The California Medical Association's 33rd Annual Legislative Leadership Day drew physicians from all over the state to discuss health reform and the push for laws that doctors and patients like. See pictures from the lobbying visits and read more about the high-stakes, practice-altering changes to come.

"I guarantee you that this year we will have comprehensive healthcare," said Gov. Arnold Schwarzenegger during an AARP-sponsored April 30 town hall meeting in Pasadena. "We will create the best system in the United States that will become a model for the rest of the country and for Washington, and once and for all show that one place has actually gotten its act together--and that is California."

Schwarzenegger's guarantee, along with his appearance as keynote speaker at the California Medical Association's 33rd Annual Legislative Leadership Day on April 24, arguably ratchets up healthcare reform on his to-do list. And reform's priority was already high: During his January State of the State Address, Schwarzenegger declared that 2007 is when the state has to "fix its broken healthcare system."

Of course, Schwarzenegger is not the only one with an eye on reform this year. In addition to the governor's proposal, several other plans are vying for dominance, while scores of stakeholders are seeking to alter the field in subtler ways, such as widening the scope of practice for ancillary practitioners. Stepping into this milieu, about 500 physicians, medical students and their allies descended on Sacramento to influence policy decisions, educate legislators and learn about the legislative process as part of CMA Legislative Leadership Day. Indeed, the draw to the event was as strong as Schwarzenegger's star power.

"The biggest hot topic everybody's talking about is how to take care of the uninsured population," said S. Ava Mahapatra, MD, president of the Riverside County Medical Association and an obstetrician and gynecologist practicing in Palm Springs. "As a physician, I would like to see everybody covered--but not at my cost, because we are already taking care of [the uninsured]."

Teaming up by county, physicians and medical students visited their state assemblymembers and senators in the afternoon. "I think most of the legislators that we talked to--at least, I met with three--were basically sympathetic to most of the things that we were looking to get passed in the Legislature," said Delmer Henninger, MD, president-elect of the Riverside County Medical Association and a sleep medicine specialist in Murrieta.

But even when physicians and legislators did not see eye to eye, "the visits at least got the conversation going about why we wanted what we wanted, and how they looked at things," Dr. Henninger added.

"[Political activism] is extremely important," said Assemblyman Bill Emmerson (R-Redlands). "I would urge every physician in the state of California to get involved in the process, because all of a sudden the debate is elevated, and then their local legislator begins to understand the problems that they confront in providing healthcare on a daily basis."

Emmerson, who is also a dentist and often an ally of the CMA on healthcare issues, said that while the event itself has a definite impact, physicians should try to amplify it. "It's always good to do some follow-up" through letters or e-mail to keep issues prominent in a lawmaker's mind, he noted.

Addressing the crowd prior to their legislative visits, CMA CEO Joe Dunn told physicians they should not be disheartened if legislators forget they were there "an hour after you have your visit." Instead, they should leave elected officials with the impression that California physicians "care and care deeply" about patients and the profession, he said.

Dunn added his own twist on post-lobbying follow-up. Physician attendees got birthday cards to sign for their elected officials. The CMA intends to send the cards at the appropriate times on behalf of the physicians as facetious reminders that doctors are watching their legislators throughout the session. Above all, doctors should work on building relationships over time, Dunn said.

Dustin Corcoran, CMA vice president of government relations, delivered the main presentation priming physician lobbyists on policy and legislation, including scope of practice, Medi-Cal reimbursement rates and penalties for cheating insurers. However, the "big stuff" this year, as Corcoran put it, has to do with access.

Focusing on Access
Although there are several proposals for healthcare reform, three of them grabbed the spotlight on Legislative Leadership Day--the plans put forward by Gov. Schwarzenegger, Senate President Pro Tempore Don Perata (D-Oakland) and Assembly Speaker Fabian Nunez (D-Los Angeles).

Of these, Schwarzenegger's is the most famous. But despite above-the-fold coverage in the New York Times heralding its introduction, "the governor has not been able to find a legislator willing to introduce the proposal," Corcoran said.

The governor's problems come from both sides of the aisle. Democrats dislike the individual coverage mandate and some of the scaled-down coverage, while Republicans dislike the employer mandate, Corcoran said. Both groups dislike some of the taxes involved in the plans, he added.

Of course, that is not the way Schwarzenegger's office portrays it. "To say the governor has been unable to secure a legislative sponsor is a little bit inaccurate, because that would imply that we've been out shopping for an author," said spokeswoman Sabrina Lockhart. Instead, the governor has been building support with a variety of groups "behind the scenes" to develop a widely accepted package, she said. "Legislatively speaking, we still have quite a bit of time to work on something."

The public certainly seems to like certain parts of the governor's plan. According to a March poll of 1,122 likely voters in the state by the Public Policy Institute of California, 65 percent favor requiring all Californians to have health insurance, with employers, individuals and providers sharing the costs. Sixty-seven percent of likely voters support requiring employers to provide health insurance or pay a fee to the state.

Most interesting for California physicians, the PPIC poll found that 63 percent of likely voters do not like the idea of requiring physicians and hospitals to pay a fee to help cover costs--a finding Corcoran advised doctors to drive home to lawmakers. "Leave your legislators with a clear understanding that at any point in this debate, if they put [a provider tax] into a legislative proposal, there will be hell to pay from everybody in this room," he said.

During his keynote speech, Schwarzenegger referred to his proposed 2 percent tax on doctors only obliquely. "Even though you have been very, very supportive on this whole endeavor of having universal healthcare, of course you have your own concerns, and we are thinking about that, and we are working with you on those issues," he said.

If the governor is working to make his proposal more universally palatable, he might well be advised to hurry, because the competition announced it would do the same--Perata and Nunez agreed in mid-April to combine their separate proposals into a single bill. On May 15, the pair cleared one of the hurdles to combining their bills with the release of preliminary results from a cost-modeling analysis of SB 48 and AB 8. Based on the analysis conducted by Jonathan Gruber at the Massachusetts Institute of Technology, the plans will require employers to spend 7.5 percent of wages on employee healthcare. In contrast, Schwarzenegger's proposal would require employers to spend 4 percent of wages. Of course, the differences do not stop there.

According to the California Senate Office of Research, the Nunez plan offers some employer-contribution exemptions for firms with payrolls under $100,000, new firms and the self employed. Schwarzenegger offers exemptions for firms with 10 employees or fewer.

Both Democratic plans aim to cover working Californians and poor children, while Schwarzenegger's proposal requires all Californians to carry insurance coverage. The MIT analysis estimates that Democratic plans will cover 3.4 million uninsured people, representing about 69 percent of all uninsured Californians.

All three plans draw financing from employer contributions, employee contributions and federal funds. Leaving aside federal funding, Nunez plans to levy a surcharge on health insurance premiums, while Schwarzenegger's proposal would redirect county funds and levy fees on physician and hospital revenues of 2 percent and 4 percent, respectively.

Up next, congressional committees will combine the Democratic bills for a vote in front of the Assembly and Senate, said Richard Stapler, a spokesman for Nunez. With the two Democratic leaders now joining forces, "it's going to be a lot more difficult for the governor to split them up and try to divide them," Corcoran said. "It also means that the Democrats now have the capacity to put the bill on the governor's desk without any Republican support--they can now pass a majority-vote bill and jam the governor."

This puts Schwarzenegger in a tough spot--a veto would betray his promise to reform healthcare, while passing the bill would negate his promise for a bipartisan solution. Either way, Corcoran concluded: "There will be a bill that will pass. It will have a major impact--in terms of the way you practice medicine and in terms of the way patients receive care in the state."

FEATURE ARTICLE SIDEBARS

SCOPE OF PRACTICE BILLS MUSHROOM

This year saw a bumper crop of bills dedicated to widening the scope of practice for nonphysicians. Eight were introduced at the start of the legislative session and one remains. "Usually we take three or four scope bills as being a massive year in scope," said Dustin Corcoran, vice president of government relations for the California Medical Association, during his Legislative Leadership Day presentation. "You can see that all the allied health professionals are having the same reaction to health reform: get while the getting is good."

Bills held in committee this session become two-year bills that will be reconsidered in 2008. Here are selected scope proposals:

AB 636 would give acupuncturists the right to use laser stimulation as part of their licenses. Status: This is a two-year bill.

AB 1436 aims to allow nurse practitioners to provide care as they are educationally and clinically competent to perform. It would also permit nurse practitioners to provide authorizations and certifications normally provided by physicians, admit and discharge patients from a hospital, eliminate the required ratio for supervising physician assistants, and remove the requirement for physicians to preapprove the order of controlled substances. Status: This is a two-year bill.

AB 1444 would allow physical therapists to treat patients without a physician's referral. Status: This is a two-year bill.

SB 557 would allow doctors of audiology to act as qualified medical evaluators for workers' compensation. Status: Passed the Senate Appropriations Committee on May 14 by a 16-0 vote and will go to a floor vote.

SB 993 would allow psychologists to prescribe psychotropic drugs after they receive training and certification from the California Board of Psychology. It would also give the Board of Psychology the power to license psychologists to prescribe drugs. Status: This is a two-year bill.


HMO AND INSURANCE BILLS CREATE A STIR

Physicians spread the California Medical Association's message throughout Sacramento's Capitol building on April 24, paying special attention to three insurance-related bills with the potential to change healthcare for better or worse.

"The CMA's legislative advocacy group has done extremely well," said Steven Larson, MD, a past president of the Riverside County Medical Association and a specialist in internal medicine and infectious diseases in Riverside. "All of our bills that we were pushing have been [passed out of committee], and most of those that we opposed have been shelved and made into two-year bills."

Here are a few bills the CMA asked physicians to lobby on:

SUPPORT

AB 1155 aims to penalize HMOs that short-change physicians by forcing them to pay a penalty at least equal to their underpayment plus interest. Offending HMOs would be compelled to repay physicians by the full amount of underpayment plus interest.

"HMOs have been deliberately, in a lot of issues, underpaying [doctors] sometimes by a few dollars, sometimes by a lot of dollars," said Ilena Blicker, MD, to Assemblyman Mike Eng. "And even if the Department of Managed Health Care has found them guilty of doing this, basically they get a slap on the wrist or a minor fine."

AB 1324 affirms that the law already prohibits insurers from retroactively canceling or modifying an enrollee's contract after the insurer has authorized a medical service that a healthcare professional has provided.

OPPOSE

SB 389 is intended to stop out-of-network physicians at hospitals from billing HMO enrollees directly, also known as balance billing. The bill would effectively allow HMOs to set rates for out-of-network emergency care. It also would require the Department of Managed Health Care and the Department of Insurance to institute an independent provider dispute resolution system.

Explaining the drawbacks of this bill to Assemblyman Pedro Nava's aide, Ventura County nephrologist Nicholas Bednarski, MD, said: "HMOs have promised to take care of enrollees, but they won't pay, or they will pay only the lowest rate. There is no issue of quality of care--there is only the issue of contracts."