Scaled-Back Solutions to Healthcare Crisis

The medical insurance crisis, like the common cold, is tenacious enough to inspire a carload of new remedies every year.

For the sniffles, there’s echinacea, vitamin C and zinc tablets. For the bankrupting of our medical infrastructure by the cost of caring for more than 6 million medically uninsured Californians, at least half a dozen legislative proposals will appear in Sacramento this year.

The good news is that this guarantees the issue a lot of attention. The bad news is that some of our customary advocates for expanding health coverage have wearied of the fight and are making proposals that represent a retreat from their traditional stance.

The California Medical Assn., for example, is shopping a plan to require all state residents to carry their own health insurance (with government subsidies for the poor). But it’s reducing the proposed minimum required coverage to catastrophic health problems and some preventive-care items such as prenatal checkups and an annual physical.


A maximum annual out-of-pocket expense limit of a few thousand dollars might keep a lid on a family’s exposure to the cost of, say, necessary but uncovered doctor visits. Comprehensive coverage, however, is off the table.

Jack Lewin, the CMA’s chief executive, who says the cost of such a policy might be half that of a fully comprehensive plan, acknowledges the proposal is “a change in position.”

What has driven the CMA to this pass is the implacable opposition of business groups like the California Chamber of Commerce to any mandates on employers, such as the ill-fated SB 2, the law narrowly overturned last November by the vote on Proposition 72. “We’re going to be realistic,” Lewin told me. “We’ve been stuck for 20 years trying to get more coverage. A stalemate between business and policymakers could last another decade.”

Some proposals in the capital plainly will earn a “not” on the gonna-happen scale. This includes a plan by state Sen. Sheila Kuehl (D-Santa Monica) to create a state-run single-payer system financed from taxes. The arrangement would replace not only Medicare and Medi-Cal but also private health plans -- a clue as to where the millions of dollars in lobbying money that would surely be deployed to defeat any such measure, if it were ever to get serious, would come from.


Meanwhile, labor unions and other supporters of SB 2 are planning to reintroduce an employer mandate to provide healthcare coverage.

But the real interest in Sacramento is coalescing around the idea of imposing a mandate on individuals, not employers. Most of the state’s uninsured are the families of workers whose employers don’t offer health plans or who don’t buy the plans that are offered.

Their reason may be that the options are too expensive (probably the majority case) or, misled by their own feelings of youth and invulnerability, they don’t see any risk in going “naked.” When they’re surprised by the onset of disease or a serious injury, their expenses are often assumed by the overall health system and reflected in the state budget or the premiums of private health plans.

Supporters of slimmed-down insurance hope that cheaper options may make a mandated purchase palatable. (For health maintenance organizations to offer anything but a fully comprehensive plan requires a change in state law.)

The key to such a glass-half-empty policy is what you leave out. One common proposal is to limit the mandated benefit to coverage of “catastrophes,” defined as major medical events with the potential to impoverish or bankrupt a family and usually taken to mean things like cancer, a stroke or a heart attack.

Plenty of policy experts think this is a sham. Low- and moderate-income families can be ruined by cases that wouldn’t be covered, such as a bout of appendicitis or chronic asthma. Catastrophic plans largely protect hospitals by picking up their costs of treating a few expensive cases. “They don’t do much for the average Joe and Jane who don’t have bills that reach that coverage level,” says E. Richard Brown, director of the UCLA Center for Health Policy Research.

But there is a middle ground.

Blue Shield of California offers a slimmed-down plan that covers the first $1,200 in annual family expenses for such items as doctor visits, emergency-room treatment and outpatient services, but then doesn’t kick in again until the family expense reaches as high as $10,000. (It does cover 80% of hospital bills, however.) Premiums are about 25% less than Blue Shield’s conventional non-HMO plan.


“It’s not an ideal solution” to crafting an affordable individual plan, acknowledges Tom Epstein, the insurer’s executive vice present of public affairs. “But it’s meaningful.” He says the plan is so popular it accounts for nearly all the insurer’s growth in the last year or so.

Some combination of these options will be in a package being drafted by Assembly members Keith Richman (R-Northridge) and Joe Nation (D-San Rafael).

Richman, a physician, was cagey with me about his proposal, which will be introduced next month. He says one important element will be “flexible benefit design,” adding that his plan isn’t merely a green light for catastrophic coverage alone.

He may include mechanisms for reducing certain requirements, such as the frequency of diagnostic tests. He may also encourage insurance purchasing pools with the aim of cutting costs for small employers. But Richman acknowledges that reducing the ranks of the uninsured in California will require government subsidies for low-

income families “no matter what.”

What isn’t clear is whether the Legislature sees that avoiding the meltdown of statewide health services looming ahead means spending money now.

“The Republican approach is no mandates, no taxes,” Lewin says. “That won’t get us anywhere.”

Golden State appears every Monday and Thursday. You can reach Michael Hiltzik at and read his previous columns at