A proposed single-payer health system in California would cost about $400 billion annually, with up to half of that money coming from a new payroll tax on workers and employers, according to a state analysis.
The report by the state Senate Appropriations Committee, issued Monday, put a price tag for the first time on legislation that would make the state responsible for providing health coverage to all 39 million Californians. The state-run system would supplant existing employer health insurance in California, as well as coverage through public programs such as Medicaid and Medicare.
One of the chief obstacles to the legislation, Senate Bill 562, is the prospect of higher taxes. It also has exposed deep divisions among Democrats over whether now is the time to pursue single-payer — just as the Affordable Care Act comes under attack from Republicans in Washington. At a hearing Monday, one Democratic legislator questioned whether the state can effectively manage a universal health care system.
The legislative analysis estimates a total annual cost of $400 billion to enact the Healthy California program for all residents, regardless of their immigration status.Use Our ContentThis story can be republished for free (details).
To put that in perspective, about $367 billion was spent on health care last year statewide, including public and private spending by employers and consumers, according to the UCLA Center for Health Policy Research.
Legislative analysts said federal, state and local taxpayer funding of about $200 billion a year for existing programs could be available to offset the overall tab of $400 billion for universal coverage. But additional tax revenue would be needed to foot the other half of the cost, according to the report, which raised the possibility of a 15 percent payroll tax on earned income.
Of course, the shift to a single-payer system should reduce current spending on health insurance by employers and workers, so those savings could offset some of the new taxes, the analysts said. The report estimated that employers and employees in California spend $100 billion to $150 billion a year now on health insurance and medical care.
“Total new spending required under the bill would be between $50 billion and $100 billion per year,” the report said.
The Senate analysis noted that all of its projections were “subject to enormous uncertainty” because the bill would mark “unprecedented change in a large health care market.”
A single-payer system likely “would be more efficient in delivering health care,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. (California Healthline is produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.)
But the proposal expands coverage to all and eliminates premiums, copayments and deductibles for enrollees, and that would cost more money, Levitt said. “You can bet that opponents will highlight the 15 percent tax, even though there are also big premium savings for employers and individuals,” he added.
State Sen. Ricardo Lara (D-Bell Gardens), a chief sponsor of the legislation, said the present system is unsustainable because health spending continues to grow faster than the overall economy, making coverage unaffordable for too many people.
Lara touted the potential savings from creating a public plan with greater bargaining power and cutting out the administrative overhead and profits of private health insurers acting as middlemen.
Overall, many of the details behind California’s single-payer proposal remain in flux. Under questioning from fellow lawmakers, Lara said the 15 percent payroll tax is “hypothetical” and “we don’t have a financing mechanism yet for this bill.”
Lara said he has sought a review from researchers at the University of Massachusetts-Amherst into potential funding sources for the measure.
Lara also said there’s no guarantee the Trump administration would grant the federal waivers necessary for California to shift Medicare and Medicaid funding into a single pot for universal health care.
With so many unknowns, the Senate Appropriations Committee didn’t vote on the measure Monday. Backers of the legislation are hopeful for a vote in the full Senate next month and then lawmakers can continue to work on the financial aspects during the summer.
At Monday’s hearing, many consumers pointed to Medicare as a model for how single-payer works now and urged lawmakers to make California the proving ground for how it can succeed at the state level.
Business groups and health insurers spoke out in opposition, saying it would lead to massive disruption and escalating costs. Even if it passes the legislature, California Gov. Jerry Brown hasn’t endorsed the idea and new taxes may require a statewide ballot measure, which are always hard-fought campaigns.
The California Chamber of Commerce said the costs would likely be far higher than what was projected and the taxes imposed on employers would trigger major job losses.
State Sen. Jim Nielsen (R-Tehama), a member of the Appropriations panel, expressed similar concerns. “The impact on employers will be astounding,” Nielsen said. “How can you say this will be fiscally prudent for the state? The state has never gotten anything right in health care.”
State Sen. Steven Bradford (D-Gardena) also preached caution, questioning whether state agencies are up to the task. “I don’t want California to move toward a program that is not sustainable and one that we can’t manage,” Bradford said.
Other states have taken a close look at single-payer and balked. Colorado voters rejected a ballot measure last year that would have used payroll taxes to fund a near-universal coverage system.
This week, I answer questions about how the Republican proposal to overhaul the health law could affect job-based insurance and what the penalties for not having continuous coverage mean. Perhaps anticipating a spell of uninsurance, another reader wondered if people can rely on the emergency department for routine care.
Q: Will employer-based health care be affected by the new Republican plan?
The American Health Care Act that recently passed the House would fundamentally change the individual insurance market, and it could significantly alter coverage for people who get coverage through their employers too.Insuring Your Health
KHN contributing columnist Michelle Andrews writes the series Insuring Your Health, which explores health care coverage and costs.
To contact Michelle with a question or comment, click here.
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The bill would allow states to opt out of some of the requirements of the Affordable Care Act, including no longer requiring plans sold on the individual market to cover 10 “essential health benefits,” such as hospitalization, drugs and maternity care.
Small businesses (generally companies with 50 or fewer employees) in those states would also be affected by the change.
Plans offered by large employers have never been required to cover the essential health benefits, so the bill wouldn’t change their obligations. Many of them, however, provide comprehensive coverage that includes many of these benefits.
But here’s where it gets tricky. The ACA placed caps on how much consumers can be required to pay out-of-pocket in deductibles, copays and coinsurance every year, and they apply to most plans, including large employer plans. In 2017, the spending limit is $7,150 for an individual plan and $14,300 for family coverage. Yet there’s a catch: The spending limits apply only to services covered by the essential health benefits. Insurers could charge people any amount for services deemed nonessential by the states.
Similarly, the law prohibits insurers from imposing lifetime or annual dollar limits on services — but only if those services are related to the essential health benefits.
In addition, if any single state weakened its essential health benefits requirements, it could affect large employer plans in every state, analysts say. That’s because these employers, who often operate in multiple states, are allowed to pick which state’s definition of essential health benefits they want to use in determining what counts toward consumer spending caps and annual and lifetime coverage limits.
“If you eliminate [the federal essential health benefits] requirement you could see a lot of state variation, and there could be an incentive for companies that are looking to save money to pick a state” with skimpier requirements, said Sarah Lueck, senior policy analyst at the Center on Budget and Policy Priorities.
Q: I keep hearing that nobody in the United States is ever refused medical care — that whether they can afford it or not a hospital can’t refuse them treatment. If this is the case, why couldn’t an uninsured person simply go to the front desk at the hospital and ask for treatment, which by law can’t be denied, such as, “I’m here for my annual physical, or for a screening colonoscopy”?
If you are having chest pains or you just sliced your hand open while carving a chicken, you can go to nearly any hospital with an emergency department, and — under the federal Emergency Medical Treatment and Active Labor Act (EMTALA) — the staff is obligated to conduct a medical exam to see if you need emergency care. If so, they must try to stabilize your condition, whether or not you have insurance.This KHN story also ran on NPR. It can be republished for free (details).
The key word here is “emergency.” If you’re due for a colonoscopy to screen for cancer, unless you have symptoms such as severe pain or rectal bleeding, emergency department personnel wouldn’t likely order the exam, said Dr. Jesse Pines, a professor of emergency medicine and health policy at George Washington University, in Washington, D.C.
“It’s not the standard of care to do screening tests in the emergency department,” Pines said, noting in that situation the appropriate next step would be to refer you to a local gastroenterologist who could perform the exam.
Even though the law requires hospitals to evaluate anyone who comes in the door, being uninsured doesn’t let people off the hook financially. You’ll still likely get bills from the hospital and physicians for any care you receive, Pines said.
Q: The Republican proposal says people who don’t maintain “continuous coverage” would have to pay extra for their insurance. What does that mean?
Under the bill passed by the House, people who have a break in their health insurance coverage of more than 63 days in a year would be hit with a 30 percent premium surcharge for a year after buying a new plan on the individual market.
In contrast, under the ACA’s “individual mandate,” people are required to have health insurance or pay a fine equal to the greater of 2.5 percent of their income or $695 per adult. They’re allowed a break of no more than two continuous months every year before the penalty kicks in for the months they were without coverage.
The continuous coverage requirement is the Republicans’ preferred strategy to encourage people to get health insurance. But some analysts have questioned how effective it would be. They point out that, whereas the ACA penalizes people for not having insurance on an ongoing basis, the AHCA penalty kicks in only when people try to buy coverage after a break. It could actually discourage healthy people from getting back into the market unless they’re sick.
In addition, the AHCA penalty, which is based on a plan’s premium, would likely have a greater impact on older people, whose premiums are relatively higher, and those with lower incomes, said Sara Collins, a vice president at the Commonwealth Fund, who authored an analysis of the impact of the penalties.
Please visit khn.org/columnists to send comments or ideas for future topics for the Insuring Your Health column.
Montana’s one and only seat in the House of Representatives is up for grabs, and in the final weekend before Thursday’s special election, the underdog Democrat was hammering the Republican health care bill in TV ads.
The ads open with Democrat Rob Quist asking, “Did you know half of all Montanans have a preexisting condition?” He then attacks Republican challenger Greg Gianforte for supporting the House-passed American Health Care Act, which would allow states to drop preexisting conditions protections.
The latest polls put the race within a single-digit margin, surprising in a mostly red state where the previous two Democrats running for the seat lost by 15 points or more. Republicans have held Montana’s statewide seat in the House since the 1996 election. It became vacant in March when Rep. Ryan Zinke resigned it to become secretary of Interior.
Quist, a political neophyte, is a Montana-famous folk singer, who has written and performed Western-themed songs across the state for four decades.
Republican Gianforte is a software entrepreneur whose only political experience is failing to unseat Montana’s Democratic governor in November, getting the fewest votes of any Republican statewide candidate in 2016. Donald Trump won Montana by 20 points.
A last-minute TV ad for Gianforte, funded by $2.5 million that the national Republican Congressional Leadership Fund has poured into the race, pairs a photo of Quist with Nancy Pelosi and says Quist supports her agenda, including “government-run health care.”
Montana resident Jim Lynch plans to vote for Gianforte. Lynch is a member of the Glacier Country Pachyderm Club. Members get together once a month in Kalispell, Mont., to talk about advancing Republican values.
Lynch says health care is a top issue for him. He hates the Affordable Care Act. He’s 63 and says his job provided good health insurance coverage throughout the Obama administration and continues to do so. But, he said, “there’s a lot of people in my shoes who aren’t that lucky. I do know, personally, that they’ve seen huge increases in health care costs, to the point that they don’t even have it anymore.”
Indeed, people who are 55 to 64 can be charged as much as three times what a younger person can be charged for ACA health insurance. Subsidies are available based on income, but older people may earn more than young people just starting their careers.
Under the GOP bill passed by the House, however, older people can be charged five times as much as younger people, and the subsidies are decreasing in aggregate.This story is part of a partnership that includes Montana Public Radio, NPR and Kaiser Health News. It can be republished for free. (details)
Lynch said he doesn’t think the House health care bill is perfect, but he’s confident that, as President Trump shepherds it through Congress, it will be modified into something much better than the Affordable Care Act.
About a hundred miles south in Missoula, Mont., restaurant owner Molly Galusha dreads the idea of Obamacare being repealed. She said the current health care law’s subsidies have made it possible for her employees to afford health coverage on the wages she can afford to pay them.
Galusha is 62 and gets her health coverage through her husband’s job. She says she doesn’t know what they’d do if their insurance went away.
“We’re old and broken,” she said with a laugh.
The Affordable Care Act’s protections for people with preexisting conditions are also likely to affect older people, because the likelihood of having a preexisting condition increases with age.
“We are uninsurable as a couple, so we’re very grateful,” Galusha said.
Republican candidate Gianforte said he won’t vote for a health care bill that doesn’t work for Montana.
“I need to know that, in fact, it’ll bring premiums down, preserve rural access and protect people with preexisting conditions,” he said.
He also said he would have voted against the House health care bill if he’d already been in Congress, because there wasn’t enough time to read the bill and understand it before the House voted.
Democrats, however, accused Gianforte of being disingenuous. They point to a recording of a phone call he had with lobbyists on the day the House bill passed, which was leaked to The New York Times. On the tape he said, “Sounds like we just passed a health care thing, which I’m thankful for, that we’re starting to repeal and replace.”
Quist pounced on those words. Quist needs Republican votes to win, so he’s trying to convince Republicans that their candidate will sell out the state’s interests on health care.
“Montanans want a congressman who’ll shoot straight, not a dishonest politician who says one thing to Montanans and another to the millionaires behind closed doors,” he said. Quist said he wants to build on the ACA and thinks the country should eventually move to a single-payer health insurance system.
President Trump’s new budget should lay to rest any belief that he’s looking out for the millions of people the economy has left behind.
President Trump’s fiscal year 2018 budget is predicated on the assumption that the economy will expand at 2.9 percent per year, on average, over the 2018-2027 decade — 1.1 percentage points per year more than the Congressional Budget Office (CBO) assumes. This large a gap between an administration’s growth forecast and CBO’s is unprecedented. This large a gap between an administration’s growth forecast and CBO’s is unprecedented, CBPP analysis finds (see Figure 1).
President Trump’s 2018 budget reportedly includes more than $1 trillion in cuts over the next decade to “mandatory” programs that help struggling families afford basics like food, housing, and health care; assist people with disabilities and their families; or supplement the earnings of low-income working families. With that in mind, let’s look at the facts about mandatory programs (those funded outside the annual appropriations process):
By effectively ending the Affordable Care Act’s (ACA) Medicaid expansion, the House-passed health bill would take coverage away from millions of people. What’s more, the way the House bill ends expansion would have the perverse effect of discouraging low-wage workers from taking better jobs.
President Trump’s new budget will reportedly cut SNAP (formerly food stamps) by $193 billion — 25 to 30 percent — over ten years and may justify the cut by claiming that SNAP caseloads and spending are higher than expected. They aren’t.
In the movie Gett: The Trial of Viviane Amsalem, the late actress Ronit Elkabetz plays Vivian Amsalem, an Israeli woman who wishes to divorce her husband because she does not love him anymore. Without his consent to deliver a get (גט, a Jewish writ of divorce) to her however, her marriage cannot be dissolved and she is seen as agunah (עגונה, “chained woman”; עגונות, agunot in plural).
While the husband’s inability to deliver a get under Jewish law generally prevents him from remarrying, the consequences of the wife’s inability to receive a get are much harsher. In addition to not being able to remarry, Jewish law considers any child born to her but not fathered by her husband a mamzer (a bastard), who is prohibited from marrying another Jew.
The inability of the agunah to receive her get may arise from the disappearance of her husband without proof of his death; the husband’s lack of legal capacity to give a get; or from his refusal to grant her a get. The husband’s refusal may be based on a variety of reasons, including disagreement on monetary or custody matters, or simply his wish to have eternal control over his wife. Such a wish became the condition for granting a get in the human drama played out in Gett: The Trial of Viviane Amsalem, where the husband agreed to divorce his wife only if she promised never to be with another man, a promise that was not legally binding.
This post highlights some of the recent legal developments designed to alleviate the agunah problem in Israel.
Israeli law does not generally recognize civil marriage and divorce. Under Israeli law, matters of marriage and divorce of Jews, citizens, and residents of Israel, are within the exclusive jurisdiction of the rabbinical courts. These courts adjudicate in accordance with Jewish law (Rabbinical Courts Jurisdiction (Marriage and Divorce), 5713-1953, §§ 1–2, SH No. 134 p. 165, as amended).
While rabbinical courts may issue decisions recognizing that the parties must divorce, they do not have the authority to dissolve a marriage. To constitute a divorce under Jewish law, the consensual transfer of a get from the husband to the wife and her consensual receipt of it must take place. Special rules govern the text of the get and the evidence necessary to prove its validity.
As the basis of the validity of a divorce is the voluntary action of giving and receiving the get by the parties, serious challenges arise when one of the parties is either not legally capable, as in the case where he/she is mentally sick or comatose, or if a party refuses to comply with a judgment requiring him/her to divorce the other party.
Enforcement of Divorce Judgments
The implementation of rabbinical courts’ rulings in Israel is governed by the Religious Courts (Forcing Compliance and Hearing Procedures) Law, 5716-1956, SH No. 200 p. 40, and the Rabbinical Courts (Enforcement of Divorce Decisions) Law 5755-1995, SH No. 1507 p. 139 (RC Law), (both as amended).
These laws authorize various measures against noncompliant defendants. Such measures include issuing injunctions to prevent defendants from leaving the country, seizing their property, and blocking Israeli passports from being issued to them. Other measures include prohibitions against receiving, possessing, and renewing a driver’s license, being appointed to government positions; operating a licensed business; and opening or possessing bank accounts. Imprisonment for a period of five years, which may be extended periodically to up to ten years, and solitary confinement may also apply.
The sanctions authorized by these laws may sometimes, however, be insufficient, as in the case of defendants who found a way to leave the country or who simply persist in their non-compliance regardless of any measures. In an effort to address the agunot problem both the Knesset (Israeli parliament) and the judiciary have recently taken actions to resolve or at least mitigate the situation.
The following are highlights of these developments. Please note that the Law Library of Congress has published a number of articles discussing these developments in its Legal Reports and on the Global Legal Monitor webpage. To access relevant articles, click on the hyperlinks in the text below.
Legislative Expansion of Sanctions on Get– DeniersOn April 3, 2017, the Knesset (Israel’s parliament) passed the Rabbinical Courts (Enforcement of Divorce Judgements) (Amendment No. 8) Law, 5777-2017 (Amendment Law), SH 2627 p. 593. The Amendment Law provides the rabbinical courts with additional enforcement authorities to limit get-refusing prisoners from participating in any prison organized educational activities; subject to some requirements, receiving food that complies with special Jewish dietary laws; staying in a special place in prison that is designated for religious prisoners; and wearing personal clothes (Amendment Law § 1, adding subsections 10-13 to § 2(a)(7) of the RC Law).
The Amendment Law further provides that a rabbinical court that has ordered the placement of a person in solitary confinement may also order that the prisoner may not be permitted to have any phone contact or have any writing or reading materials except for a prayer book. (Amendment Law § 2, adding subsection (f) to §3 A of the RC Law).
Blocking Further Review of Get Arranged and Delivered with Rabbinical Court’s Approval
On March 30, 2017, Israel’s Supreme Court, sitting as a High Court of Justice, accepted an appeal against a Rabbinical Court of Appeals decision to review an appeal submitted by an unrelated third party against the legitimacy of a get. The get was arranged and delivered to the petitioner by a person appointed by the regional rabbinical court as her comatose husband’s agent, with the husband’s guardian announcing that under the special circumstances of the case he found no reason to object. (HJC 9261/16 Anonymous v. Rabbinical Court of Appeals (Mar. 30, 2017), TAKDIN LEGAL DATABASE (by subscription, in Hebrew).)
The significance of this decision is in the Supreme Court’s prevention of the re-opening of a case by the Rabbinical Court of Appeals that might have re-subjected the petitioner to an endless marriage as agunah with all the consequences associated with this status.
Recognition of “Recommendation” of Extrajudicial Sanctions
In its February 28, 2017 split decision, Israel’s Supreme Court, sitting as a High Court of Justice, set a precedent by rejecting an appeal lodged by two Jewish husbands against (separate) rulings by rabbinical courts to subject the men to the application of 12th century social/religious sanctions not expressly authorized under Israeli law. (HCJ 5185/13 Anonymous and Gez v. the Great Rabbinical Court in Jerusalem (decision rendered Feb. 28, 2017).
The sanctions, known as Rabeinu Tam’s Distancing Rules (RTDR), were originally proposed by Rabbi Yaakov Ben Meir as a way to pressure Jewish husbands, when ordered by a rabbinical court to divorce, to present their wives with a get. (Jacob ben Meir Tam, 1100-1171, Sefer ha-yashar (Vienna: Gedruḳṭ bei G. Hroshontsḳie, ).
According to the majority opinion, application of the RTDR was merely “recommended” rather than required and therefore did not contradict enforcement authorities provided under law. The majority opinion was opposed by two justices based on constitutional grounds and possible implications on implementation of other laws.