun, either,” Bergen said.

Flu season in the U.S. typically starts in October and ends in May, peaking between December and February.

  1. This season’s flu vaccine is likely to be less effective than in previous years.

U.S. flu experts say they won’t fully know how effective this season’s vaccine is until the end of the season. But Australia’s experience suggests effectiveness was only about 10 percent. In the U.S., it is 40 to 60 percent effective in an average season. Vaccines are less protective if strains are different than predicted and unexpected mutations occur.

  1. You should get the flu shot anyway.

Even if it is not a good match to the virus now circulating, the vaccine helps to ease the severity and duration of symptoms if you come down with the flu. Young children are considered among the most vulnerable to complications from the disease, and a shot can significantly reduce a child’s chances of dying. High-dose vaccines are recommended for elderly people, who also are exceptionally vulnerable to illness, hospitalization and death related to the flu, according to the CDC.

“Some protection is better than no protection,” Bergen said, “but it’s certainly disappointing to have a vaccine that’s just not as effective as we’d like it to be.

Shots may still be available from your doctor or local health clinic, as well as at some chain drugstores. Check the Vaccine Finder website (https://vaccinefinder.org/) for a location near you.

  1. Basic precautions may spare you and your family from days in bed.

As much as possible, avoid people who are sick. Wash your hands frequently and avoid touching your mouth, nose and eyes.

Masks aren’t particularly effective in keeping you from catching the flu, although they may help keep sick people who wear them from spreading their germs further.

If you are sick, cover your cough and stay home from work if you can, Bergen said. Remaining hydrated, eating nutritious foods and exercising can also help strengthen your immune system.

Because elderly people are so vulnerable to the flu, some nursing homes and assisted living facilities may limit visitors and resident activities, depending on the level of illness.

  1. Don’t mistake flu symptoms for those of a common cold.

The hallmarks of flu are fever and body aches that accompany cough and congestion, Bergen said.

If you feel as if you’re having trouble breathing, or if your fever can’t be controlled with medication like Tylenol, check with your doctor. It’s even more important for patients to see a doctor if they have a chronic medical condition like diabetes or heart disease, or if they are young or elderly.

Kaiser Permanente doctors now are being advised to prescribe antiviral drugs like Tamiflu — given as a pill or, for kids, an oral suspension — even without a lab test for influenza, Bergen said. According to a report in the Los Angeles Times, however, Tamiflu supplies are running low.

And Bergen cautioned that these medications are only partly effective, reducing the time of illness by just a day or two.

 

 

Fear Compromises The Health, Well-Being Of Immigrant Families, Report Finds

December 14, 2017 by · Leave a Comment 

Luis Ramirez has lived in the U.S. without immigration papers for two decades, but he is more worried about deportation now than ever before.

Ramirez said he and his wife, Luz Cadeo, who is also here illegally, have already made plans in case they are arrested by immigration police: The couple, who live in Lakewood, Calif., would try to find work in their native Mexico while their youngest U.S.-born children, ages 15 and 18, stayed in the U.S. with a relative.

“We are taking it very seriously,” Ramirez, who works as a welder, said in Spanish. But, he added, “it’s very difficult to explain to [our children] the reality of what could happen.”

Immigrant families like Ramirez’s are living with heightened fear and uncertainty because of stricter immigration policies and increased enforcement under the Trump administration, according to a report released Wednesday by the Kaiser Family Foundation. (Kaiser Health News, which produces California Healthline, is an editorially independent program of the foundation.)

The fear, and the stress it creates, is compromising children’s health, possibly for the long term, the report said. It is also causing some parents to forgo health care or withdraw from public health programs such as Medicaid, which covers people with low incomes, and Women, Infants and Children, which provides nutritional assistance.

The report, based on focus groups with 100 parents and interviews with 13 pediatricians, found that immigrants across the nation are anxious about being deported and separated from family members. Some parents are reluctant to leave their homes or participate in recreational activities.

This post-election anxiety isn’t limited to immigrants without papers, according to the report.

“These feelings of fear and uncertainty extend broadly across different groups of immigrants, including immigrants who are here legally,” said Samantha Artiga, director of the disparities policy project at the Kaiser Family Foundation and one of the authors of the report. “They no longer feel like a green card is enough and [believe] that they really need to seek citizenship to feel secure and stable in the country.”

Shirley Avalos, a U.S. citizen, said she saw that anxiety in her mother, a legal permanent resident, also known as a green card holder. At one point, her mom couldn’t find her green card, and she was scared to drive until she found it. Donald Trump has gone “overboard,” said Avalos, who lives east of Los Angeles.

In the interviews, parents and pediatricians reported that immigrant children were suffering from depression, anxiety, stomach ailments and headaches. They also saw children who were having problems eating, sleeping and doing schoolwork. The overall stress could have lifelong consequences for the health of those children, said Lanre Falusi, a pediatrician at Children’s National Health System in Washington, D.C., and past president of the local chapter of the American Academy of Pediatrics.

Immigrants fear using healthcare services could lead to deportation. (EGP archive photo)

Immigrants fear using healthcare services could lead to deportation. (EGP archive photo)

“The ongoing, consistent, serious fears and stress that these families are experiencing can have actual physical effects on kids,” Falusi said. “Their brains are still developing, so they are particularly sensitive to their environments and their experiences.”

While most parents said they were still taking their children to the doctor, the report showed that some families have shifted toward more walk-in visits to avoid having to provide personal information to schedule an appointment.

Ramirez said his family still goes to the doctor when needed, but they try not to give any more personal information than necessary.

Falusi said she has seen a diminished use of health care services firsthand since the 2016 election. “When there are rumors around immigration raids, the parking lots are empty,” she said. “The clinics are empty.”

To try to help families feel more secure, physicians are posting welcoming signs and stationing bilingual staff out front. They are also reassuring families that their information will be kept confidential.

Both parents and pediatricians also reported that racism, discrimination and bullying — especially toward Muslims and Latinos — had increased since the election.

“The anti-immigrant rhetoric has really emboldened people to be outwardly hateful, and that is damaging for our kids in particular,” said Jenny Rejeske, senior health policy analyst at the National Immigration Law Center.

In addition, many aspects of daily life — including everything from driving to seeking jobs — have become more difficult for immigrant families, according to pediatricians and parents. One Latino parent from Boston, for example, said the children used to go to the park but now they spend more time inside for fear of being deported.

Daisy Juarez, 27, who was born in the U.S. and lives in Los Angeles, said the strict immigration policies have affected her entire family, especially her stepfather, a construction worker who is here illegally. Juarez’s sister, 10-year-old Amy, said she gets nervous about her dad being arrested by immigration officers. “What if they deport him and I can’t see him anymore?” she wondered. “If they deport him, I’m gonna miss him a lot.”

While deportations also soared under President Obama, they mostly targeted undocumented immigrants with criminal records, Rejeske said. President Trump has shifted that focus to all immigrants here illegally, regardless of how long they have been in the U.S. or whether they have children who are U.S. citizens, she said.

Trump also has banned travel from certain countries, boosted immigration enforcement and announced the end of the Deferred Action for Childhood Arrivals program, which provides temporary legal status to people brought to the U.S. illegally when they were children.

The two older children of Ramirez and Cadeo are both part of that program, known as DACA. Cadeo said she worries because now authorities have all of their children’s information and can easily find and deport them.

The pediatricians, interviewed this fall, were from eight states and the District of Columbia, and they serve immigrant populations. The focus groups were conducted in five languages with parents from 15 countries, including Mexico, Syria, Brazil and Korea. The discussions took place in Chicago; Boston; Bethesda, Md.; and five California cities — Fresno, San Diego, Oakland, Los Angeles and Anaheim.

Many of the parents who participated in the focus groups came to the U.S. after fleeing war and violence in their native countries, said Artiga of the Kaiser Family Foundation.

“They don’t have an option to return to their native country and now they are really worried about whether they are going to be able to remain here,” Artiga said. “Those individuals are in a really difficult situation.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

You can reach the author Anna Gorman at: agorman@kff.org, @AnnaGorman.

 

Whistleblower: Monterey Park-Based Medicaid Managed-Care Firm Improperly Denied Care To Thousands

December 8, 2017 by · Leave a Comment 

In early October, an executive at one of the nation’s largest physician-practice management firms handed her bosses the equivalent of a live grenade — a 20-page report that blew up the company and shook the world of managed care for poor patients across California.

For years, she wrote, SynerMed, a behind-the-scenes administrator of medical groups and managed-care contracts, had improperly denied care to thousands of patients — most of them on Medicaid — and falsified documents to hide it.

The violations were “widespread, systemic in nature,” according to the confidential Oct. 5 report by the company’s senior director of compliance, Christine Babu. And they posed a “serious threat to members’ health and safety,” according to the report, which was obtained by Kaiser Health News.

Days later, someone sent the report — labeled as a “draft” — anonymously to California health officials. Within weeks, state regulators had launched an investigation, major health insurers swept in for surprise audits, the company’s chief executive announced the firm would close and doctors’ practices up and down the state braced for a tumultuous transition to new management.

Jennifer Kent, California’s health services and Medicaid director, said her agency received the whistleblower’s report Oct. 8 and, working with health plans, confirmed “widespread deficiencies” at SynerMed, which manages the care of at least 650,000 Medicaid recipients in the state.

“I think it’s pretty egregious actions on the part of that company,” Kent said in an interview this week.

In a Nov. 17 order issued to insurers, state Medicaid officials said “members are currently in imminent danger of not receiving medically necessary health care services” due to SynerMed’s conduct. The state ordered insurers to determine how many enrollees experienced delayed or unfulfilled services.

Consumer advocates expressed alarm at the whistleblower’s findings and questioned why these problems went undetected for so long. Some said it underscores a lack of accountability among companies involved in Medicaid managed care — which receive billions in taxpayer dollars and have expanded significantly under the Affordable Care Act.

SynerMed headquarters in Monterey Park, Calif. The management firm oversaw care for 1.2 million patients. (Chad Terhune/California Healthline)

SynerMed headquarters in Monterey Park, Calif. The management firm oversaw care for 1.2 million patients. (Chad Terhune/California Healthline)

Linda Nguy, a policy advocate at the Western Center on Law and Poverty in Sacramento, called the situation “outrageous.”

“It raises questions about oversight by the state and the health plans,” she said.

Besides managing care for Medicaid patients, SynerMed also oversaw managed care services for people on Medicare and commercial insurance — 1.2 million patients in all. Physician groups it managed have contracts with most of the state’s largest insurers, such as Health Net, Anthem and Blue Shield of California.

SynerMed, founded in 2001 and based in the Los Angeles area, served as a key middleman in the managed-care industry between health plans and independent physician practices, and its role only grew after Medicaid was expanded under the ACA. Most, if not all, of the patients whose care it managed were in California.

Under Medicaid managed care, the government pays a fixed rate per patient to health plans, whose job is to coordinate patient care effectively and efficiently. In this case, health plans passed a share of their money — along with the financial risk of a fixed budget — to physician practices under SynerMed management.

As is typical in the managed-care industry, SynerMed and the physician practices could pocket whatever money they did not spend on patients and other expenses.

The whistleblower’s report does not address what the motivation was for falsifying denial letters to patients — except to note that the small team of employees felt intense pressure from their supervisors to clear a backlog of paperwork dating back months.

But Babu made clear that this was not a rogue operation. The methods they used were outlined in written training materials and knowledge of the procedures extended at least as high as a senior vice president, she wrote. After her investigation, other top executives were informed of her findings.

According to the report, she became aware of the problems in late September when a compliance manager heard about an employee falsifying a patient letter for an upcoming health plan audit.

Through interviews with sometimes tearful staffers, Babu wrote, she learned that an overworked team routinely fabricated denial letters without supervision from doctors or others with clinical training. The report suggested some cases were reviewed by medical personnel, but “staff members who are not clinicians could drastically misrepresent the medical director’s instructions.”

Some employees interviewed said they did not know what they did was wrong and said they were fearful of their bosses. One supervisor told Babu that these practices at SynerMed had persisted for many years and “that it had become normal for her,” according to the internal report.

Patients in Medicaid managed care and commercial plans are entitled to a written denial notice within two business days of the decision, giving them the ability to appeal to their health plan and then to regulators. Industry-wide, treatment denials were overturned in nearly 70 percent of all medical review cases handled by the state last year.

But the compliance department found that affected patients were not properly informed, and the violations “resulted in thousands of members unaware of their appeal rights going back years past. As such, members may experience delays in care, lapse in coverage, delay in access to care and or financial hardship.”

The denial letters fabricated by employees to satisfy auditors often were not sent to patients, according to Babu’s internal investigation. Employees also used software to backdate faxes to doctors’ offices to suggest physicians were informed promptly and properly about the denials.

The compliance investigation focused on activities at SynerMed and didn’t address what occurred at physician offices, so it is unclear what doctors knew and what patients actually were told when care was not authorized.

Babu said that “the severity of the conduct is magnified by the fact that a large number of SynerMed’s patient population is low-income, and likely unable to afford medical services not covered by their insurance.”Key Dates Whistleblower Kaiser Health News

In her report, Babu said she felt threatened and pressured to drop the matter during conversations with her boss, the general counsel and chief compliance officer. That person is identified elsewhere in the report as Renee Rodriguez.

During a meeting in her office on Oct. 3, Babu said “it seemed as if [Rodriguez] was trying to convince me to drop the case.”

The following day, Babu wrote “there is a likelihood that they [leadership of SynerMed] would terminate me. … I indicated that I would not stop fighting for what is just, and that I was prepared to involve the authorities as I now felt uneasy about everything.”

Babu couldn’t be reached for comment. Rodriguez didn’t return calls.

In a Nov. 6 email to employees, SynerMed’s chief executive, James Mason, said the company was shutting down. In a statement Wednesday to Kaiser Health News, apparently in reference to Babu, he said: “It is unfortunate that one of our employees jumped the gun and disclosed confidential information regarding our clients and members.”

Mason said the company suspended “this individual immediately so we could investigate exactly what information was transmitted,” including whether it included confidential patient information. That person and others were later laid off, he said, as health plan auditors stepped in and the company’s operations wound down.

He said the company took the allegations seriously and quickly investigated them.

In a separate statement, SynerMed’s chief medical officer, Dr. Jorge Weingarten, did not directly address whether rules were broken. Instead he emphasized that the company had protocols in which “all denials on the basis of medical necessity must be made by licensed physician or a licensed health care professional who is competent to evaluate the specific request.”

Health plans that contract with SynerMed’s medical groups condemned the alleged wrongdoing and said they were committed to helping any patients who may have been affected.

“There was a pattern of deception this organization was willing to engage in that raises integrity questions about the entire operation,” said John Baackes, chief executive of L.A. Care Health Plan. “For them it was better to cheat than follow the rules. We take it extremely seriously, particularly when lives are at stake in terms of getting timely access to care.”

Anthem Blue Cross, the nation’s second-largest health insurer, said some physician groups will be terminating their contracts with SynerMed due to the allegations. The company said it’s working closely with state officials and physicians “to ensure a smooth transition for all of our members affected by these changes.”

State Medicaid officials said health plans, at their own cost, also must collectively hire an independent firm to monitor activities at SynerMed during its shutdown to ensure an orderly transition and “retention of records.”

Nearly 11 million people in California’s Medi-Cal program, or 80 percent, are enrolled in managed-care plans, rather than the traditional fee-for-service system.

SynerMed billed itself as “one of the largest Medicaid/Medicare management service organizations in the nation.” Given its size and growing stature, insurers, doctors and regulators were caught off guard by the company’s sudden change of fortune.

“SynerMed has been at the forefront in how Medicaid expansion has moved forward in California,” said Bill Barcellona, senior vice president for government affairs at CAPG, a national trade group for physician organizations.

Unlike in private health insurance and Medicare Advantage, Barcellona said Medicaid managed care is more dependent on smaller physician groups that are less organized.

“SynerMed figured out they could create scale to provide some of the necessary infrastructure,” he said. “It has grown tremendously, and this has been a shock and a real setback.”

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Acute Confusion As Exchange Enrollment Gets Underway

November 2, 2017 by · Leave a Comment 

If the comments on Covered California’s Facebook page are any indication, you’re all suffering from acute health insurance confusion:

“I wanted to sign up again this year. … I’m hesitant now because of what Trump has done. Should I still consider?”

“Does the removal of subsidies mean we might lose our premium tax credits during the year?”

“So you’re telling me that [Trump’s] executive order didn’t do anything? I am so confused.”

Ask Emily is a series of columns answering consumers’ questions about California’s changing medical landscape.

I don’t blame you. Choosing a health plan will be doubly hard this year given President Donald Trump’s recent move to cut off federal payments for a key consumer subsidy, his administration’s decision to shorten exchange open-enrollment periods in most states to 45 days, Congress’ failed attempts to repeal Obamacare and the departure of some insurers from certain markets.

Let me ease your mind straightaway on three critical points:

  1. In California, open enrollment for individuals and families who buy their 2018 plans through Covered California and in the open market lasts three months, from Nov. 1 to Jan. 31.
  2. You won’t lose the tax credits that help you — and the vast majority of Covered California enrollees — afford your premiums, assuming you still qualify.
  3. The same goes for the cost-sharing subsidies that reduce out-of-pocket costs for some Covered California members, despite Trump’s decision to stop funding them.

But shopping will be challenging. Anthem Blue Cross is pulling out of a large swath of California’s individual market, on and off the exchange, forcing hundreds of thousands of consumers to find new plans. And in addition to regular, annual rate hikes — averaging 12.3 percent statewide — silver-level plans will bear an additional 12.4 percent average surcharge to make up for the loss of federal funding for the cost-sharing subsidies.1-ASK EMILYopen-enrollment-prices1

Remember, those are averages. Your actual premium will depend on several factors, including where you live, your income, what level of coverage you choose and which insurer you pick.

In an unexpected twist, some people may actually benefit from the surcharge because it could bring plans with more robust coverage within financial reach.

Before we get into all that, my most important piece of advice remains the same this year as before:

Don’t do this alone. Help from certified insurance agents and enrollment “navigators” is free. You can find local options by clicking on the “Find Help” tab on Covered California’s website, www.CoveredCA.com.

Silver-Plan Surcharge

Nearly half of Covered California enrollees qualify for cost-sharing subsidies, which lower their copays, deductibles and coinsurance. The subsidies are paid directly to insurers, and are separate from the tax credits that reduce monthly premiums.

These discounts are available only to silver-plan enrollees whose annual income falls between 139 percent and 250 percent of the federal poverty level — about $34,200 to $61,500 for a family of four. That’s why Covered California added the 12.4 percent average surcharge only to silver plans amid Trump’s threats — and ultimate decision — to stop funding the subsidies.

Covered California estimates that 78 percent of subsidized consumers will pay the same as — or less than — this year, despite the surcharge, because their tax credits will rise with their premiums. About half of the remaining 22 percent will see increases of less than $25 per month.

“This is potentially good news for both insurers and consumers,” says Greg Fann, a senior consulting actuary based in Murrieta. “And bad news for taxpayers,” who are footing the bill for the increased tax credits.

Fann offers advice to consumers based on their income.

Covered California enrollees with incomes up to roughly 200 percent of the federal poverty level — or about $49,200 for a family of four — should probably remain in silver plans, he advises, because they qualify for significant cost-sharing reduction subsidies.

Policyholders who make between 200 and 400 percent of the federal poverty level (400 percent is about $98,400 for a family of four) should consider ditching silver plans and applying their higher tax credits to gold or platinum plans, he says. Tax credits are pegged to the cost of silver plans, which means that all subsidized enrollees will benefit from higher tax credits as silver premiums rise, regardless of which plan they ultimately purchase.

Gold and platinum plans are more expensive than silver plans, but they offer higher levels of coverage and lower out-of-pocket costs.

In some cases, “the gold may be cheaper than the silver,” Fann says.

You could also apply your increased tax credits to bronze plans, which have lower premiums and higher out-of-pocket costs. According to Covered California, three-quarters of enrollees can sign up for bronze coverage for less than $10 a month.

“I suspect a lot of people are going to downgrade their plans to high-deductible plans,” says Helena Ruffin, an insurance agent in Playa Vista.

Finally, there are about 65,000 Covered California enrollees with silver plans who don’t receive premium tax credits, says exchange spokeswoman Amy Palmer.

People in this group must pay the entire cost of their premiums.

“These are the ones in the middle class that are … getting hammered,” Ruffin says.

If you’re in this category, avoid the surcharge by buying a bronze, gold or platinum plan. Or, opt for a newly created silver plan sold off the exchange that won’t be subject to the surcharge — if you’re confident your income will remain above the threshold to qualify for premium tax credits.

“There may be better options off the exchange,” Palmer says. But if your income fluctuates, “it may be better to stay on the exchange so that you can receive tax credits if you become eligible,” she adds.

Health Plan Departures

Anthem will pull out of 16 of California’s 19 pricing regions, affecting about 300,000 policyholders who purchase from the individual market, both on and off the exchange.

Its departure will leave about 60,000 Covered California consumers with one option — Blue Shield of California. If you do not select a new plan by mid-November, Covered California will automatically enroll you in one. If you’re not satisfied with its decision, you can change it before the end of open enrollment, assuming you have a choice.

For those of you losing your insurer, you’ll want to know whether your existing providers are in any other Covered California plan networks.

Unfortunately, “the doctors networks are smaller and smaller all the time,” says Tom Freker, an insurance broker in Fountain Valley.

Covered California this year has debuted a revamped online directory that will allow you to search five doctors, hospitals or pediatric dentists at once.

It’s part of the agency’s “Shop and Compare” tool that allows you to enter your personal details to retrieve your plan choices and costs.

Because the directory is new, I urge you to cross-check with your plan and/or your provider.

Also, if you’re in the middle of treatment for a complex medical condition and lose your insurer, you may have options. A new state law will allow some seriously ill patients to continue seeing their current providers for a limited time.

Your new insurer may also be able to work with your existing provider to finish your treatment. Covered California advises you to call your new health plan to explain your situation.

 

 

Beyond The Shattered Lives And Bodies, Money Worries Weigh On Las Vegas Victims

November 2, 2017 by · Leave a Comment 

LAS VEGAS — Kurt Fowler and his wife, Trina, were celebrating their 18th wedding anniversary at a country music festival when the shooting started. Fowler, 41, knew he’d been hit in the ankle and couldn’t run. He hid under the stage until the gunfire ended.

“I knew my foot was completely useless,” said Fowler, a firefighter from Lake Havasu City, Ariz., and a father of three. He underwent surgery, spent nearly two weeks in the hospital and still may need another operation. He also will need rehabilitation and follow-up visits with a specialist.

Fowler has a Blue Cross Blue Shield PPO through his job, but he said he doesn’t know how much he will have to pay out of his own pocket for the care he is receiving. In an era of higher deductibles and limited choice of in-network doctors, however, he knows he could face significant medical bills.

His insurance card says his individual deductible is $5,000 and his coinsurance 20 percent. He said he didn’t know how much his health plan would cover for out-of-state care.

“Medical expenses are astronomical these days,” Fowler said from his bed at Sunrise Hospital & Medical Center here. “It’s a mountain that just doesn’t seem like it’s gonna be climbable, but we are gonna do our best.”

As hundreds of survivors struggle to recover emotionally and physically from the Oct. 1 attack, they are beginning to come to terms with the financial toll of the violence perpetrated against them. Even those who are insured could face untold costs in a city they were only visiting.

Michael Caster, from Indio, Calif., was shot as he ran from the Route 91 Harvest festival in Las Vegas. Now, he is paralyzed from the waist down. Fowler’s mom, Patricia, was also at the festival and said she fears how expensive his medical care may be. But she said, “Whatever expenses come down the road, we’ll handle it somehow.” (Anna Gorman/KHN)

Michael Caster, from Indio, Calif., was shot as he ran from the Route 91 Harvest festival in Las Vegas. Now, he is paralyzed from the waist down. Fowler’s mom, Patricia, was also at the festival and said she fears how expensive his medical care may be. But she said, “Whatever expenses come down the road, we’ll handle it somehow.” (Anna Gorman/KHN)

The total costs of medical care alone could reach into the tens of millions of dollars, said Garen Wintemute, who researches gun violence at the University of California-Davis. And that is just the beginning. Many survivors will be out of work for months, if they are able to return at all.

“We really don’t have a good handle on the intangible costs of something like this … the ripple effects on family and friends and neighborhoods when a large number of people have been shot,” Wintemute said.

 

More than 100,000 people are shot every year in the U.S., according to the Centers for Disease Control and Prevention. That generates about $2.8 billion per year in emergency room and inpatient charges alone, according to a recent study in Health Affairs. The average emergency room bill for an individual gunshot victim is $5,254 and the average inpatient charge is $95,887, according to the study.

The U.S. senators representing Nevada, Dean Heller and Catherine Cortez Masto, wrote a letter to America’s Health Insurance Plans, an industry trade group, and CEO Scott Serota of Blue Cross Blue Shield requesting help with out-of-network bills, copayments and deductibles for the Las Vegas shooting victims. Many of the people who were shot had traveled from other states, including California, Iowa and Tennessee.

California and some states protect consumers from such bills, but Nevada is not one of them, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. But Corlette said most insurers allow patients to request exceptions based on the circumstances. “In this situation, I imagine most insurers are going to want to be compassionate and work something out,” she said.

The victims and their families aren’t the only ones who will be affected financially by the mass shooting. Taxpayers, too, pick up much of the tab for the health care costs associated with gun violence because many patients are covered by Medicaid and Medicare, two government insurance programs.

And hospitals will also be on the hook for some of the care for patients who don’t have insurance. Hospitals in Las Vegas quickly mobilized to treat the hundreds of victims who were streaming in that night, and they don’t know yet how much of the care will be reimbursed.

At Sunrise Hospital & Medical Center, staff treated more than 200 patients. Sunrise plans to file insurance claims and will “be extremely sensitive to the financial status” of patients when considering their out-of-pocket portions, a spokeswoman said.

Valley Hospital Medical Center is encouraging patients to complete paperwork for a state program called Nevada Victims of Violent Crime, which would pay their balances. And Dignity Health’s St. Rose Dominican said it will bill insurers and accept donations but will not require payment from victims.

California victims can also get help with medical expenses and income loss from the California Victim Compensation Board.

Mary Moreland gets an update on her daughter from neurosurgeon Keith Blum at Sunrise Hospital & Medical Center. Moreland’s daughter, Tina Frost, was shot in the eye and was in a medically induced coma for two weeks. Frost has insurance through her job as an accountant in San Diego, but her mother said she knows it won’t cover everything. (Anna Gorman/KHN)

Mary Moreland gets an update on her daughter from neurosurgeon Keith Blum at Sunrise Hospital & Medical Center. Moreland’s daughter, Tina Frost, was shot in the eye and was in a medically induced coma for two weeks. Frost has insurance through her job as an accountant in San Diego, but her mother said she knows it won’t cover everything. (Anna Gorman/KHN)

In addition, a GoFundMe account started by a Clark County commissioner has raised more than $11.3 million thus far. And many survivors have individual GoFundMe accounts.

Kurt Fowler’s GoFundMe page has raised more than $41,000. Fowler said he doesn’t have disability insurance so he will rely on the funds to help cover his expenses while he is recovering and missing work.

Michael Caster, 41, who lives in Indio, Calif., has a GoFundMe account that has raised over $27,000 so far. He’s paralyzed from the waist down after a bullet lodged in his spine.

At Sunrise Hospital, doctors drained the blood from Caster’s lungs and removed some of the bullet fragments. Sitting in a hospital bed 11 days after the shooting, Caster said he didn’t know how much of his care would be covered by his health insurance.

He works in human resources at a California hospital and has a job-sponsored policy with Anthem Blue Cross. “I’ve never really dealt with injury,” he said. “I don’t want to be stuck with a bunch of bills.”

His bills could rise further: That day, he was scheduled to be flown to a rehabilitation center in Colorado for people with spinal cord injuries.

Mary Moreland, whose daughter Tina Frost was shot during the country music festival, said that at first she didn’t understand why so many families were setting up fundraisers. Then, the severe financial strain the shooting would take started to dawn on her.

Now, Moreland said she’s grateful for the $583,000-plus raised as of Sunday through GoFundMe.

 

Frost, a resident of San Diego, had emergency brain surgery the night of the shooting. A bullet had pierced her eye and exploded in her brain. As she lay in ICU earlier this month, her mother said small improvements were major milestones. “Today she squeezed my hands,” Moreland said.

The next night, Frost came out of a medically induced coma and was later flown to Johns Hopkins Hospital in Baltimore, near her mother’s home. Over the next weeks and months, she will need multiple operations and a slew of specialists, including neurosurgeons, plastic surgeons, occupational therapists and mental health counselors.

Moreland said she cannot even begin to imagine what her daughter’s care will cost. Frost has Blue Cross insurance through her job at Ernst & Young in San Diego, but Moreland said she doesn’t know what the deductible and copayments are.

“Being realistic, knowing what I know about costs of health care, it’s scary,” Moreland said. “But she’s alive. She’s not one of the 58 other people.”

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation. Anna Gorman: agorman@kff.org, @AnnaGorman

Imagining A Single-Payer Health System In California

October 5, 2017 by · Leave a Comment 

With the crumbling of the latest GOP plan to repeal and replace the Affordable Care Act, many Americans seem more willing to discuss what a single-payer system might look like and whether it is desirable — or even possible.

U.S. Sen. Bernie Sanders (I-Vt.) recently introduced a Medicare-for-All Act, which would gradually expand the government-financed system to the general population while eliminating private insurance companies and consumer cost sharing, such as copays and deductibles. Although the bill is backed by 16 Democratic senators, including California’s Kamala Harris, observers predict it has no chance of moving through a Republican-controlled Congress.

California lawmakers took a fresh look at single-payer health care this year through SB562, a proposal to create one government-financed program that covers all Californians. That bill stalled, but debate will continue this fall in legislative hearings. A grass-roots campaign is underway to put a plan to finance such a system before voters.

“It is time to have those discussions [as] to how we actually get everyone covered, and get them covered in a way that they can afford to pay for care when they need it,” said Jen Flory, policy advocate with Western Center on Law & Poverty, a group that supported the single-payer bill in concept.

But Rob Lapsley, president of the California Business Roundtable, expressed concerns about the enormous costs of building such as system, saying “the numbers matter.” He said a government-financed health care system for all cannot be allowed to endanger funding for other public services — like education and public safety — which ensure a high quality of life in California.

Flory and Lapsley were among the consumer advocates and industry players who last week sat side by side in Sacramento to debate the merits and challenges of universal health care coverage, whether through a single payer or other means.

The discussion occurred during a conference in Sacramento last week called “Health Care In Crisis,” organized by Capitol Weekly and the USC Sol Price School of Public Policy. California Healthline/Kaiser Health News Sacramento correspondent Pauline Bartolone moderated the discussion.

Other panelists included Dr. Paul Song, co-chair of the Campaign for a Healthy California, a coalition that formed to support California’s single-payer effort, and Mark Sektnan, president of the Association of California Insurance Companies.

 

California Healthline is produced by Kaiser Health News, delivering expanded coverage of health policy news in California and original reporting that highlights the state’s outsized influence on the nation’s health care system.

Tips On Finding Nursing Home Bed When On Medi-Cal

October 5, 2017 by · Leave a Comment 

Most everyone agrees it can be very difficult — next to impossible, really — for Medi-Cal enrollees to snag a spot in a nursing home, especially if they’re transferring from their homes or assisted living facilities rather than going straight from the hospital.Senior man taking cough syrup while reclining on hospital bed

Not everyone agrees on the reasons, however.

“There’s massive, systemic Medi-Cal discrimination,” says Pat McGinnis, executive director of California Advocates for Nursing Home Reform. She believes some nursing homes illegally turn away enrollees because they don’t want to accept Medi-Cal’s lower reimbursement rates.

“If they can get more money with private pay or Medicare, they would rather accept one of them,” she says.

Deborah Pacyna, director of public affairs for the California Association of Health Facilities, which represents most of the state’s standalone nursing homes, says it’s illegal for nursing homes to discriminate based on payment type. She blames access problems on the state’s rapidly aging population.

“Projections are that we will run out of nursing home beds by 2020,” Pacyna says. “That is putting even more pressure on the Medi-Cal population.”

No matter what you believe, the situation amounts to a crisis for Californians who desperately need a nursing home and are covered by Medi-Cal, the state’s version of the federal Medicaid program for low-income residents, says Susan Geffen of Hermosa Beach, an elder law attorney, gerontologist and author of the book “Take That Nursing Home and Shove It!”

If you think low-income doesn’t mean you, think again. Many middle-class Californians need Medi-Cal to help pay for their long-term care because they run out of money paying the bills on their own, she says.

Despite the access challenges many Medi-Cal enrollees face, about two-thirds of California’s nursing home residents rely on the program to cover all or part of their costs.

The state Department of Health Care Services (DHCS), which oversees Medi-Cal, says that nearly 90 percent of California’s 1,400 nursing homes accept its enrollees. The department is the only entity I interviewed that “is not aware of Medi-Cal members who are having difficulty finding a nursing home that will accept them.”

Today, I’m offering some advice if you or a loved one needs a nursing home for a long-term stay. It will be easier if you’re already in the hospital, which I realize is cold comfort.

Finding a bed if you’re not in the hospital — especially a bed in your community — might mean you’ll have to pay out of your own pocket initially. Or it might require some creative maneuvering, like working with your doctor to get you admitted to a hospital. Even then, “a hope and a prayer” might be necessary, says Derrell Kelch, executive director of the California Association of Area Agencies on Aging.

 

If You’re Coming From the Hospital

More than 90 percent of nursing home admissions last year came directly from hospitals, according to data from the Office of Statewide Health Planning and Development.

If you or a loved one is in the hospital and may not be able to return home afterward, “start working with the hospital discharge planner immediately” and ask for a list of nearby nursing homes, Kelch advises.

If you have fee-for-service Medi-Cal, you will require prior authorization, and the request must be made by the hospital or the nursing home, says DHCS spokeswoman Carol Sloan. If you’re in a Medi-Cal managed care plan, it will help determine where you go, she says.

You may want to visit the facility first before committing your loved one to it, Pacyna suggests. Also check out Nursing Home Compare on the Medicare website for quality ratings.

Medicare, the publicly funded health insurance program for older Americans, is often the first payer when you move into a nursing home. Under certain conditions, it will cover you for a limited time — up to 100 days.

The traditional form of Medicare will pay 100 percent for the first 20 days, after which you will owe $164.50 a day for up to 80 additional days. But you can qualify for this coverage only if you enter a Medicare-approved nursing facility within 30 days of an inpatient hospital stay that lasted at least three days. Beware: “Observation” care in the hospital won’t count as an inpatient stay.

Medicare does not cover long-term nursing home stays.

So, once you are in the nursing home, don’t wait to apply for Medi-Cal if you’re not already enrolled in it, Geffen says. Medi-Cal can help cover your Medicare copays, if you’re eligible, and then take over when your Medicare coverage ends, she says.

“They can’t just discharge somebody [from a nursing home] because they’re going on Medi-Cal,” McGinnis says.

If the nursing home balks and says it can’t keep you after you’ve switched to Medi-Cal, you can seek help from McGinnis’ organization (www.canhr.org or 800-474-1116) or another advocacy group, including legal services organizations or your local Long-Term Care Ombudsman, she says.

Be sure to let the facility know that you know it can’t discriminate against Medi-Cal enrollees, McGinnis adds.

If You’re Coming From the Community

Just because a small percentage of patients admitted to nursing homes last year came from their homes or assisted living facilities doesn’t mean people aren’t trying, says Mike Connors, an advocate for McGinnis’ group.

“It’s just extraordinarily difficult,” he says. “People end up waiting for months. … They get sick and get hospitalized.”

To find a facility that is certified for Medi-Cal, go to the state Department of Public Health’s database at hfcis.cdph.ca.gov. You might need to target larger nursing homes that have higher turnover, McGinnis says.

If it’s financially possible, consider starting out as a private-pay client.

Instead of getting rid of all of your money ahead of time to become eligible for Medi-Cal long-term care coverage, Geffen suggests keeping some in reserve so you can gain entry as a cash customer.

Then, once you’re a resident and run out of money, “they’re not allowed to kick you out,” Kelch says.

Geffen also knows of people who have gone to the hospital in the hope of getting admitted, so they can be discharged directly into a nursing home. “Some people have had to go to extraordinary feats in order to get into a nursing home on Medi-Cal,” she says.

You can also consult with your doctor to devise a plan. If she agrees that you need to be in a facility, request documentation that you can take to the nursing home as proof, Pacyna says. Or, “if you’re ill, it may be appropriate to be admitted to the hospital,” Connors says.

I wish there were more support for individuals and families struggling through this.

Placement services, such as A Place for Mom, can help you find a nursing home with openings. You can also talk to an elder law attorney.

You can even ask your county social services department for help, says Benson Nadell, director of the San Francisco Long-Term Care Ombudsman program. “People cannot navigate this complex system on their own,” he says.

 

Feds Give Calif. Poor Marks On Monitoring Foster Children

September 28, 2017 by · Leave a Comment 

The federal government has given California bad marks on monitoring the well-being of children in foster care.

State officials were slow to investigate complaints of abuse or neglect, failed to notify investigators of serious sexual abuse allegations and didn’t follow up to ensure cases were resolved, according to an audit released late Monday by the U.S. Department of Health and Human Services’ Office of Inspector General.

In some cases, investigations took more than a year to complete, according to the report. It said these problems arose either because officials didn’t follow procedures or because they had not been properly trained to handle complaints. An audit released in May by the inspector general revealed similar deficiencies in the foster care agency of Texas.

Michael Weston, a spokesman for the California Department of Social Services, said his agency agreed with the report’s findings, which were provided to the agency earlier, and either has implemented or is working on the changes recommended by federal auditors. The auditors noted that the agency has re-hired former employees to support investigations of complaints and has created dashboards for managers to better track the progress of investigations.

The state agency oversees about 60,000 children under 18 who are in foster care. Federal auditors reviewed 100 cases selected from among the nearly 6,200 complaint investigations completed by the state agency between 2013 and 2015.

California’s child welfare system has been scrutinized in recent years as media reports have highlighted the overuse of powerful psychiatric drugs and the dubious arrests of foster children in temporary shelters around the state. The state has been criticized previously for lagging on investigations of abuse and neglect. California’s privatization of some foster care, leaving independent agencies to recruit and oversee foster families, also has raised concerns.

Child welfare experts say that it’s important to investigate reports of abuse or neglect in foster homes quickly and thoroughly because the consequences for vulnerable children can be severe, even fatal. A 4-year-old Sacramento girl was killed in her foster home in 2010, apparently burned by a Molotov cocktail. She previously had been injured while in foster care, according to media reports.

The state agency’s official goal is to investigate all cases within 90 days. But the federal audit found that in some cases, no investigative actions were logged for up to 15 months, suggesting that no one was working on them. In addition, investigators either did not visit or could not provide proof that they had visited the foster family home, group home or foster care agency cited in the complaint within the 10 days required by law.

“The failure to complete investigations in a timely manner — noted in 78 of 100 complaints — is the most egregious finding in the report,” Bill Grimm, senior attorney at the National Center for Youth Law, wrote in an email.

Grimm said the agency’s existing goal of investigating abuse or neglect complaints within 90 days “should be unacceptable” because the goal is only 30 days for children who are not in foster care.

If investigations aren’t completed promptly, children who have been maltreated often move on to other foster care placements “and critical information is lost,” he said.

Stacy Castle, chairwoman of the Child Abuse Council of Santa Clara County, said she and her colleagues have long worried about how complaints of child abuse against all children — including foster children — were logged and investigated by the state. But she said a new manager at the California Department of Social Services earlier this year improved the situation by adding staff to the complaint hotline and extending its hours.

“There’s been a significant turnaround in a lot of these” issues raised by the audit, Castle said.

Has California Hit The Brakes In Regulating Breath-Robbing Big Rigs?

July 27, 2017 by · Leave a Comment 

OAKLAND, Calif. — James Lockett sits on his bed and opens the drawer of his nightstand, revealing a stash of asthma inhalers: purple disc-shaped ones he uses twice a day to manage his symptoms and others for full-blown attacks.

Lockett, 70, says he never leaves home without an emergency inhaler.

His senior housing complex in East Oakland is less than a mile from Interstate 880, a major corridor for freight trucks shuttling to and from the Port of Oakland. On the way to factories and warehouses, the trucks often roll through streets near homes, schools and libraries.

The diesel-fueled big rigs are a major source of air pollution, spewing soot and other pollutants that can cause or aggravate respiratory conditions such as asthma and bronchitis.

Just walking while talking on his cellphone can leave him short of breath, Lockett said. “The [asthma] triggers here, without my medications, it would be terrible.”

California has cleaned up its diesel fleet significantly in recent years by phasing out older trucks and requiring operators to install the latest pollution-control equipment. But local air district officials and environmental advocates say more needs to be done and that the emissions goal should be close to zero.

Efforts to get there are stalled, they say, in part because of a provision in the $52 billion road improvement law signed in April by Gov. Jerry Brown. That provision exempts most diesel trucks on the road from future emissions reduction requirements for many years.

Regulators and environmentalists warn that, without further reductions in emissions, many residents who live near major truck routes or the port remain at high risk of cancer, heart problems, asthma and other lung diseases, especially children and seniors.

Asthma is a critical problem in Oakland for these two groups. Among other indicators, the rate of emergency room visits for asthma among seniors (age 65 and older) in East Oakland, where Lockett lives, is nearly three times higher than it is statewide, and the rate in West Oakland is nearly two times higher, according to state and county data.

Austin Carter, 13, learns how to properly use an inhaler during his visit at the Breathmobile clinic in Oakland in May. (Heidi de Marco/California Healthline)

Similarly, children in these neighborhoods go to the emergency room for asthma at more than double the rate of their peers statewide, according to 2016 data. In the heart of West Oakland, near the port, nearly 21 percent of children have been diagnosed with asthma, according to 2014 data from the California Health Interview Survey. That’s well above the statewide average of 15 percent.

A mobile asthma clinic called a Breathmobile regularly parks at elementary schools near the port, and Darryl Carter makes good use of it for son Austin, 13. During a recent visit, he recalled a terrifying attack eight years ago that sent Austin to the hospital. Since then, the boy’s been back to the hospital three or four times — not ideal, but the Breathmobile visits have made a difference.

Asthma has multiple causes and triggers, including poor housing conditions, a family history of the disease, certain weather conditions and exposure to cigarette smoke. Poverty, lack of access to health care and little knowledge of preventive care all can contribute to high rates of emergency visits, said Dr. Washington Burns, administrative director of the Breathmobile in Northern California.

However, “there’s often more asthma around corridors with trucks and cars than in areas where there aren’t,” Washington said.

Diesel trucks account for 2 percent of vehicles but emit 30 percent of key smog-forming nitrogen oxides and 65 percent of the soot attributable to motor vehicles, according to the state Air Resources Board (ARB).

A ‘Dirty Deal’?

In 2015, the Oakland City Council began diverting trucks from streets with homes, schools or senior centers. But some community activists say enforcement of these local ordinances has not been strong enough.

The provision in the state’s new law exempts all but the oldest or highest-mileage trucks from any new emission reduction rules the state might impose. The exemption lasts 18 years from the time they meet current emissions standards or until they have traveled 800,000 miles.

It’s unclear exactly how the exemption will affect local air districts and ports that want to cut emissions further. Environmentalists say these agencies may face resistance and risk being sued by the trucking industry if they forge ahead with more aggressive plans.

Critics say the governor agreed to the last-minute exemption to gain the trucking industry’s support for higher diesel and gas taxes that, along with vehicle fees, are expected to raise $5.2 billion annually over 10 years to repair roads and bridges and to expand public transit.

 

Bill Magavern, policy director for the Sacramento-based Coalition for Clean Air, said improving infrastructure is laudable but should not come at the cost of clean air.

“There’s a lot to like in that bill, and we hated to oppose it,” but there was a “dirty deal” thrown in at the last minute, Magavern said.

Gov. Brown’s office referred questions on the truckers’ amendment to the ARB, the state’s clean-air agency.

The ARB said it can provide incentives to further reduce emissions without imposing additional requirements. And the new law, it said, will strengthen enforcement of existing rules.

Under the law, “truck operators can be denied [Department of Motor Vehicles] registration if they’re not meeting the current rules,” board spokesman David Clegern said. “Diesel pollution will be reduced by bringing 300,000 more trucks into compliance.”

Local air managers in Southern California say greater enforcement of current rules is important, but it won’t sufficiently accelerate turnover of the truck fleet. And that’s crucial to helping Southern California meet federal clean-air standards, said Philip Fine, deputy executive officer of planning and rule development with the South Coast Air Quality Management District.

The problem for local air districts and ports is that when it comes to directly regulating mobile sources of pollution like diesel trucks, the state is the boss. It approves local district plans, and the local districts more or less oversee the ports. So the most effective way to reduce trucker emissions is to set stringent policy at the state level, as California has aggressively done in the past.

Emissions Way Down

But truckers say the state has imposed enough requirements. Chris Shimoda, vice president of government affairs for the California Trucking Association, said diesel emissions from trucks in California ports have fallen dramatically in recent years.

“This is attributable to the current $1 billion annually being invested by truckers in the cleanest available technology throughout the state,” Shimoda said.

He also said that being exempted from any future state emissions-reduction requirements reassures the trucking industry that it will recoup the investment it is making in new engines to meet current state standards.

Under existing state rules, owners of heavy-duty trucks must have 2010 or newer-model engines by 2023.

Those rules have dramatically improved air quality. A study by the Bay Area Air Quality Management District, among others, found that from 2009 to 2013 emissions of black carbon from trucks at the Port of Oakland dropped by 76 percent and nitrogen oxides by 53 percent.

People living near ports like the one in Oakland have benefited from the state’s efforts to clean up the truck fleet — by phasing out older models and requiring operators to install the latest pollution-control equipment. (Heidi de Marco/California Healthline)

Critics: More Progress Needed

Still, ports throughout the state rely mostly on diesel to power vessels, yard equipment, trains and trucks. Ports in Southern California remain the single-largest fixed source of smog-forming pollution in the region. And the Port of Oakland is the largest fixed emitter of diesel pollution in the Bay Area, local air managers say.

That’s why local districts were alarmed by the governor’s concession to the trucking industry, said Tom Addison, legislative and policy adviser for the Bay Area air district.

It “gives the trucking industry a get-out-of-jail-free card,” said David Pettit, senior attorney with the Natural Resources Defense Council. “It bars any kind of state regulations that might require truckers to move to a different kind of truck — natural gas-powered, electric or hydrogen fuels — when those become available in the market.”

Last month, the mayors of Los Angeles and Long Beach set ambitious goals for the ports to transition to zero-emission truck and yard equipment over the next 20 years. The mayors affirmed that the ports’ 2017 clean-air blueprint, which is expected to be released Wednesday, will include further emissions reductions from ships and the development of a zero-emissions truck pilot program.

But the new state law calls into question whether those plans — and others in coming years — will be enforceable.

If the ports in Southern California announced that in five years they’re going to have an all zero-emissions fleet, Pettit said, “they’d be sued [by the trucking association] in a heartbeat.”

Updated 4:30 p.m.: Includes entire text of original story published by California Healthline.

Calif. Officials Sound Alarm, Envisioning $114B Hit To Medi-Cal Under U.S. Senate Bill

June 29, 2017 by · Leave a Comment 

California risks losing $114.6 billion in federal funds within a decade for its Medicaid program under the Senate health care bill, a decline that would require the state to completely dismantle and rebuild the public insurance program that now serves one-third of the state, health leaders said Wednesday.

The reductions in the nation’s largest Medicaid program would start at $3 billion in 2020 and would escalate to $30.3 billion annually by 2027, according to an analysis released by the state departments of finance and health care services.

“It is not Medicaid reform,” Jennifer Kent, director of the state Department of Health Care Services, said in an interview. “It is not entitlement reform. It is simply a huge funding reduction in the Medicaid program. We are deeply concerned what that means for the long-term viability of the program as it stands today.”

Los Angeles County Supervisor Hilda Solis and other county leaders pledged to fight Republican efforts to overturn Obamacare. “The bill ends Medi-Cal as we know it,” Solis said during a press conference Tuesday in downtown Los Angeles. “We are not going to give up.” (Anna Gorman/California Healthline)

Los Angeles County Supervisor Hilda Solis and other county leaders pledged to fight Republican efforts to overturn Obamacare. “The bill ends Medi-Cal as we know it,” Solis said during a press conference Tuesday in downtown Los Angeles. “We are not going to give up.” (Anna Gorman/California Healthline)

Medicaid covers a staggering 13.5 million low-income Californians — children, people with disabilities, nursing home residents and others. About 3.8 million of them, many of whom are chronically ill, became eligible for coverage under the Affordable Care Act, informally known as Obamacare.

California would face the biggest losses of any state, according to a report issued Wednesday by the consulting firm Avalere Health. Federal funding would drop by 26 percent over 10 years, the report said. Many states, including Alabama, Georgia, Texas and Florida, would face a drop of less than 10 percent.

The Senate bill to repeal and replace the ACA would be a “massive and significant fiscal shift” of responsibility from the federal government to states, according to the analysis. It would force difficult decisions about who and what to cover and how much to pay doctors, hospitals and clinics, the report said.

In addition to expanding its Medicaid population early and vigorously under Obamacare, the state began covering undocumented immigrant children last year. California’s program, known as Medi-Cal, also provides dental care and other services that are optional under federal Medicaid rules.

The state’s Medicaid director, Mari Cantwell, said Republican proposals present a fundamental problem that can’t be solved by making cuts around the edges.

“Nothing is safe — no population, no services,” Cantwell said. “It is really disheartening and honestly horrifying to think about the world under this Senate bill and what it would mean.”

The losses are more than what was predicted under the House bill. The analysis said that’s because the cost shift increases over time under the Senate proposal.

Ken Bascom, 62, was diagnosed with kidney cancer after becoming eligible for Medi-Cal in 2014. Bascom is now cancer-free but said that without insurance, “more likely than not, I would’ve been dead.” (Anna Gorman/California Healthline)

GOP leaders in Congress have been trying to repeal the ACA for seven years, deeming it disastrous public policy that costs too much and leaves consumers with rising premiums and too few choices for care.

The Senate bill would overhaul Obamacare in several ways. Besides revamping the Medicaid program, it would dramatically change the system of tax credits used to help low-income Americans get health coverage. The Congressional Budget Office concluded that the bill would cut the federal deficit by $321 billion over the next decade while leaving 22 million more Americans without health insurance.

Unable to lock down the support he needs in the Senate, Majority Leader Mitch McConnell on Tuesday postponed a vote on the bill until after the July Fourth holiday. Its fate remains uncertain as senators head back to their districts for a weeklong recess.

Under the legislation, the federal government would pay a fixed amount to states for Medicaid expenditures, a per capita rate, instead of paying for a share of all expenses incurred.

State health leaders predict that the state’s costs would outpace the federal government’s allocation, meaning California would have to come up with an additional $37.3 billion between 2020 and 2027.

“Whether it’s drugs or cost of living going up or new technologies in health care, there are costs we can’t control,” Cantwell said. “And if you have a trend factor that doesn’t really reflect the reality of what health care looks like, the state is always going to be in a place of not being able to bring the costs within that target.”

The proposed financial caps would have a “devastating and chilling effect” on spending in the Medicaid program and would pinch providers further, the analysis said. California already ranks near the bottom for how much it pays Medicaid providers.

The Senate’s overhaul of Obamacare would also force hospitals and clinics serving the poor and uninsured to live within the new financial limits, leading to “uncompensated care in the hundreds of millions, if not billions annually,” according to the analysis.

In addition, the Senate bill would phase out funding for the expansion of Medicaid, which enabled 3.8 million single, childless adults and others in the state to qualify. Under the Affordable Care Act, the federal government pledged to pay for 90 percent of their costs. But the Senate bill would reduce that to 50 percent beginning in 2024.

Without the promised federal funds, California would have to spend five times more than previously estimated to continue covering those newly eligible. By 2027, the cumulative cost to California would be $74.1 billion, according to the analysis.

California leaders vowed Tuesday to fight the bill, known as the Better Care Reconciliation Act. “Simply stated, this is a terrible bill and we must defeat it,” said Democratic Sen. Dianne Feinstein in a call with reporters.

Sen. Kamala Harris, also a Democrat, added that the most vulnerable populations are the ones who have most to lose: children, people with disabilities, seniors. “This bill is nothing short of a disaster, and it’s no wonder they did it in secret because they have nothing to be proud of,” said Harris, who aims to kill the bill before it hits the Senate floor.

The fallout would be particularly bad in Los Angeles County, home to 1 of every 20 Medicaid recipients in the nation, county officials said Tuesday.

“L.A. County will be ground zero for the plan’s deadly consequences,” said county Supervisor Sheila Kuehl during a press conference. “This is not just about money. … This is about the people who count on us for health care.”

During the conference, several Los Angeles County residents and union members held up signs that read “Healthcare is a Human Right” and, in Spanish, “SALUD para todos,” or “Health for everyone.”

Ken Bascom, 62, who lives in Venice, Calif., and attended the gathering, said he lost his job and his employer-based insurance during the recession. Soon after Bascom became eligible for Medi-Cal in 2014, he was diagnosed with kidney cancer. Now cancer-free, Bascom said he often thinks about what would have happened if he hadn’t been able to get health care.

“More likely than not, I would’ve been dead,” said Bascom, who gets care at Venice Family Clinic. “It’s very scary.”

Also in attendance was Steven Martin, 27, who said he depends on insurance he got through Obamacare to pay for his leukemia treatment. Martin, who has private insurance through Covered California, the state’s exchange, said his medication costs tens of thousands of dollars each year.

“Without insurance, I’m not going to have access to my medication,” he said.

Los Angeles County Health Agency Director Mitch Katz said the ACA made a “huge difference” in the county — dramatically cutting the uninsured rate, reducing wait times at emergency rooms and helping connect patients to primary care doctors.

“The emergency rooms themselves often had two- and three-day waits,” he said. “Because of the ACA, that is no longer the case. … The emergency room now is back to what is should be — for emergencies.”

Katz said he feared all of that would change if the Republicans succeed in overhauling the health law.

Ana Ibarra contributed to this report.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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