Some Californians will clearly fare better than others under President Clinton's proposed health plan.
The plan is good news for many people not now covered by health insurance. But it is bad news for many of those covered now who might find they have to pay more.
Small employers who don't provide insurance to their employees figure to be hit hard, but many large employers will be helped.
The full extent of what the Clinton plan means for California won't be known for months. But enough of the plan has been released so far to give those familiar with the health system a good idea of what may be in store for the state.
California stands to benefit more than other states in at least one important respect: It has more uninsured than anywhere else--an estimated 6 million people--due in part to the state's sluggish economy that has put many people out of work.
"The sigh of relief here if the plan passes will be a little louder than anywhere else because we have more uninsured," said Drew Altman, president of the Henry J. Kaiser Foundation, which has done extensive polling and analysis of the health system.
Key groups of the uninsured in California include unemployed aerospace and defense industry workers and the thousands in the Hollywood movie industry who lack permanent jobs and the benefits that go with them.
Many unemployed aerospace and defense industry workers have been out of work so long that their transitional health benefits have run out. They would all be covered under the Clinton plan.
In the movie industry, workers could join large purchasing pools supported by contributions from employers. But many in the movie industry are uninsured because they jump from show to show, and job to job, sometimes with long, unemployed dry spells in between.
"Some of the studios provide health insurance, but the requirement can be that you have to work there six months. Since I never work anywhere that long, I never get insurance," said free-lance movie production coordinator David Craig, 29.
Expectations are high that the money following the newly insured would greatly improve the position of Southern California hospitals, who are considered to be in worse shape than their counterparts in other parts of the nation because of the uncompensated cost of serving the high number of uninsured patients. A recent study showed that in 1991, 57% of the hospitals in six Southern California counties lost money.
But while the uninsured and those who serve them are expected to gain, some Californians may have to pay more for insurance than they do now and may face disproportionately higher costs than other parts of the country.
One reason is that health costs here are higher than elsewhere, and the new insurance system is likely to reflect that. Southern California, for example, has the distinction of having more high-tech magnetic resonance imaging (MRI) equipment, which provides expensive diagnostic tests, than anywhere else in the country.
One group that could see higher fees are those currently in traditional fee-for-service indemnity plans that allow consumers to choose their own doctor and direct their own health care. The price of those plans could get steeper, in part because all of the economic incentives in the Clinton system are expected to be aimed at encouraging people into managed care plans.
The increases, when they come, could be in deductibles: the out-of-pocket expenses that consumers must make before their insurance kicks in.
Annual out-of-pocket deductibles of $1,500 for each individual and $3,000 per family are being mentioned now as caps.
But already insurance companies are warning that Clinton's plan to cap premiums--without comparable limits placed on the fees charged by doctors, hospitals and other health care providers--would create pressure to raise deductibles.
Those who may be in for the softest landing in the new system are persons already enrolled in some kind of managed care plan, like Kaiser. A third of Californians are enrolled in health maintenance organizations, compared to 16% nationwide.
While the rest of the nation is bracing for the new system and such wrenching decisions as whether to give up the family doctor in favor of the more impersonal health maintenance organizations, Californians have been there already. With 75% of the Californians who have health insurance already in some form of managed care, industry analysts say the system is particularly well suited for the state and its transient lifestyle.
"California is years ahead of the rest of the country," said Dr. Paul Ellwood, president of the Jackson Hole Group, a collective of health experts that played a big role in pushing the nation to managed care. "I don't see a change other than an acceleration of the changes already under way in California."
Dr. Robert Karnes, president-elect of the Los Angeles County Medical Assn., a national powerhouse because it represents nearly 30,000 doctors, said physicians can find little to argue with so far with the Clinton health plan.
But he suspects that might be because elements of the plan that have been released so far have been front-loaded with good news. The bad news will come later.
"Everybody's on a high from the President's speech. But for most of us, the collegialism stretches as far as our arm to our wallet. We are all going to have to pay, but people don't know what that means," he said.
Consumer advocate Ralph Nader figures the big winners in the new system will be the same ones gaining the most from the present system: doctors, pharmaceutical companies, hospitals and large insurance companies.
"The controversy is going to be in the details and we don't have the full details," said Nader, part of a coalition pushing for a single-payer health program based on one being used in Canada.
Already, many of the state's 2 million small business owners are saying they will be big losers.
They think the mandate that employers provide their workers with health insurance is a bad idea, one that could hurt the very people it is supposed to help. They predict that financially strapped employers might cut jobs or withhold pay raises to come up with the money.
That argument was used last year to defeat Proposition 166, a physician-backed proposal that would have required small businesses to provide health insurance for full-time employees on a statewide basis. Californians rejected it by a 2-to-1 margin.
As for the Clinton plan, "It is a regressive tax on jobs that will hit poorest employers hardest. It will hurt the newest, weakest, most marginal small businesses, and the low-wage uninsured workers who rely on them for jobs," said Martyn Hopper, California state director of the National Federation of Independent Business.
"The employer mandate touches a raw nerve and because we have so many small businesses, it will be a big issue here, as elsewhere," said Kaiser Foundation President Altman.
By the same token, Altman said, "It will also help big employers (by spreading out the costs of the health system), and we have a lot of them here, too. It will help small employers, too, who now cover their employees and have to bear those costs."
If employers begin shaving payrolls, it's not just employees of small businesses who may be hurt.
During negotiations with the Service Employees International Union earlier this year, Kaiser Permanente Southern California, one of the nation's largest HMOs, signaled the possibility of things to come when it told union negotiators it couldn't afford a pay raise for 12,000 workers.
"They said there just wasn't anything more they could do for employees this year because they had to get ready for national health care reform," said William Pritchett, Western regional director of the union. Eventually union members got a small raise.