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Last updateTue, 18 Sep 2018 1pm

The federal government now requires hospitals to publish online its “charge description master”—a list of what the hospital charges for various services and items.

When this new policy, which took effect Jan. 1, was announced last year, it was heralded as an overdue move to promote fairness and transparency within our country’s expensive and often-confusing health-care system.

Unfortunately … that’s not how things have turned out.

The Independent decided to see how this new policy is working at the three Coachella Valley hospitals. I dove into my research enthusiastically, easily locating and downloading the charge masters, as these lists are called, from the Eisenhower Medical Center (EMC) and Desert Care Network (DCN) websites.

Then … well, I opened the charge masters. Just as I thought I was gaining useful information, I discovered the downloaded documents, practically speaking, are useless to any layperson who lacks a knowledge of oft-unintelligible medical terminology. It’s also nearly impossible to compare between hospitals, since each uses its own terms and formats.

Download the Eisenhower Medical Center Chargemaster here.

Download the Desert Regional Medical Center Chargemaster here.

Download the JFK Memorial Chargemaster here.

Oh, one more thing: If you have insurance, you and your insurance company aren’t paying the amounts listed on the chargemaster, anyway.

According to the Association of American Medical Colleges: “The hospital charge description master … represents 100 percent of services used by patients in a hospital setting. The use of charge masters began in the early 1950s with the advent of indemnity insurance products; in this environment, hospital rates were set based on billed charges for individual services. As the health insurance industry matured, hospitals moved to payments based on negotiated rates, and the billed charges expressed in the charge master remained largely as a rate schedule for those patients who were private pay or uninsured. … The process for updating the charge master is not intended to ensure that it is a comprehensive document for tracking relative prices. Instead, hospitals focus on adding new services and calibrating highly competitive services rather than updating rates for older services.”

Still … I wanted to ask why the charge masters from our local hospitals were so unwieldly, poorly organized and confusing.

I received no reply from Eisenhower, but I did speak briefly with Todd Burke, California director of communications for Tenet Healthcare, which runs the two valley hospitals within the Desert Care Network: Desert Regional Medical Center in Palm Springs, and JFK Memorial Hospital in Indio. He provided a corporate statement which read: “The hospitals of the Desert Care Network focus on providing high-quality, cost-effective care to all patients we serve. We understand that the costs of health care can be confusing. When looking at the charges posted to our website, it is important to know that the charges posted are a reference price and not the amount that patients or insurers actually pay. When inquiring about actual costs of care, we strongly encourage patients to speak with their insurance provider, or if uninsured or those patients who have Medicare or Medicaid, to speak with the hospital’s financial services department.”

Burke also suggested that I reach out to Jan Emerson-Shea, the vice president for external affairs at the California Hospital Association. So I did.

“You know, people often like to say, ‘Well, I shop for shoes, and I shop for cars, so why shouldn’t I be able to shop for health care, and look at prices ahead of time?’” Emerson-Shea said. “We understand the desire for that level of price transparency, and hospitals are always willing to do the best they can to provide that information. But it’s important for people to understand that these things are different, because you’re talking about a person’s individual health-care needs. So if I happen to have diabetes, and you don’t, we might be having the same health-care procedure, but mine might be more complicated and more expensive due to my pre-existing health condition. People have to understand that everything with health-care pricing is dependent on what your actual needs are as a person, and then it’s also dictated by what your insurance coverage is—and if you are uninsured, California has a decade-old law that limits how much you can be liable for in terms of your hospital care. Depending on your income level, this state law says that hospitals are required to give you either free or discounted care based on a sliding scale. So, really, no patient ever winds up paying the dollar-cost amounts that are shown on any charge master list.”

In other words … all the hospitals in the United States are complying with this requirement to post their charge masters because they’re required to do so, yet everybody involved knows that the charge masters are of no use to anyone in the patient population?

“Yes. That’s exactly right,” she replied.

Where does this leave the discussion about cost transparency within the health-care industry?

“Legally, we are complying with what the laws and regulations require,” Emerson-Shea said. “Is it fair to say that hospitals understand that this information is not very useful, and that we’re looking for ways to make it more useful? Yes. This is not an easy discussion, but I can certainly say that our association is working with our member hospitals to figure out what other options there may be. There are some hospitals in the state that have looked at new technologies to see if there’s a way to put a price estimator on their website that allows patients to go in pre-surgery and enter their information. I think it’s certainly fair to say that there’s a live conversation going on.”

She them summed up the puzzle facing all parties involved.

“If you’re faced with having a procedure done at a hospital, you’ll be going to the hospital where your doctor practices, or you’re being taken to one by an ambulance. … Are you really going to shop around for prices in that situation? I know the California Health Care Foundation has done some research on this question, and they found that, for the most part, consumers are not shopping for health care in that way. … It is not similar to shopping for any other type of a consumer product. Still, I think it’s fair to say that hospitals are looking at how to make this information more useful for patients.”

Published in Features

On this week's polar vortex-free weekly Independent comics page: This Modern World realizes Sparky the Penguin may need a new job; Jen Sorensen just says no to billionaire presidential candidates; (Th)ink examines the difference between wall vs. cave; Red Meat enjoys the benefits of regularity; and Apoca Clips watches as Sarah Huckabee Sanders declares that everything is fine.

Published in Comics

Galileo Galilei once said, “Wine is sunlight, held together by water.” Of course, Galileo never made his way to sunny California—but if he were here now, something tells me he’d want to be at the WineLover’s Auction, taking place at the Thunderbird Country Club on Saturday, Feb. 16.

The WineLover’s Auction is the signature annual fundraiser for Coachella Valley Volunteers in Medicine. Doug Morin is the executive director of CVVIM, which operates the only free medical clinic in the Coachella Valley, in Indio at 82915 Ave. 48.

“This rose out of a study that was undertaken by JFK Memorial Hospital in 2007. The conclusion of that was the valley needed a free clinic for individuals who did not have insurance by whatever means,” Morin said. “The program was modeled after a national program called Volunteers in Medicine. … After a couple years of fundraising … in 2010, we started providing services near JFK.

“There was a lot of community support behind opening the clinic. Part of what was so time-consuming was getting the nurse practitioners, doctors and dentists to volunteer, as well as (raising money for) the operational costs and the direct patient costs, like the bandages and all the other sorts of things that are required for treatment and diagnostic services. … The county helped out by providing a county-owned office for us; our cost is the maintenance of the office space.

“Since then, we have consistently seen about 1,000 unduplicated clients every year, totaling around 3,500 visits … Many have a chronic illness that requires ongoing follow-up, like diabetes, which is our No. 1 issue that we see clients for, (followed by) COPD and congestive heart failure. We provide primary care and a few specialty services, but not urgent or emergent care. If someone breaks a leg, or has a heart attack, or an open wound, then they have to go to the emergency room.”

Morin said the clinic also offers case-management services to those in need, as well as education services. “A lot of diabetes education is designed for healthy living, to help the patient get around with diabetes and keep it stable,” he said.

“Almost two years ago, we began a homeless-outreach program around the Indio and Coachella area. We have physicians, nurse practitioners, nurses, psychologists, social workers and a number of other Individuals who work in the field. We tend to think that (homeless people) need blankets and shoes, which they usually do, but what most of them really need is medical services. Often, they’ll get vaccinations or A1C level checks in the field.

“We do all of this with about 200 volunteers and six full- and part-time staff for the year.”

Who can receive treatment at Coachella Valley Volunteers in Medicine?

“We do have eligibility requirements,” Morin said. “One is that you must be a resident of Coachella Valley. You can’t have medical insurance, or you (must be unable to afford) to use your current medical insurance, and you must be at 200 percent of the federal poverty level. For an individual, that means making only about $20,000 a year.”

So … what about the WineLover’s Auction?

“This is the fourth annual wine auction, and it has, for the past three years, raised more than $200,000 each year. Our yearly budget is $600,000 to cover patient care, so almost a third of our yearly budget is raised from this,” Morin said. “We have presenting sponsorships from both JFK Memorial Hospital and the Desert Regional Medical Center. The evening starts off with a wine reception and a general silent auction, and then moves into the dining room for the live auction. There’s not just wine, but a lot of things that are wine-related; for example, there are trips to Napa Valley, trips on yachts and cruises for several hours, some featuring foods and wine. Sometimes there’s art involved. … There’s something for everybody. The auction items’ values are anywhere from $100 to several thousand dollars.

“Our biggest wine sponsor is Chateau Ste Michelle. They provide all the wine for the reception and the dinner. They also provide a number of packages of rare wines, signed bottles and collector bottles. … To cap the evening’s festivities off, there is usually some entertainment with songs from a winner of a local talent show.”

The WineLover’s Auction takes place at 5 p.m., Saturday, Feb. 16, at the Thunderbird Country Club, 70737 Country Club Drive, in Rancho Mirage. Tickets start at $250. For tickets or more information, call 760-625-0737, or visit cvvim.ejoinme.org/winelovers-auction.

Published in Features & Profiles

Before responsible Riverside County voters go to the polls on Nov. 6, not only will they need to determine which candidates are the most qualified; they’ll need to examine candidates’ statements and positions to determine what is based on fact—and what is not.

This brings us to the race for California’s 28th Senate District—which includes the entire Coachella Valley—where incumbent Republican State Sen. Jeff Stone is running for a second term against Democratic challenger Joy Silver.

Silver is an underdog in the race. In the June primary election, Stone received 56 percent of the vote, compared to 34.7 percent for Silver—a margin of more than 34,000 votes. (A third candidate, Anna Nevenic, a Democrat, received 9.3 percent.)

We asked each candidate why he or she thought constituents should vote for them.

“Probably because I have a proven track record of being an elected official,” said Stone during a recent phone interview. “I’m completing my 26th year (of holding elected office). You never really forget who your boss is, and that’s your constituents, so you have to make sure that you’re always doing things in their best interests.

“Whether I was on the city council (of Temecula), or the board of supervisors (of Riverside County) or now in the California state government, whenever I meet with a governing body, I always feel like I’ve got my constituents sitting on my shoulder, and I ask myself, ‘Is this something they would like or not like?’ Certainly, coming to the state Senate has been a much more challenging experience, because you have a third dimension, which is not one that we had at a local level too much, and that’s partisanship. The partisanship is something you can cut with a knife.”

Silver is a small-business owner who built a successful career as a health clinic executive, senior housing developer and business consultant.

“I think it’s important for people to know that I’m not a career politician,” Silver said. “I’m an outsider who will bring real change to Sacramento, and that will include standing up to those policies coming out of Washington when they hurt all Californians. I want to bring my experience to work on our local priorities, and to fight for the values of our Riverside County constituents … all of us.”

The Independent asked what their priorities would be if elected to the four-year term.

“I carry some very basic fundamentals with me in being an elected official,” Stone said. “One is that government has limited responsibilities, mostly ensuring that our citizens are safe and healthy; and for those who don’t have financial resources, we need to make sure that we help them, especially those who want to help themselves.

“We’ve seen public safety deteriorate with all these terrible initiatives like Prop 47 (which reduced penalties for some crimes, passed in 2014), Prop 57 (passed in 2016, it incentivizes prison inmates to take responsibility for their own rehabilitation, among other things) and AB 109 (passed in 2011 in response to a U.S. Supreme Court order to reduce California prison populations, it transferred certain nonviolent offenders from the state prison system to county-level supervision). These public-safety experiments have come at the cost of a lot of lives and the demise of many businesses.”

Statistics, however, don’t support Stone’s claims. A June 21 report from the Public Policy Institute of California indicates that property-crime rates have decreased slightly since 2011, when the first of these laws was enacted. While violent-crime rates have increased slightly in that time frame, they are still about 50 percent less than year 2000 levels.

Silver said her priorities would include job creation, universal healthcare for all California residents, developing a clean energy economy, career/vocational training, the expansion of affordable housing, and advocacy for immigrant communities.

We asked if universal health care was a realistic goal.

“I do think it is an achievable goal, and with my expertise in the provision of healthcare services, I think I can help move that concept into a place (where) it can work,” she said. “We do have a large economy. Certainly, there are smaller economies in the world that are providing health care for their people, and I think that with the right plan, we can make it happen here for Californians.”

The ever-increasing cost of many prescription drugs is another concern she hopes to address.

“I feel that there needs to be a particular focus on the ability to do group purchases,” Silver said. “Certainly, I’m not the first one to come up with that. When I did work in the health-care business, and we did provide service to a mostly Medicaid patient population, the key there was for independent ambulatory surgical centers to participate in group purchases of items, and that helped us turn around and provide needed goods to the population that we were serving. I think that would be one of the ways to contain costs in a larger venue like our state.”

Stone—who ran unsuccessfully for Congress against Dr. Raul Ruiz in 2016—said the business climate is a top concern.

“I’ve been an active opponent to taxation since I started my political endeavors in 1992, and I’ve never voted for a tax,” Stone said. “We need to do a better job of keeping jobs in California. We’re seeing a flight of the middle class out of the state. We see the price of homes out of the reach of middle-class Californians. Look at the flight out of San Francisco—the liberal experiment that goes on (there) where you have ‘shooting galleries,’ which are places to shoot heroin. And you see the homeless population exponentially increasing there with people bagging feces on the street, and hypodermic needles all over the place. … Even the property values here in Sacramento have been climbing like crazy. Why? Because the people in the Bay Area are trying to escape all this horrific policy that has reduced the quality of life of the people living in those areas.”

The Independent asked both candidates what solutions they would propose to combat the proliferation of wildfires in our state.

“We have to take into consideration that the dryness is part of that issue,” Silver said. “I know that in Idyllwild, they’ve had a plan, and because that plan was in place with various stop-gap measures and ways to coordinate with local fire departments at different points in time, they were able to contain the smaller fires that were initiated by embers. I think that Northern California (communities) could benefit from a plan such as the one in Idyllwild, because they knew how to control and contain. Aside from that, we’re going to have to look at climate and environmental issues to see how we can bring down the heat factor. We have to look at how we can work with a clean-energy economy to do that.”

Stone pointed out that he’s on a committee of lawmakers looking into the spate of fires.

“This has been the worst fire season that we’ve had, and it’s attributable, in some sense, to climate change, but it’s also due to our radical environmental policies that don’t allow us to go in and thin forests and get rid of the 129 million dead or dying trees in the state of California, all in the name of ‘environmental stewardship,’” he said.

The estimate on the dead-tree population came from the U.S. Forest Service in December 2017.

“But at the same time as environmentalists have prohibited us from going in to clear brush and trees, look at how many acres now have been completely erased from California’s landscape,” Stone continued. “How many endangered species and animals have perished in all of these fires that maybe we could have prevented? Certainly we couldn’t have prevented those involving arson, which includes two (recent) fires in my district, the Cranston Fire and the Holy Fire. But in other areas of the state, we could have prevented some of these fires potentially, or at least (lessened) the magnitude of the fires had we cleared the brush.”

The facts don’t necessarily support Stone’s position—particularly his placement of blame on environmentalists for the fires. According to an article from Aug. 7 in The Sacramento Bee, “As of 2015, through the national forests, national parks, Bureau of Land Management, and others, the federal government manages more than 40 percent of California’s total (forest) acreage. The California Department of Forestry and Fire Protection, by comparison, manages a little more than 30 percent. The Trump administration’s own budget request for the current fiscal year and the coming one proposed slashing tens of millions of dollars from the Department of Interior and U.S. Forest Service budgets dedicated to the kind of tree clearing and other forest management work experts say is needed.”

Published in Politics

On this week's seasonably muggy weekly Independent comics page: This Modern World looks again at life in the Stupidverse; Jen Sorenson debates which crowd-funded health-care plea to support; The K Chronicles celebrates even more of life's little victories; Red Meat takes the weekend off; and Apoca Clips discusses the latest move by Steven Seagal.

Published in Comics

On this week's hot and muggy weekly Independent comics page: Jen Sorenson sows collusion confusion; The K Chronicles discovers a rooster; This Modern World asks whether you're a Goofball or a Galahad; Red Meat shows concern about Wally's health; and Apoca Clips has Lil Trumpy having a vote-motivated tantrum.

Published in Comics

By many measures, the rambunctious campaign for a single-payer health-care system in California appears to be struggling.

A bill that would replace the existing health-care system with a new one run by a single payer—specifically, the state government—paid for with taxpayer money remains parked in the Assembly, with no sign of moving ahead. An effort by activists to recall Assembly Speaker Anthony Rendon for shelving the bill has gone dormant. And an initiative that would lay the financial groundwork for a future single-payer system has little funding, undercutting its chances to qualify for the ballot. 

But even if single-payer is a lost cause in the short term, advocates are playing a long game. For now, it may well be less a realistic policy blueprint than an organizing tool.

And by that metric, advocates are making gains.

Riding a wave of enthusiasm from progressive Democrats, supporters of single-payer have effectively made it a front-and-center issue in California’s 2018 elections. It’s been discussed in virtually every forum with the candidates running for governor, emerged as a point of contention in some legislative races, and will likely be a rallying cry at the upcoming California Democratic Party convention.

“This issue is not going away,” said Garry South, a Democratic political consultant who has worked with the California Nurses Association, which sponsored the stalled single-payer bill. “The progressive elements who are supportive of the single-payer concept know that it’s not going to happen now; it’s not going to happen tomorrow. It’s a long-term process, and Jerry Brown is gone as of January 2019.”

The governor has not needed to stake a position on the bill, because it skidded to a stop in the Assembly last summer without reaching his desk. But state Sen. Toni Atkins, a San Diego Democrat who co-authored Senate Bill 562, said Brown was not receptive. Analyses peg the cost of a statewide single-payer system at between $330 billion and $400 billion—far exceeding the state’s entire budget. That made it an anathema to Brown’s record of prioritizing fiscal stability for state government.

“When the governor saw that we introduced that bill… all he could look at me and do is shake his head and say, ‘$400 billion dollars.’ And I kept trying to say, ‘Can we back up and talk about what you've got to do to get (there)?’" Atkins said in an interview.

“He wasn’t letting it go.”

Atkins, who will take over as Senate leader next month, said she’s not giving up on the goal of single-payer, but does not expect it to happen this year. “People are polarized on this issue in a way that’s not good for coming together to get it done,” she said.

Led by the nurses association—a labor union that embraces firebrand activism—supporters of single-payer have targeted Rendon after he shelved the bill last summer, saying it lacked critical information on how to pay for a massive overhaul of the healthcare system. They peppered social media with images that not only portrayed the bill fight as a boxing match between Rendon and the nurses, but also depicted a knife labeled “Rendon” back-stabbing the bear symbol of California.

The nurses were not involved in the campaign to recall Rendon, said recall organizer Stephen Elzie, who has since dropped the effort and is now helping Democrat Maria Estrada challenge Rendon’s re-election bid. But the nurses union leapt into the governor’s race as one of the first labor unions to endorse Lt. Gov. Gavin Newsom. Single-payer has emerged as one of few issues on which the Democratic candidates disagree.

Newsom and Delaine Eastin, the former state superintendent of schools, have both said they support the nurses’ single-payer bill. Fellow Democrats Antonio Villaraigosa, former mayor of Los Angeles, and John Chiang, the state treasurer, say they want to expand health care so that everyone is covered, but not necessarily with the single-payer model that would abolish private health insurers and replace them with a government-run system.

A coalition of medical groups is lobbying against the single-payer bill, arguing that it makes more sense to protect and expand the federal Affordable Care Act, which has increased the number of Californians who have health insurance. Some members of the coalition have a history of spending big money to sway California elections. One of them, the doctors’ association, donated to Newsom before he voiced support for single-payer; it’s not yet clear if they will shift support to another candidate. 

Almost two-thirds of Californians like the idea of a statewide single-payer health-care system, although enthusiasm drops significantly if it would require raising taxes, according to polling last year by the Public Policy Institute of California. Still, Californians didn’t cite health care as a top priority when asked last month what the Legislature and governor should focus on in 2018.

The Assembly just wrapped up a series of hearings on what it would take to create a health-care system that covers all Californians. It exposed many obstacles—in both federal and state law—to swiftly enacting single-payer. For one, the state would need permission from the federal government—and perhaps an act of Congress—to shift billions of dollars from Medi-Cal and Medicare into a state-run single-payer plan. For another, if lawmakers raised taxes to fund single-payer, voters would likely need to approve changes to the California Constitution to allow the money to go to health care instead of schools. (That’s the only single-payer initiative that someone is trying to get qualified for the ballot; while a Silicon Valley tech consultant is gathering signatures for it, he doesn’t have support from the nurses’ union or any other well-financed group.)

Assemblyman Jim Wood, a Healdsburg Democrat who chaired the panel, called the single-payer bill “aspirational” and said he’s instead considering legislation that could help more Californians get health care without requiring permission from the federal government. One idea: extending subsidized health plans to adults who are undocumented immigrants.

“I believe we can actually get to single-payer, once we go through a lot of study and a lot of work,” Wood said. “But this feels, at times, more like a litmus test.”

CALmatters.org is a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in Politics

California’s resistance began before there was a resistance.

When Gov. Jerry Brown unveiled his final budget on Jan. 10, it bookended eight years of a progressive march to reduce greenhouse gases, expand health care, grant more rights to undocumented immigrants and raise the minimum wage to $15 an hour. Along the way, voters have assented by passing temporary taxes on the rich—not once, but twice. The top marginal income tax rate is now 13.3 percent, the highest state income tax rate in the country.

In short, policies that are now labeled acts of resistance to President Donald Trump were alive and ascendant in California long before Trump won the White House. But the contrasts have become much more stark.

Instead of cutting taxes, the Democratic governor and his party’s legislative leaders have passed a gas tax to help pay for aging infrastructure. Instead of trying to shift government out of the healthcare marketplace, California is looking for a way to fund single-payer health care, including coverage for undocumented immigrants. Instead of criminalizing pot, the state is looking forward to collecting taxes on marijuana sales.

In the months between now and the June deadline for a final budget, the governor and the Legislature will hammer out details. The focus this year: what to do with an expected surplus of $6.1 billion—and there are definitely differing opinions all around. Republicans say return it to California’s 40 million residents as a nice tax refund. The governor's priority is to fill up the state’s rainy-day fund. Democratic legislators mostly want to spend it.

“We have a very different approach,” said Assemblyman Phil Ting, D-San Francisco, who chairs the Assembly Budget Committee. “Our focus, the people who we think need tax relief, are the working Californians who are making less than $25,000. That’s where we want to spend our money, making sure they have money to pay rent, to pay for food.”

Rather than giving out “huge corporate tax breaks and a huge tax break for the wealthiest in this country,” Ting has a long list of how he would like to spend that extra money, including:

• Increasing the state’s Earned Income Tax Credit, which puts money into the hands of the working poor.

• Expanding Medi-Cal health care for poorer Californians to cover all remaining uninsured residents, mostly undocumented immigrants.

• Expanding early education for 4-year-olds through preschool and transitional kindergarten programs.

• Increasing college aid.

• Expanding mental and social services to reduce the number of criminals who go on to re-offend.

As supportive as Brown might be of these Democratic aspirations, his administration is urging legislative leaders to proceed with caution. The state’s tax structure is more vulnerable than ever to the stock market gains and losses of its wealthiest citizens, and the governor said California must prepare for the next economic downturn, because a mild recession could wipe away at least $20 billion a year in revenues.

He also warns of uncertainty from Washington, D.C.

“There are certain policies that are radical departures from the norm, and California will fight those, whether it’s immigration or offshore drilling,” Brown said. “We don’t know what will happen. I wouldn’t want to portray a California-Washington battle, although there are some key differences, and we’ll espouse our values.”

Since Brown was elected to begin his second stint as governor in November 2010, the state has climbed out of the recession and enjoyed economic prosperity. The unemployment rate, which topped 12 percent, now stands at 4.6 percent. Since his return, California has added 2.4 million jobs, and hourly wages are up $4.76 an hour. The state, which carried a $25 billion deficit in his first year back, has enjoyed billion-dollar surpluses in recent years, and the state now has a rainy-day fund.

The governor’s proposed $190 billion budget is dominated by spending on education (29 percent) and health care (32 percent). Health care spending has been growing particularly fast since the state embraced the Affordable Care Act, also known as Obamacare. The act not only grew the marketplace for private health plans; it allowed states to expand their Medicaid health insurance programs for the poor.

Because California is among 30 states that expanded Medicaid, the federal government is paying at least 90 percent of the cost for newly eligible enrollees. That has allowed California to draw billions in extra funding from the federal government to bolster Medi-Cal, the state’s version of the national Medicaid program. As a result, the number of people without health coverage in the state has dropped to a historic low: from 17.6 percent in the 1980s to 7.6 percent in 2016. Today, one in three Californians is covered by Medi-Cal.

Public schools too have greatly benefited since the recession, with much of the extra spending on schools going to improve teachers’ salaries.

However, if the federal government doesn’t reauthorize the Children’s Health Insurance Program for 1.3 million children, that could add more than $850 million in costs to the state over two years.

Worse, if Republicans in Washington slash Medicaid funding in 2018, the state could lose between $25 billion and $50 billion, said Chris Hoene, executive director of the California Budget and Policy Center, a progressive think tank in Sacramento.

“The reality is California could not afford the scale of the cuts the GOP has been proposing,” Hoene said. “That’s going to put state leaders in a position of deciding who gets state services and how do they fund that.”

Other factors are straining the budget. For example, pension costs for public workers continue to be one of the fastest-growing liabilities—driven by lower investment-rate assumptions, higher health care costs and longer life spans.

Voters, too, could turn on Brown and lawmakers. Early polling suggests Republicans have a decent shot at repealing a gas tax hike that went into effect late last year. Brown said at a press conference Wednesday that he believes a repeal initiative could be defeated.

The Legislature’s nonpartisan budget analyst is also urging lawmakers not to commit to too many new spending programs.

“As it crafts the 2018-19 budget and future budgets, we encourage the Legislature to consider all of the uncertainty faced by the budget in future years and continue its recent practice of building its reserve levels,” the analyst wrote.

On the flipside, Republicans are calling for a tax refund, if not an outright repeal of state income taxes. They argue that California’s high taxes chase residents out of state.

“This surplus is a direct result of Capitol Democrats overtaxing hard-working Californians,” said Assemblyman Matthew Harper, R-Huntington Beach. “Rather than expanding an ever-growing list of government programs, our leaders should figure out a way to return that money to the people who earned it in the first place.”

Assemblyman Vince Fong, R-Bakersfield, said he plans to introduce tax cuts aimed at helping families and small businesses stay in California.

“As we see all too often now, we are losing families and small businesses to neighboring states that have tax burdens much lower than California’s high-priced tax code,” Fong said on Twitter. “We have an opportunity to change that.”

Brown dismissed the refund idea, saying it would only prompt service cuts to public schools and universities later. “If you want to budget responsibly, you need big surpluses in years that are good,” he said.

Still, there’s a growing sentiment that California may have to respond to recent changes in the federal tax plan, specifically a $10,000 cap on state and local deductions that will hit millions of households.

According to the state Finance Department, the average deduction for state and local income taxes alone is nearly $16,000 per return, while state and local property taxes average less than $6,000 per return. Because a portion of those taxes will no longer be deductible, it acts as double taxation for California taxpayers.

Senate President Pro Tem Kevin de León, who is running for U.S. Senate, introduced legislation Thursday to shield Californians from bearing the costs of the tax overhaul. The bill, dubbed Protect California Taxpayers Act, would allow taxpayers to make charitable deductions to the state and receive a dollar-for-dollar tax credit on the full amount of their contribution. By having residents donate to the state government as a charitable contribution, the contribution remains deductible on federal taxes.

“The Republican tax plan gives corporations and hedge-fund managers a trillion-dollar tax cut and expects California taxpayers to foot the bill,” de León said in announcing his legislation. “We won’t allow California residents to be the casualty of this disastrous tax scheme.”

Brown was particularly vocal against the GOP tax proposal, calling it a “tax monstrosity,” but the governor expressed reservations about whether the state could sidestep federal law.

“It looks interesting,” Brown said. “But two questions: Can it work? If it does work, can the Internal Revenue Service issue a regulation and completely subvert it?”

De León responded that he was confident it would work, because similar charitable deductions have already been given out for education-based contributions.

For now, state Democrats are in agreement about a common threat.

Whether it’s federal tax changes or entitlement cuts, the leader of the Assembly, Anthony Rendon, D-Paramount, said he’s most concerned Republicans in Congress and the Trump administration will take another swipe at liberal California in 2018. “We’re worried about the next shoe to drop.”

CALmatters is a nonpartisan, nonprofit media venture explaining California policies and politics.

Published in Politics

On this week's weekly Independent comics page, which could be fired by Donald Trump at any moment: The K Chronicles checks in with Republican Sen. Jerry Mandering; This Modern World examines a confederacy of sociopaths; Jen Sorenson hails the freedom to be screwed; Red Meat needs to use the bathroom; and Apoca Clips looks in on the shenanigans of Lil' Trumpy.

Published in Comics

With a small brown paper bag in her hand, Julie walked out of a Planned Parenthood clinic in Roseville with a new supply of birth control. It didn’t matter that she didn’t have health insurance.

“It’s awesome to have Planned Parenthood,” said Julie, who did not wish to give her last name. “To go to a regular health clinic like this would have cost $100, which would make you think twice about having to go.”

It’s the kind of clinic that President Donald Trump and conservative Republicans in Congress hope to cut off from receiving any federal funds. The federal government already prohibits any federal dollars from paying for abortions, except in cases of rape, incest or to save the mother’s life. But this effort seeks to block federal funds from paying for any other kind of health care by providers who also perform abortions.

If the effort succeeds, the impact would be particularly strong in California—a state where legislators over the years have interpreted federal laws and rules in ways that have allowed more federal dollars to flow to Planned Parenthood clinics. Roughly half of the federal funding that Planned Parenthood receives nationwide currently goes, mostly via Medicaid reimbursements, to cover health care and family planning services for Californians, mostly in the lower-income brackets.

Ironically, Planned Parenthood officials say if they were to lose all their federal funding, their California abortion clinics would remain open; those already are funded by private sources and by state reimbursements for poorer patients. Instead, what would be at risk are all the nonsurgical sites that provide other medical and contraception services.

The state’s progressive state policies, put in place 30 years ago under Republican Gov. Pete Wilson, created a friendly environment for Planned Parenthood to expand and offer family-planning services to low-income men and women above the federal poverty level. That’s in stark contrast to states such as Texas and Mississippi, which unsuccessfully sought to ban their state Medicaid healthcare programs for the poor from channeling any money to health care providers that perform abortions.

As a result, Planned Parenthood today is one of California’s major health care providers, operating 115 clinics that serve 850,000 mostly low-income patients a year who rely on Medicaid (in California, Medi-Cal) for health care. That’s nearly a third of the 2.5 million patients who visit Planned Parenthood clinics nationwide for basic health-care and family-planning services.

“Planned Parenthood is a major safety-net provider at a time of increased health care demand,” said Sara Rosenbaum, a professor of health law and policy at George Washington University. “In a state like California, with more Planned Parenthoods, the reliance would be that much greater.”

The Republican-controlled Congress, bolstered by President Trump’s election, is eyeing several strategies to stop the flow of federal funding to Planned Parenthood. That money—roughly $500 million a year nationwide, through Medicaid reimbursements, Title X family planning money and grants—pays for services such as cancer screenings, breast exams, birth control, prenatal care and the treatment of sexually transmitted diseases.

Although Trump has frequently acknowledged that Planned Parenthood helps millions of women, he also has said he would support congressional efforts to ban funding.

“I would defund it because of the abortion factor,” he said at a February 2016 GOP presidential debate. “I would defund it, because I’m pro-life.”

A draft House GOP bill obtained by Politico would eliminate all federal funding to Planned Parenthood as part of a repeal of the Affordable Care Act. While that provision is likely to clear the House, its fate is uncertain in the Senate, where several moderate Republicans could side with pro-choice Democrats.

If the effort were to prevail, California Planned Parenthood would lose $260 million a year in federal funds—approximately 80 percent of its operating budget. Unless it found a way to replenish that money, the organization warns that it could have to close its 82 California sites that furnish basic health care and family-planning services to mostly low-income patients.

Meanwhile, its remaining 33 surgical abortion sites—which don’t get federal funding—would remain open, said Kathy Kneer, president and CEO of California Planned Parenthood.

“The irony here is that they are going to put in place more barriers for women to gain contraception, and that will lead to more abortions—and by the way, all the abortion sites will stay open,” Kneer said.

The House recently voted to reverse an Obama administration regulation that requires states and local governments to distribute family-planning funds to health centers, even if they perform abortions. President Barack Obama issued the rule in his final days in office after more than a dozen conservative states directed those funds only to community health-care centers.

Such an 11th-hour move by an outgoing president, Republicans argued during the floor debate, was an affront to states’ rights.

“I know that vulnerable women seeking true comprehensive care deserve better than abortion-centric facilities like Planned Parenthood,” said Rep. Diane Black, R-Tenn.

The resolution is now awaiting a vote in the Senate, where California Democratic Sen. Dianne Feinstein is working to defeat it. It would have no effect on California, given that it is not among the states that have tried to limit those Title X dollars. Nonetheless, she noted that Planned Parenthood provides the only Title X family planning services in 13 California counties, and that any effort to strip federal funding would take a toll in other states and leave “huge numbers of women across the country (with) no place to go for essential health services.”

Trump on the campaign trail vowed to defund Planned Parenthood, and then he appointed Health and Human Services Secretary Tom Price, a former Republican congressman from Georgia who has supported cutting off taxpayer money to Planned Parenthood. Both men have suggested the federal government could reallocate taxpayer dollars to community health centers. But many experts and health care advocates say those health centers cannot absorb the significant number of patients who now rely on Planned Parenthood.

That concern was echoed in January when the Democratic-controlled California Legislature approved resolutions opposing any congressional efforts to defund Planned Parenthood. They did so after Planned Parenthood President Cecile Richards met with Democratic senators at their annual policy retreat in Sacramento.

Assembly Speaker Anthony Rendon, D-Lakewood, proclaimed: “California stands with Planned Parenthood, because Planned Parenthood stands with California.”

But his sentiment was not unanimous. Several Republicans spoke out against the resolutions, with state Sen. Mike Morrell, R-Rancho Cucamonga, saying he could not support an organization that provides abortions. 

“I have no war against women,” he said. “But I also do not have a war against babies created in the image of God.”

With a Democrat-controlled state Legislature, California Planned Parenthood is hopeful it could ask lawmakers to backfill any federal shortfall. However, Medicaid funding is already strapped in the state, where a record one in three Californians are receiving Medi-Cal benefits. Given the potential for other federal cuts in health funding, it’s unclear whether the state would be able to make up the difference.

Meanwhile, Planned Parenthood is drafting contingency plans.

“We are looking at scenario planning. These are all very difficult decisions,” Kneer said. “Closing any location is the last thing we want to do.”

One option is to more aggressively raise funds, but Kneer said private donations can’t possibly make up what they would lose. She also raised the question of whether private funds should be required to pay for a government reimbursement that other organizations receive.

Even if President Trump receives and signs legislation to strip Planned Parenthood of all its federal funding, Planned Parenthood could still challenge in court whether such a restriction is constitutional.

In the last few years, federal courts across the country have denied other states’ efforts to block Planned Parenthood as an eligible provider of taxpayer-funded health, ruling that such moves violated the First Amendment right of free speech and free association to choose a medical provider, and the right of a clinic to provide abortion services under the equal protection clause of the Fourteenth Amendment, said Julie Cantor, an adjunct professor at UCLA who teaches a law class on reproductive medical ethics.

“The government’s behavior has to comport with the Constitution,” Cantor said.

Samantha Young is a contributor to CALmatters.org, a nonprofit, nonpartisan media venture explaining California policies and politics.

Published in National/International

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