ABX1-1 Postmortems

For those distracted by — oh, let’s face it — no one could have been so distracted as tp not know Assembly Bill X1-1 died in the Senate Health Committee on Monday. The compromise health care reform package hammered out by Governor Arnold Schwarzenegger and Speaker Fabian Nunez received a single “aye” vote. Seven Senators, including all four Republicans, voted against it. Three of the committee’s seven Democrats abstained.

ABX1-1 was deeply flawed, but it also was creative and forward-looking. Many aspects of the legislation will be part of the health care reform debate — here in California and nationally — for years to come. Here’s a round-up of what folks are saying now that the year of health care reform is officially ended.

The Sacramento Bee’s Daniel Weintraub has a blunt, and on point, analysis of why ABX1-1 failed.

Frank Russo, who publishes the California Progress Report blog laments the liberal-against-liberal infighting that surrounded ABX1-1 and reminds all sides that “politics is the art of the possible.”

A sampling of California newspaper coverage from San Jose Mercury News, the Los Angeles Times, and the San Diego Union and an editorial from the San Francisco Chronicle.

And here’s how out-of-towners reported on the demise of ABX1-1 in the New York Times, the Wall Street Journal, and, from way out of town, a Chinese news outlet (why not?)

Here’s what Governor Schwarzenegger, Speaker Nunez and Senate President Pro Tem Don Perata had to say (the legislative leader’s statements were made prior to the Senate Health Committee vote). A video of a press conference held by the Governor and Speaker after the vote is on the Administration’s web site (right now it’s on the home page, I don’t know where it will be moved to later). And here’s where you can listen to Senator Perata’s press conference after the vote.

Finally, here’s a thorough review of what happened, and why, posted by the California Healthcare Foundation on its California’s Healthline web site. 

Can The Troika Pull a Rabbit Out of the Committee’s Hat?

Anyone have any idea how Governor Schwarzenegger, Assembly Speaker Fabian Nunez and President Pro Tem Don Perata are going to pull this rabbit out of their hat?

The Senate Health Committee seems poised to defeat their troika’s health care reform package, Assembly Bill X1-1. The math is pretty straightforward:

There are seven Democrats and four Republicans on the committee. Two of the Democrats have announced their opposition to the bill and none of the Republicans have ever said anything indicating they’re supporting the bill. That means the bill fails five-to-six. And that assumes none of the other Democrats decides to vote against the bill.

Seems to me there’s only three ways to turn this around:

1. Stack the committee. It’s been done before. Replace a no vote with a yes-Senator. But Senator Perata told the San Jose Mercury News he won’t do this.

2. Get a Yes vote from one of the Democrats currently committed to voting No. Committee Chair Shiela Kuehl or Senator Leland Yee have both come out against the bill. In his opening statement to the committee, Senator Perata took a none too subtle swipe at Senator Yee in his prepared statement before the start of the Health Committee hearing. “I am a little dismayed that some committee members have seen fit, or maybe one committee member, is seeing fit to pre-judge the LAO’s report without reading it. Be that as it may, I guess we all approach our work in a different manner.” As means of persuading someone to change their minds on one of the most public and publicized decisions of their political career, this approach leaves something to be desired.

More likely is that Senator Perata, the Governor and Speaker will seek a courtesy vote from one of the Democrats. Their argument could be: 1) you’ll get to vote no on the floor of the Senate; 2) we’ll owe you big time; 3) you’ll keep your office; and 4) eventually the voters will decide if they like this health care reform — why would you stand in the way of letting the people decide? 

This last argument might — emphasis on the word “might” — work. ABX1-1 is entirely dependent on a funding measure passing on the November 2008 ballot. If the initiative fails, the bill never gets implemented. So moving the bill forward can be seen as simply giving the people a chance to make the final determination. Will either Senator Kuehl or Yee buy into this? That’s a big unknown.

3. Get a Republican to vote Yes. It’s worth a try. However, the most likely GOP Senator to buck the party is Senator Abel Maldonado. He was, after all, the only Republican Senator to support the 2007-08 budget during the 52-day standoff.

However, according to someone who was there, at a meeting with constituents on Friday, Senator Maldonado expressed concern about committing the state to substantial new expenses before the state’s $14 billion deficit is fixed. As the observer described it, Senator Maldonado explained that everything he knows from his own business experience and his commitment to being a responsible elected official points to a “No” vote on Monday.

OK, there’s a glimmer of a chance that the troika can find a courtesy vote. Or they can convince Senator Maldonado to listen to their financial analysis and not that of the non-partisan and highly respected Legislative Analyst. But it’s a long shot.

Nonetheless, some Sacramento insiders, even some opposed to the bill, are convinced they’ll pull it off. The Governor, Speaker and Senate Leader simply have too much invested in ABX1-1 to let it fail this close to the finish line.

I can’t figure out how they could do it. But if any of you have a guess — or better yet, inside information — please share with the class.

Senate Health Committee Hearing on ABX1-1 Roundup

California voters should send thank you notes to the Senate Health Committee. For the first time in the 14 month health care reform “debate,” the compromise health care reform plan worked out by Governor Arnold Schwarzenegger and Speaker Fabian Nunez, with an assist from Senate President Pro Tem Don Perata got a full and thorough vetting. Whether you support the legislation, Assembly Bill X1-1, or oppose it, you have to acknowledge the value of what the Senate Health Committee accomplished. Over the course of an 11 hour hearing they heard from dozens of witnesses on virtually every aspect of the bill.

Among the many sources describing what happened at the hearing, here are some of the most useful:

The Associated Press as published by the Monterey County Herald, “Schwarzenegger health reform bid teetering in key committee”
Kaiser Family Foundation “California Senate President Pro Tempore Delays Vote on Health Care Overhaul Measure”
California Healthline “California Senate Panel’s Vote on Health Reform Plan Delayed” 
Health Access has several valuable posts on the hearing
San Francisco Chronicle “Key vote on health care coverage delayed”
San Diego Union “Senate Democrats express doubt over insurance proposal ”
Speaker Fabian Nunez video and press release on the Legislative Analyst’s Office report and on ABX1-1 health care reform

If a vote had been taken after Wednesday’s hearing, the 11 member Senate Health Committee would have defeated ABX1-1. Democratic Senators Sheila Kuehl and Leland Yee had publicly announced their opposition to the bill. None of the Republicans had indicated much enthusiasm for ABX1-1. Senator Perata asked for a delay of the vote until Monday to give him time to find a sixth vote.

ABX1-1 has the support of the Governor, Speaker and President Pro Tem. It’s a comprehensive response to a problem a majority of Californians consider critical. Passage should be a slam dunk, yet ABX1-1 is on the brink of failing. Why?

What’s happening to ABX1-1 illustrates why it’s so difficult to pass comprehensive health care reform. Stakeholders cling dearly to their positions. The political process makes it easier to attack the most visible problems (health insurance premiums, for example) and pushes to the background initiatives to deal with the root cause of the problems (skyrocketing medical costs). A change in one area creates new issues. It’s like pick-up-sticks. Try to lift one problem from the pile and you’re likely to jostle others in undesirable ways.

For example, a lot of those testifying at the hearing yesterday want carriers to sell coverae to all applicants for coverage. Yet they were among the first to object to requiring all Californians to buy coverage. Without both of these corresponding mandates, the result is skyrocketing premiums and substantially reduced consumer choice.

Passing ABX1-1 in the best of times would be a challenge. Passing ABX1-1 as the economy whipsaws the state’s finances and has lawmakers, economists and the media warning of a recession is nearly impossible. How do you ask state legislators to support a $14 billion health care package that risks running up a $4 billion deficit in its first five years of operation (according to the report published by the Legislative Analyst’s Office) at the same time you’re asking them to cut $14 billion from the current state budget?

That’s the question Governor Schwarzenegger, Speaker Nunez and Senator Perata need to answer before the Senate Health Committee votes on ABX1-1 on Monday, January 28th.  The odds are against them.

Senate Health Committee to Delay Vote on ABX1-1

Assembly Bill X1-1, the compromise health care reform plan hammered out by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, is in deep trouble. Even co-sponsor Senate President Pro Tem Don Perata is expressing pessimism.

At the Senate Health Committee’s hearing today Democrats and Republicans alike seized on the serious risks identified by the Legislative Analyst’s Office’s (LAO) report on the legislation’s impact on the state’s finances. Most significantly, two Democrats on the 11 member Committee have indicated they will oppose moving ABX1-1 forward. Assuming the Committee’s four Republicans continue to oppose the bill, this deprives the bill of the majority it needs.

To provide Senator Perata an opportunity to find the elusive sixth vote, Committee Chair Senator Shiela Kuehl agreed to his request to delay a vote on the bill until Monday. In the interim, Senator Perata will no doubt be having serious conversations with Senator Kuehl and Senator Leland Yee, the second Committee Democrat to announce he would oppose the bill. Senator Perata may even spend some time with the four Republicans. 

What he won’t be doing, according to the San Jose Mercury News, is shuffling the membership of the Committee to assure a majority will support ABX1-1.  This even though he admits to being pessimistic about the chances of ABX1-1 reaching the Governor’s desk. “You don’t instill public confidence by doing things that people don’t understand and they don’t think is a high priority. And I don’t think anybody right now believes anything (is more important) right now but the economy …” he told Mike Zapler of the Mercury News.

The LAO report is complicating the Senator’s quest. Using assumptions nearly as optimistic as those used by the bill’s sponsors, the LAO estimates the reform package would lose nearly $4 billion during its first five years of operation. It also identified other significant financial risks. Given the state faces a $14.5 billion deficit, this has, understandably, created substantial misgivings among lawmakers.

If a vote was held today it would fail. We’ll have to wait until Monday to see if the political skills and clout of Senator Perata, Governor Schwarzenegger and Speaker Nunez, can change this result.

ABX1-1 Coming Up Short in Senate Health Committee

Senator Leland Yee has apparently moved from the “undecided” to the “oppose” column concerning Assembly Bill X1-1, the health care reform package being pushed by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez. The bill will be heard by the Senate Health Committee tomorrow in what promises to be a long, thorough and, for the legislation’s supporters, bruising session.

As I posted on January 20th, Senator Yee had expressed strong concerns over the weekend about the state’s ability to afford ABX1-1. Today the Sacramento Bee’s CapitolAlert web site reports an aide to the San Francisco State Senator is confirming he will be vote no on the bill.

It takes six votes to pass a measure through the Senate Health Committee. With its four Republicans members and Democratic Chair, Senator Shiela Kuehl, already inclined to oppose the legislation, ABX1-1 appear to be headed to defeat tomorrow.

But a lot can still happen between now and then. As I speculated in the earlier post, Senator Kuehl could give the bill a “courtesey vote,” to keep it moving, even while pledging to vote “no” on the legislation when it reaches the full Senate. When asked if she’d consider such a gesture, she replied she “can’t answer that,” according to CapitolAlert.

Senator President Pro Tem Perata, who previously expressed concerns similar to those of Senator Yee, but who now appears interested in moving ABX1-1 forward, could restructure the Committee. He’s proven himself capable of such a move in the past, although its rare for a committee’s membership to be shuffled over just one bill. And whether he cares enough about the fate of the legislation to make such a move is questionable.

Anothe scenario: the CapitolAlert post speculates that one of the Republican Senators might vote for ABX1-1. They identify Senator Abel Maldonado of Santa Maria as the most likely suspect. The odds of this are slim, however. Senator Maldonado, although having shown a willingness to buck the party line, has indicated no enthusiasm for ABX1-1 or any similar health care reform packages.

Given normal circumstances, it would appear ABX1-1 will be defeated in the Senate Health Committe tomorrow. But, these are not normal circumstances.

ABX1-1 represents more than a year of negotiations between the legislative leaders and Governor Schwarzenegger. They’re not giving up yet. And there’s an election in  California just two weeks from today. One of the ballot measures, Proposition 93, will determine if the state’s term limits law is changed in a manner which enables Speaker Nunez and Senator Perata to hold onto their powerful posts. Do they really want to kill health care reform so close to that vote?

A lot can happen between now and the Committee’s vote tomorrow evening. And, given this is California and the topic is health care reform, most likely, a lot will happen.

Senate Health Committee Analysis of ABX1-1

In preparation for the January 23rd Senate Health Committee’s hearing on Assembly Bill X1-1 the Committee’s staff has issued its analysis of the bill. ABX1-1 is the compromise health care reform worked out between California Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez.

The Senate Health Committee Staff Analysis of ABX1-1 is the most thorough of study of the bill to date. It wil provide plenty of ammunition for both supporters and opponents of the bill, raising serious questions about the complex measure as well as identifying the benefits it could deliver. Along with the analysis due soon from the Legislative Analyst’s Office on the impact ABX1-1 will have on the state’s fiscal condition, the staff study provides Committee members with a rich source of information and questions for the hearing.

For legislation this important and complicated, it has received relatively little scrutiny. The Senate Health Committee’s hearing, will be a long one. Given the substance provided in the analysis, it is likely to be thorough as well. Regardless of the outcome, this can only be a good thing.

ABX1-1 Could Fail to Pass Senate Health Committee

The Governor wants the bill passed. The Assembly Speaker wants the bill passed. The Senate President Pro Tem may want the bill passed — or not, it’s hard to tell. Anyway, several powerful unions want the bill passed. So do some business groups and consumer groups. So why is Assembly Bill X1-1, California’s comprehensive health care reform package in danger of failing to make it past its first committee hearing?

On January 23rd, the Senate Health Committee is expected to dive deeply into ABX1-1. The hearing will start in the morning and is likely to go into the evening. (Here’s the anticipated agenda). But how thoroughly a bill is reviewed doesn’t always correlate with its viability.

What’s endangering ABX1-1 is the make-up of the Committee. There are seven Democrats and four Republicans on the Senate Health Committee. When it comes to ABX1-1, the four Republicans will certainly oppose it. That means supporters can only afford to lose one of the Democrats. Lose two and the bill fails.

There are at least two Democrats who could vote against the measure. The Committee Chair, Senator Sheila Kuehl, has been an outspoken critic of the compromise bill.  The legislature’s chief proponent of a single-payer health care system for California, Senator Kuehl voted against Speaker Fabian Nunez and Senator Perata’s previous health care reform bill, Assembly Bill 8. And most observers would be surprised to see her vote for that bill’s successor.

Another Democratic considering a “no” vote on ABX1-1 is Senator Leland Yee of San Francisco. The Associated Press, in a story posted on the San Francisco Chronicle’s SFGate.com web site, quotes Senator Yee as saying, “It’s rather difficult for me to vote for a health care plan that’s going to cost $14 billion at the same time I’m looking at cutting $14 billion” due to the fiscal crisis facing the state.

The non-partisan and highly regarded Legislative Analyst’s Office (LAO) is preparing a detailed report on the legislation’s impact on the state’s finances. Senator Yee will be relying heavily on this report in determining his vote. “I think all of us are trying to find something that’s going to be of help to the people of California and not in any of the out-years find that there are unintended consequences or that it’s going to shift the burden of costs to workers unfairly,” the Associated Press writer Steve Lawrence quotes Senator Yee as saying.

None of this means that ABX1-1 is doomed. Senator Kuehl could vote for it in Committee as a courtesy to the authors regardless of how she intends to vote on the bill when it reaches the Senate floor. The LAO report could show, as some believe it will, that the state’s financial situation would benefit from passage of ABX1-1, meaning Senator Yee could comfortably support the legislation. There’s numerous plausible scenarios that have the bill sailing through the Committee.

Then again, it’s easy to come up with scenarios that have ABX1-1 crashing in flames. It’s tough to tell how hard Senator Perata will be pushing to get the legislation through his chamber, so the pressure to pass the bill along may not be as strong in the Senate as it was in the Assembly. The LAO report could raise questions that make Senator Yee — and perhaps others — unable to support it.  Or the Committee’s thorough review of the bill could bring to light previously unknown structural or drafting problems with ABX1-1 that are severe enough to have the committee hold the bill over. This is, after all, the first real vetting this version of the legislation is receiving.

We won’t know until Wednesday evening. What’s surprising, at least to me, is that the outcome is in doubt at all. It’s actually an encouraging turn of events. After all, this is how the legislative process is supposed to work: lawmakers making up their minds based on public input, thorough analysis and their political beliefs.

Senate Health Committee Hearing on ABX1-1 Agenda

Previously I’ve written about the thorough vetting Assembly Bill X1-1 was likely to receive before the Senate Health Committee. That should be Vetting, with a capital “V.”

ABX1-1, the compromise health care reform package has yet to be subjected to a thorough, formal review. Drafted by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, it passed the full Assembly the same day it was printed in final form. This may be business as usual in the legislature, but it’s no way to review complex, complicated and critical legislation.

So Senate Health Committee Chair Sheila Kuehl is doing Californians a favor by making the time to thoroughly analyze the bill. Her motivation may be fueled, at least in part, by her numerous problems with ABX1-1 (as described in that previous post),  but who cares? What’s important is that lawmakers understand what’s in the bill before they vote on it.

Senator Kuehl’s approach to reviewing the bill, breaking it up into manageable pieces, should make it easier for Senators to dive deeply into different aspects of the legislation. One can question the way it’s broken up. For example, reviewing the mandate on residents to maintain minimum creditable coverage separate from the market reform which requires carriers to issue coverage regardless of an applicant’s health condition, is a bit disjointed. The reason a mandate to buy coverage is necessary is to make the mandate to sell policies work. However, that’s a relatively minor quibble with the approach. Far more important is that details of the bill will have a better chance of coming to light.

The Committee will take up the bill on January 23rd at 9:00 am. Based on the agenda the hearing should last all day. While all witnesses are created equal, some are more interesting than others. The representative of the Legislative Analyst’s Office (LAO) will be the marquee witness. Senate President Pro Tem Don Perata asked the LAO to analyze the impact ABX1-1 was likely to have on the state’s finances back in December when he felt passage of health care reform legislation before Sacramento addresses the state’s budget crisis was “imprudent and impolitic.” He’s since managed to overcome his reluctance, much as Governor Arnold Schwarzenegger seems to have overcome his concerns about changing the state’s term limit laws without redistricting reforms. Coincidence? Nahhhh.

Anyway, back to the hearing, Elizabeth Hill, the Legislative Analyst, is highly regarded by legislators of all parties. Her office’s report will be highly influential if,and it’s a big if, it makes definitive statements instead of couching it’s findings in an ocean of hedges. If the report is full of “ifs,” “potentiallies” “coulds” and “perhapses” then it’s impact will be muted, unless Committee members can get the LAO’s representative at the hearing to refine the conclusions a bit. We’ll have to wait a few more days to see if that will even be necessary.

For those who want to follow along at home on the 23rd (again, beginning at 9:00 am), the hearing will be broadcast online. To listen in, visit the California Senate’s web site and click on room 4203. The Committee’s expected agenda, subject to change, follows:

Outline for Hearing on ABX1 1 (Nunez)

I. Author’s presentation, including presentation by Secretary Belshe or administration representative

II. LAO presentation of fiscal analysis 

III. Testimony, by topic (order for each topic will be support, support if amended or with amendments, concerns, oppose unless amended, oppose)

  A. Mandate to maintain minimum creditable coverage

  B. Purchasing pool, coverage expansions, and proposed tax credits

  C. Requirements for health coverage outside of purchasing pool

  D. Health insurance market and regulatory reforms

  E. Financing (including provisions of proposed initiative) 
     — Employer assessments
     — Redirection of county funds
     — Tobacco tax
     –Hospital assessments
     –Federal funds
     –Individual contributions
     –Contingencies in event of funding shortfall

  F. Testimony on Massachusetts health plan

  G. Scope of practice changes

  H. Data collection and transparency and pay for performance provisions

  I. Other provisions
     –Hospital and physician rates
     –In-Home Supportive Service (IHSS) worker provisions
     –Electronic prescribing and medical records
     –Healthy actions and incentive rewards
     –Public insurer provisions
     –Diabetes, obesity and smoking provisions
     –Prohibition on hospital balance billing
     –Other

IV. Author’s close