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The Union That Roars: Nurses Aren’t Giving Up On California’s Single-Payer Push

To some, the California Nurses Association’s political tactics in pushing for a single-payer health system seemed a bit, well, extreme.

Never mind the raucous demonstrations it brought to the state Capitol in recent weeks, the “shame on you” chants in the hallways, the repeated unfurling of banners in the rotunda despite admonitions from law enforcement.

To further the nurses’ cause, the union’s executive director, RoseAnn DeMoro, tweeted out a picture of the iconic California grizzly bear being stabbed in the back with a knife emblazoned with the name of a powerful state lawmaker who stalled the single-payer bill sponsored by the union.

Before and after that tweet, the legislator — a Democrat — said he was besieged by death threats.

Meanwhile, the union’s public relations guy blasted a blogger for Mother Jones magazine — named after the famous union firebrand — for being insufficiently liberal in his single-payer coverage. “Maybe you can recommend the name of your magazine be changed … to Milton Friedman, which would better reflect your class sympathies,” communications director Chuck Idelson wrote acidly.

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Dramatic and, to some, offensive, tactics are nothing new for this California union of about 100,000 registered nurses, which has made a name for itself in the state and nationally as a progressive and aggressive political powerhouse. Its reach has only broadened with the advent of social media. Leader DeMoro counts more than 29,000 Twitter followers, and CNA’s operation has a knack for mobilizing protesters and drawing crowds.

“The politicians are afraid of these angry intense grass-roots activists” mobilized by the union, said Mike Madrid, a Republican and principal at the public affairs firm Grassroots Lab, who believes the tactics could backfire. “Using fear and intimidation as a tactic in the legislature usually doesn’t get you too far.”

Others are impressed with the union’s drive and creativity, recalling how in 2005 CNA members taunted California’s then-governor, Arnold Schwarzenegger, trailing him wherever he went to protest his attempts to roll back hard-won nurse-to-patient requirements in hospitals. Activists dressed up as the Republican leader and staged theatrical protests at baseball games, rock concerts and even the San Francisco Ritz-Carlton.

In the single-payer fight, the union has shown it will go just as fervently after Democratic leaders in a heavily Democratic legislature. While the union isn’t responsible for everything freelance activists do in a campaign, the Assembly Democratic caucus has condemned the “bullying tactics” and violent rhetoric in the CNA-led effort.

Though not always admired for its approach, the CNA often gets results — or works up a sweat trying. It counts among its legislative successes the 1999 passage of the strict nurse-to-patient ratios, the nation’s first such mandate to bolster staffing in hospitals. It has fended off attempts to overturn that law, worked to protect employee pensions and pushed for campaign financing reform. And it lent its considerable political muscle to Bernie Sanders’ presidential campaign.

Historically, the nurses have had the upper hand in labor negotiations, says Joanne Spetz, director of the Health Workforce Research Center at UC-San Francisco. That’s partly because in some areas of California it represents most or all of the registered nurses, including many thousands who work for the managed-care giant Kaiser Permanente. (Kaiser Health News, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Members of the California Nurses Association Board of Directors, Martha Kuhl (left) and Nancy Casazza, show their support for a 1994 state proposition to implement single-payer health care in California. (Courtesy of the California Nurses Association)

The union, founded in 1903, has always “punched above its weight,” said Thad Kousser, chair of the political science department at University of California-San Diego.

Sherry Bebitch Jeffe, a professor of public policy communication at the University of Southern California, agreed.

“I’m not sure we would be discussing single-payer if not by the push of the nurses’ association,” Jeffe said.

The union, which is affiliated with National Nurses United, makes no apologies for its approach, saying it is determined to hold lawmakers accountable. And it has no intention of backing off its campaign for a single-payer system in the state, an effort that would put the California government in charge of funding health care.

“We’re going to demand that the legislature legislate and move this bill,” said Michael Lighty, director of public policy at California Nurses Association/National Nurses United. The group planned to stage a “people’s assembly health committee” mock hearing Tuesday in Sacramento.

Lighty said that the rallies reflect Californians’ desperation and fear about losing health coverage under Republican proposals to repeal Obamacare more than anything else.

Although Lighty said the union’s elected nurse leaders collectively decide on its actions, supporters and critics alike see DeMoro as setting the tone and agenda.

People focus on DeMoro because she “pushes the parameters of the politically possible” and that rubs “defenders of the status quo” the wrong way, Lighty said. DeMoro, on vacation, was unavailable for comment.

Former state senator Sheila Kuehl, who attempted several times to pass a single-payer bill, said the California Nurses Association has always been “very aggressive for the things they believed in.”

Former state senator Sheila Kuehl, who authored single-payer legislation in the 2000s, participates in a 2008 rally in San Francisco. (Courtesy of the California Nurses Association)

A smaller health consumer advocacy group persuaded Kuehl to carry the bill for the first time in 2003-04, Kuehl recalled, but the California Nurses Association brought more visibility and credibility when they joined her effort. Eventually, it became a co-sponsor.

“CNA, as fierce and progressive as they are, gave the idea a real boost,” said Kuehl, now a Los Angeles County supervisor.

Two of her bills passed through the legislature, but both were vetoed by Schwarzenegger.

Kuehl doesn’t buy the argument that the union’s in-your-face strategies may hurt their chances of passing single-payer later. Union members made nasty comments about Schwarzenegger at their rallies and that didn’t hurt the CNA’s reputation, she said.

Madrid, the Republican political consultant in Sacramento, says the CNA’s aggressive advocacy for a single-payer health system reflects the intense political polarization seen around the country right now — as well as conflicts among members of left-leaning causes.

More mainstream Democrats, including Assembly Speaker Anthony Rendon — the recipient of online death threats — say the legislature’s priority is to defend California against a GOP-proposed repeal of the Affordable Care Act and massive cuts to Medicaid, the state and federal health plan for the poor.

Rendon also said the single-payer bill, though approved by the state Senate, was “woefully incomplete” and needed to be recast. Among other problems, it carried a $400 billion annual price tag, according to an analysis by the state Senate Appropriations Committee.

But the CNA sees an opportunity for broader change and believes single-payer can move forward even as the state fights the Republican proposals in Washington.

If the single-payer bill stays idle in the legislature this year, the group vows to try again next year, making it a campaign issue in the 2018 elections.

“The best way to fight the GOP is to have an alternative,” Lighty said.

California Healthline correspondent Ana B. Ibarra contributed to this report.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN’s coverage in California is funded in part by Blue Shield of California Foundation.

Your Credit Score Soon Will Get A Buffer From Medical-Debt Wrecks

For many consumers, an unexpected health care calamity can quickly burgeon into a financial calamity. Just over half of all the debt that appears on credit reports is related to medical expenses, and consumers may find that their credit score gets as banged up as their body.

Changes in the way credit agencies report and evaluate medical debt are in the works that should reduce some of the painful financial consequences of having a health care problem.

Starting Sept. 15, the three major credit reporting agencies — Experian, Equifax and TransUnion — will set a 180-day waiting period before including medical debt on a consumer’s credit report. The six-month period is intended to ensure there’s enough time to resolve disputes with insurers and delays in payment.

In addition, the credit bureaus will remove medical debt from consumers’ credit reports once it’s paid by an insurer. (Some credit scoring models don’t penalize paid medical debt from any source.) 

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.

This KHN story can be republished for free (details).

The changes grew out of two efforts by states to aid consumers: a 2015 settlement negotiated by New York Attorney General Eric Schneiderman and the three credit reporting agencies and an agreement shortly afterward between the agencies and 31 state attorneys general. The changes will be instituted nationwide.

The 180-day waiting period is “a big step forward toward a more equitable process,” said Julie Kalkowski, executive director of the Financial Hope Collaborative at Creighton University in Omaha, Neb., which provides financial education and coaching to low-income, single mothers.

Rather than attempting to collect past-due medical bills themselves, hospitals and doctors’ offices typically engage collection agencies to dun patients. But the timing on when providers take that step varies widely.

“Without a standardized process, some bills get sent to collections because they’re 30 or 60 days past due as opposed to six months,” Kalkowski said.

Kalkowski said several of the women who went through the Creighton program had doctor bills that were sent to collections before they were 60 days past due. The total amount owed in most cases was under $150, she said.

Forty-three million Americans have medical debt in collections that’s adversely affecting their credit, according to a 2014 report by the federal Consumer Financial Protection Bureau, the bureau’s most recent data. The average amount of medical debt in collections was $579, compared with $1,000 for non-medical debt. For 15 million consumers, medical debt was the only blemish on their credit report, the study found. 

Perhaps this isn’t surprising given the growth in the number of people with high-deductible health plans and significant out-of-pocket financial responsibilities for health care, said Chad Mulvany, policy director at the Healthcare Financial Management Association, a membership organization for finance professionals.

“More people who typically would have been a good credit risk are now saddled with big bills,” he said.

Lenders use credit reports and credit scores to evaluate the risk that someone won’t repay a loan. The credit-scoring companies build algorithms that use the data in people’s credit reports to assign a three-digit credit score, typically between 300 and 850, that summarizes someone’s credit risk based on the information in a credit report at that time. Higher scores indicate lower risk.

Credit-scoring companies like FICO and VantageScore that develop these models have been adjusting their formulas to account for the fact that medical debt isn’t necessarily an accurate predictor of whether someone is a good credit risk.

“Those with medical accounts are less likely to default on their accounts than non-medical accounts,” said Ethan Dornhelm, vice president of scores and analytics at FICO.

To address this issue, newer FICO and VantageScore models differentiate between medical and non-medical debt. People with medical debt in collections receive a smaller penalty than those with non-medical collections, said Sarah Davies, senior vice president at VantageScore Solutions.

The change can make a difference in people’s credit scores.

Under FICO9, the newest model, someone whose only major credit blot is one or more medical collections would see their median score increase roughly 25 points over older versions, said FICO’s Dornhelm.

But there’s a catch: Many banks and other lenders haven’t yet adopted the newer versions of the credit-scoring models. So even though medical debt shouldn’t have as strong an impact on someone’s credit score now, in many cases nothing may have changed.

What’s a consumer to do? You can’t control which scoring model a lender uses, but you can check your credit report regularly to make sure it’s accurate. Consumers are entitled to a free credit report from each credit reporting company annually.

“If there’s medical debt that’s been paid, it should be removed going forward, and if it’s less than six months old, find out when it’s going to be removed,” advises VantageScore’s Davies.

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Crippling Medicaid Cuts Could Upend Rural Health Services

ATLANTA — Each day as Ginger Peebles watches daughter Brenlee grow, she sees the importance of having a hospital close by that delivers babies.

Brenlee’s birth was touch-and-go after Peebles realized something was wrong. “I couldn’t feel the baby move, and my blood pressure was sky-high,” said Peebles, a nurse.

Dr. Roslyn Banks-Jackson, then an OB-GYN specialist at Emanuel Medical Center in Swainsboro, Ga., diagnosed preeclampsia, a potentially lethal complication of pregnancy, and induced labor to save Peebles and the baby. Brenlee was born on Oct. 28, 2014, completely healthy.

Had Peebles given birth the following year, she might not have been so fortunate, she said. Emanuel shuttered its labor-and-delivery unit the next spring, becoming one of a handful of such units in the state to close from 2010 to 2015, most because of budget problems. Another is expected to close this month, said Daniel Thompson, executive director of the Georgia OBGyn Society.

This KHN story also ran in USA Today. It can be republished for free (details).

Republican bills to replace the federal health law would worsen rural areas’ financial straits through reductions in Medicaid funding. Patient advocates predict that would lead to fewer enrollees, more shutdowns of rural facilities, reduced payments to doctors and fewer programs for people with health needs or disabilities. In the aggregate, such changes threaten the health of thousands of state residents, especially those in rural areas.

“I’ve seen changes, and I’ve seen cuts, but I’ve never seen changes like what’s being proposed in this bill,” said Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities. “This is the first time it’s been this scary.”

Possible Strains On A Lean Budget

One of the key aims of the House and Senate bills is reversing the Affordable Care Act’s expansion of Medicaid. But the legislation also would institute changes to the federal-state health program for low-income residents that could devastate states such as Georgia that didn’t expand Medicaid. Georgia already ranks 45th in the nation in per capita Medicaid spending, according to the Georgia Budget and Policy Institute.

The bills would switch Medicaid from an entitlement — in which the federal government agrees to pay its share of costs for anyone who qualifies for the program — to a system in which the federal government by 2020 would limit its payments and reimburse states based on a per capita formula.

The nonpartisan Congressional Budget Office concluded in a report released June 29 that the Senate plan would slash 35 percent of expected federal Medicaid funding by 2036.

“Cuts now would cripple rural Georgia,” said Dr. Ben Spitalnick, president of the Georgia chapter of the American Academy of Pediatrics.

He said that is because most primary care visits, which include OB-GYN, pediatric and adult care, in the state’s sparsely populated areas rely heavily on Medicaid reimbursements.

The federal cutbacks would have to be offset by the state. But that means taking money from other programs or raising taxes. As a result, state officials facing those shortfalls would likely scale back an already lean Medicaid coverage.

“If you cut back, [people] still go to the hospital, they’ll still need care. No matter what you do, the buck stops somewhere,” said Renee Unterman, a Republican state senator who chairs the health and human services committee. In the end, she added, the cost for that uncompensated care gets passed to taxpayers and consumers through higher health costs and insurance premiums.

Georgia’s rural hospitals have proved vulnerable. Five closed in the past five years and another two merged. Plus, several have closed their emergency rooms.

That translates to a loss of doctors in affected counties. Of Georgia’s 159 counties, 79 do not have an OB-GYN specialist, and 65 do not have a pediatrician, according to 2015 figures from the Georgia AAP and the Georgia OBGyn Society.

Close to 1.7 million Georgians, or nearly 1 in 5 state residents, live in these areas, according to figures from the Rural Health Information Hub.

Improving Pay For Doctors

For 15 years, Georgia Medicaid reimbursed primary care doctors at only 60 percent of the amount that the federal Medicare program reimbursed similar services, said Ward.

But in 2015, the Legislature implemented three rounds of pay increases to primary care doctors, including pediatricians and OB-GYNs, to bring them in line with the Medicare reimbursement.

Many of these doctors are now concerned those rates would be the first to be lowered. “That’s our big fear,” said Rick Ward, executive director of the Georgia chapter of the AAP. “We just clawed our way back and to deal with it again would just be unbelievable.”

Key among those concerns are prenatal care in rural areas. With a maternal mortality rate that is among the worst in the country, OB-GYNs are worried that the cuts would eliminate fragile solutions to doctor shortages that the state has implemented.

For example, pregnant, low-income women in 17 counties around Augusta can arrange for a ride in a van, paid for by Medicaid, for their prenatal visits at the medical school at Augusta University. The service has been vital in keeping these women healthy and insuring successful births. Advocates fear it is the type of program that could face problems if Medicaid funding becomes tight.

People With Disabilities Fearful

Advocates for residents with disabilities worry that home health care would be likely to suffer from the cuts.

That’s because while states are required under Medicaid to pay for nursing home stays, care for people living at home has been optional.

About 38,000 people in the state get the services, also called community-based benefits. Qualifying takes years, and benefits are not guaranteed, even for people who are eligible. Almost 10,000 Georgians are on the waiting list, according to Jacobson, because there is not enough money in the Medicaid budget to cover everyone.

One of those who is getting coverage is Joshua Williams, 22, who has severe cerebral palsy and needs constant care at home and school.

“I’m terrified” that funding cuts could end the program, said his mother, Mitzi Proffitt, 53. “I’d have to quit my job” to take care of him. Williams’ stepfather, Jack Proffitt, 65, has advanced cancer and cannot provide much assistance.

Joshua Williams, who receives home health care services through Medicaid, is worried about funding changes being considered by Congress. But he is counting on President Donald Trump to keep disability benefits in place because “he said he has heart.” (Photo by Virginia Anderson/KHN)

Nursing home or institutional care for a year, on average, is $172,280, said Jacobson, while the average home health care is $28,901.

Williams, who is on the dean’s list at East Georgia State College in Swainsboro and loves NASCAR, also admits to being “very scared.” He said if his coverage is discontinued, he would have to drop out of college, ruining his hopes of becoming a sports broadcaster. He is eager to get a part-time job until he graduates.

“I want to work. I don’t want handouts,” he said.

A supporter of President Donald Trump’s, Williams said he is counting on the president to keep disability benefits in place and to ensure that health care is affordable for all.

“He thinks that if Trump knew his story, he’d get on this and fix things,” said Mitzi Proffitt.

“I like him because he’s a businessman, but he said he has heart,” Williams added.

Millions Of Kids Fall Outside Senate Plan To Shield Disabled From Medicaid Cuts

Aidan Long is a 13-year-old from Montana who has suffered multiple daily seizures since he was 4. The seizures defy medical cure, and some of them continue for weeks, requiring Aidan to be airlifted to children’s hospitals in Denver or Seattle, said his father, Ben Long. The medical bills to Medicaid and his private insurance have been enormous.

“I kept track of these until about 2 million bucks, and then I said I can’t spend any more time worrying about it,” his father said.

As Senate Republicans seek to limit the amount Medicaid will spend on poor people’s health, they recognize that one group has complex medical issues warranting protection: severe special needs. But Aidan and several million other children would not meet the Senate’s highly restrictive definition of “blind and disabled” children whose health coverage would be excluded from the vast reductions Republicans are pushing.

This KHN story also ran in The Washington Post. It can be republished for free (details).

With federal Medicaid spending predicted to drop 35 percent by 2036 under the GOP plan, states would have to shoulder the high medical costs of children with disabilities or else reduce or rescind health services Medicaid now pays for. Those include doctors and specialists; nurses in schools and at home; prescription drugs; and occupational, speech and physical therapy.

“It’s just a fraction of kids who we consider having special health needs who would qualify for the carve-out,” said Janis Guerney, co-public policy director at Family Voices, an organization of families of children with special needs. “The caps are going to put states under so much financial pressure that they are going to do away with the things they don’t have to cover.”

At risk not only are children living in poverty but also kids from working- and middle-class families who have been allowed to enroll in Medicaid because their medical problems are so extensive that most private insurance will not cover it all.

“Absent those supports paid for by Medicaid, the only option many families will have is institutionalization,” said Meg Comeau, a researcher at the Boston University School of Public Health’s Catalyst Center, which helps states improve insurance for children with special needs. “You’ll see kids going into pediatric nursing homes, kids not being able to be discharged from hospitals.”

States Are ‘Going To Be In A Pickle’

Of the 5 million to 6 million children with special needs estimated to be enrolled in Medicaid, 1.2 million would meet the Senate’s definition of “disabled,” which relies on strict criteria to qualify for federal Supplemental Security Income, or SSI, payments. Those children must come from impoverished families who can prove they are blind or have “marked and severe functional limitations” that are fatal or will last continuously for at least a year. Under the Senate bill, the federal government would continue to pay for a portion of their medical bills without setting a financial ceiling.

That would not be the case for the majority of other children with special needs on Medicaid. They qualify because their families have low incomes, so there has been no reason for states to keep track of them separately. Under the Senate plan, the federal government would give states the same amount of Medicaid funding for those children as they would for a child without disabilities, even though that child’s health costs would likely be much higher.

“The potential consequences could be devastating,” said Sara Bachman, another researcher at the Catalyst Center. “States on their own are quite variable on the ability to support the services kids need. The federal participation in the Medicaid program is in an essential underpinning. States are really going to be in a pickle.”

A Republican Senate aide, who was authorized to speak only on condition of anonymity, said Sen. Orrin Hatch (R-Utah), the chairman of the Senate Finance Committee, and several other Republicans wanted to exempt all children with disabilities from the per capita payment limits. But bill drafters ran into a problem: Lack of information about the broad population of children with special needs on Medicaid impeded them from crafting a more expansive definition, and the Congressional Budget Office, or CBO, could not estimate the costs, the aide said.

“We were trying to get as many of them, if not all of them, exempted from the cap,” the aide said. “But the problem is the only good definition and the only good numbers we had were for SSI.”

The Senate bill would require states to begin reporting details on children with special needs so that Congress could expand the exclusion. “Hopefully in a couple of years, when we have a better idea of who they are, we can get them in there,” the aide said.

Some Middle-Class Families Would Also Be Hit

Until then, the most severe repercussions from the Senate bill would fall on a third group, roughly 400,000 severely impaired children from families who are not in poverty but whose children have high health-related expenses. Over the years, states have received permission from the federal government to let these children go on Medicaid so they could be cared for at home. Otherwise they might need to live in an institutional setting such as a hospital or pediatric nursing home or have a parent quit work to stay with them.

Some of these families, including Aidan Long’s, have private health insurance through work. But even the best policies rarely pay for as much as Medicaid does.

Christy Judd’s 8-year-old son, Ethan, has a congenital neuromuscular disease and needs a ventilator to breathe at night. Every week he gets physical therapy to improve his balance and mobility, and Medicaid picks up the hefty copays for both equipment and care. Ethan is able to attend school in Inwood, W.Va., only because Medicaid pays for nurses and aides to watch him.

“His health care would exceed what we make in a year despite the fact that we have very high-quality health care insurance,” said Judd, a high school history teacher. “He requires eyeballs on him 24/7. My husband and I are human beings. We have to sleep. Without access to Medicaid, he could die.”

I wish she was still here … but if this darn Senate bill passes, I’m almost grateful she’s gone.

Cara Coleman, speaking of her 11-year-old daughter, who died in March

Medicaid paid for nurses, a feeding tube and special food for Cara Coleman’s 11-year-old daughter, Justice, until the girl’s death in March. Coleman is an attorney from Waterford, Va., and her husband is an executive, but their private insurance provided only $500 in nursing benefits a year. Justice required 12 to 16 hours of nursing a day, which Coleman said might have exceeded $80,000 a year. Medicaid also paid for a portion of her wheelchair and all of the palliative and hospice care that eased Justice’s pain in her final year of life.

“I wish she was still here and that we didn’t have to let her go so early, but if this darn Senate bill passes, I’m almost grateful she’s gone,” she said. “If she were still alive and we had to face the per capita caps in Medicaid, I’m sure we would be in medical bankruptcy and her life would go down the tubes. I’m glad she went on her terms.”

At Aidan Long’s school in Kalispell, Mont., nurses or aides paid by Medicaid must watch him to make sure a seizure doesn’t cause him to fall and strike his head, Ben Long said. He also gets physical, occupational and speech therapy at school, also paid by Medicaid.

“He has to be relearning basic things, how to walk, how to balance himself,” Long said. Occupational therapy helps Aidan use a pencil and put on his shoes. The school district charges Medicaid for those services, but the Senate plan could jeopardize the funding, potentially forcing superintendents to choose between reductions in special-education services or general programs.

Aidan Long, 13, who is covered by Medicaid because of his serious, nearly daily seizures, enjoys fishing with his father, Ben Long, near their home in Kalispell, Mont. (Family photo)

“We’re really grateful for the local support our school district has shown, but they’re kind of stuck like sandwich meat between the rights of the kids and the capacities of the local taxpayers,” Long said.

Aidan Long’s mother, Karen Nichols, put her photography career on hold to care for him. Still, the Longs need nurses to come to their home four or five times a week to relieve Aidan’s parents. Without that support, Ben Long said he would have to leave the communications nonprofit organization where he works.

On his good days, Aidan is active, kicking a soccer ball and fishing with his dad. When the seizures do not stop, the costs can be huge: $70,000 to fly him to a children’s hospital, where the room alone costs $10,000 a night, Ben Long said. “That’s not the care, that’s just the space,” he said.

As the GOP leadership pushes for the Senate measure’s passage, Long has been trying to rally advisers of Montana’s Democratic governor to raise concern, and he has repeatedly sought to reach Montana’s Republican senator, Steve Daines. He said that after he called, wrote and tweeted the senator, Daines responded with a form letter.

“You meet these parents of other kids with these severe disabilities, these parents are fighting to keep their families together and they’re fighting for their kids’ lives,” Long said. “Everybody’s so busy keeping things together, they don’t have the luxury to hire lobbyists.”