The ITUP Spotlight on Health Reform

While most of our state elected officials are on summer recess (this the last week of break before members return to Sacramento), there has been much rhetoric from the Governor and Democratic leaders on the budget... but they still seem miles apart.

Governor Schwarzenegger even hinted that he may have to duck the budget entirely this year and leave the mess for his successor... "If I do not get all of the things that we need... I will not sign a budget, and it could actually drag out until the next governor gets into office," Schwarzenegger was quoted in yesterday's L.A. Times.

Senate President Darrell Steinberg said he was "prepared to grant [Schwarzenegger] his wish" if he "continues to insist on granting billions in corporate tax cuts financed by drastic cuts to public education and programs for working mothers and their children."

While this back-and-forth may just be high-level posturing, the consequences for California's essential health and other safety net programs are significant and their longevity get increasingly precarious with every passing day...

(Blog post care of ITUP intern Christina Vane)

Last week on the Blog, we began the conversations about health reform “navigators,” organizations and individuals who will be helping participants embark on what will undoubtedly be the confusing task of applying for and selecting a health insurance plan through the Exchange.

In what seems to be an effort by the Legislature to ease the process even further, AB 2787 (Monning & Alquist) is moving through the legislative process; if passed, the bill would create the California Health Ombudsman Office to further consumers' abilities to digest and navigate the new reform legislation.

What’s an ombudsman, you ask? In simplest terms, it is a trusted person or agency that smooths the process, investigates complaints and mediates settlements between parties (in this case, the insured members and health plans).

As envisioned by AB 2787, the new Ombudsman office would be established using part of the $30 million in newly-appropriated Consumer Assistance Grants with the intention of boosting consumer protections. The creation of the office will hopefully help consolidate the nine (or so) agencies that currently provide consumer assistance with health plans.

If implemented, the Office will help Californians:
• Lean more about their health care choices;
• Enroll in health plans;
• Obtain tax credits created by the health care reform law; and
• Receive answers to their questions through a 24-hour hotline.

The bill would also require state agencies to make referrals as well as coordinate and record consumer complaints in concert with the Ombudsman Office. For this reason, the bill is currently receiving opposition from many health plan and health insurance lobbying groups stating unnecessary spending of funds for duplicative services.

Current status... The bill passed the Senate Health Committee last month and is scheduled to go before the Senate Appropriations Committee sometime in August. Let’s see what happens!

(Blog post care of ITUP intern Kandis Driscoll...)

Heads up that a new maternity care bill -- well, new to this blog -- AB 1825 (De La Torre) is poised to reach the Senate floor.

Some background first... In California, there is no existing law requiring health insurers to designate which basic health care services are covered, so health insurers are not forced to provide coverage for maternity services. As a result, an estimated $21 million is paid for women who already have insurance, but are lacking or enduring substandard maternity care, and thus, seek this care through state programs, such as AIM, the Access for Infants and Mother’s program.

AB 1825 would require health insurers to submit to the CA Department of Insurance revised policy forms that provide coverage for specified maternity services, including prenatal care, ambulatory care maternity services, involuntary complications of pregnancy, neonatal care, inpatient hospital care with labor, delivery and postpartum care.

Status... AB 1825 is currently parked at the Senate Appropriations Committee due to a budgetary analysis stating that two staff positions will be needed for effective implementation, roughly totaling $100,000 each year. (In these lean budget years, most bills with any price tag at all get held up at Approps).

Despite this associated expense, Beth McGovern, legislative director of the California Commission on the Status of Women, believes the bill will actually save money. She is convinced that, "women who don't have health insurance are likely to delay or forego prenatal care, which increases the likelihood of pregnancy complications, and complications at birth…that often involves public cost to take care of both the patient and the child."

The committee is set to take up AB 1825 again in August once the state Legislature reconvenes. Will update readers then...

In addition to the newly announced Consumer Assistance Grants, the Affordable Care Act (aka health reform) has created a number of other exciting funding opportunities.

Below are links to the grant centers for the federal agencies administering many of the grants under reform. At each site -- and at Grants.gov -- you can search for relevant grant opportunities.

· OCIIO Health Insurance Premium Review Grants
· Administration for Children and Families Grants
· Administration on Aging Grants
· Agency for Healthcare Research and Quality
· Health Resources and Services Administration Grants
· Indian Health Service Grants
· National Institutes of Health Grants
· Substance Abuse and Mental Health Services Administration Grants

Check em out!

The federal government is now accepting applications for health reform’s Consumer Assistance Grants. The grants will provide nearly $30 million to help states educate consumers about their health coverage options and ensure access to accurate information about health reform.

All States and territories may apply for these grants to expand consumer assistance efforts such as:
· Helping consumers enroll in health coverage;
· Helping consumers file complaints and appeals against health plans;
· Educating consumers about their rights and empowering them to take action;
· Tracking consumer complaints to help identify problems and strengthen enforcement; and
· Establishing a health insurance consumer assistance (or ombudsman) program through the state’s insurance department, attorney general, or independent consumer assistance agency.

Eligible applicants include state insurance departments, attorneys general offices, independent consumer assistance agencies, and other state agencies. States and territories may also partner with non-profit organizations that have a track record of working with consumers.

Grant applications are available now! Go to the federal government's grant website and search for CFDA # 93.519.

In the application, states must explain how the program will assist people with all types of coverage, collect data about any problems and questions, and provide assistance in a culturally appropriate manner.

Applications are due September 10, 2010.

According to the Council of Economic Advisors' (CEA) quarterly report on the continuing effects of the American Recovery and Reinvestment Act (ARRA), the magnitude of the fiscal stimulus and its positive effect on the U.S. economy have been increasing substantially in the first half of 2010 (from $108 billion in the first quarter of 2010 to $116 billion in the second quarter).

CEA estimates that the 2009 stimulus has (1) boosted GDP by 2.7 percent and (2) raised employment by 2.5 million jobs since February 2009, relative to what would have occurred absent the stimulus.

According to CEA, ARRA has spent $480 billion and using numbers from Stimulus.org, about $260 billion of that is spending and $220 billion is tax cuts. The amounts are further broken down into several tax and spending categories on the Stimulus website.

On Wednesday at 2:00 pm PDT, the California Primary Care Association (CPCA) and the regional consortia will be kicking off an educational campaign highlighting the important and beneficial provisions of health care reform (HCR) that will make community clinic and health centers and their patients, better able to thrive.

The training is open to everyone interested in learning about the newly enacted law. However, they encourage staff that directly interact with patients on an ongoing basis -- clinicians, outreach workers, health educators, eligibility workers, front desk employees, etc. -- to participate.

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To join the training session
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1. Go to this site
2. Enter your name and email address.
3. Enter the session password: 72810HCWa
4. Click "Join Now".
5. Follow the instructions that appear on your screen.

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To join the session by phone only
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To receive a call back, provide your phone number when you join the training session, or call the number below and enter the access code.
Toll-free number: 866-469-3239
Access code: 925 392 727

If you have additional questions in advance of the webinar, please contact Aracely Navarro at anavarro @ cpca.org.

Yesterday, the state convened the fifth in a series of §1115 Hospital Waiver Stakeholder Adviser Committee Meetings, conducted in accordance with the Bagley-Keene Open Meeting Act.

The meeting included updates on:
(1) negotiations with CMS;
(2) state legislation;
(3) budget neutrality;
(4) federal financing; and
(5) early implementation activities.

Speakers included:
• David Maxwell-Jolly, DHCS Director
• David Panush, Senate President Pro-Tempore’s Office
• Sumi Sousa, Assembly Speaker’s Office
• Toby Douglas, DHCS Chief Deputy Director, Health Care Programs
• Gregory Franklin, DHCS Deputy Director, Health Care Operations

I. Update on Discussions with CMS (David Maxwell-Jolly)
• In June, the state sent a 70 page concrete waiver proposal to CMS
• Since then, there has been a very intensive and steady back-and-forth
• CA has been extremely well received by CMS, with “attention and vigor”
• CMS very much in a problem solving mode, looking for solutions
• CMS likes CA’s approaches to better care coordination, medical home, ACOs.
• CMS especially interested in effective investments in our safety net systems and global budgeting proposals
• CMS wants to ensure mandatory enrollment of the SPD population happens as a graceful transition. CA must identify folks with high healthcare needs and be sure the state is doing everything to ensure plan readiness.
• Lots of interest from CMS re: coordinating behavioral and physical health.

II. Legislation / Trailer Bill Language Update
David Maxwell-Jolly
o Lots of talk in Sacramento since language went live last month, lots of dialog around the issues being raised, solutions emerging. There are continuing and frank discussions with health plans, advocates and other stakeholders.
o Common concern: implementing the waiver provisions effectively and meeting the needs of the beneficiaries
o Moving toward more specifics on care coordination and medical homes.
o Will be one, if not more, rounds of additional amendments.
o Trying to strike a balance between what is practical and reasonable ways to meet critical needs so that the systems do work

Sumi Sousa
o Lots of attention/conversation on the SPD, CCS, and duals. Refinement will happen, but the attention will shift a little now.
o Time to start focusing on important hospital financing provision – nothing else will matter without a $ figure at the end

David Panush
o Amendments to the Waiver bills are being done through an iterative process.
o New amendments probably out in the middle of next week.
o These won’t be the final set of amendments. We are still waiting on CMS for financing piece (more below). Once we know the total federal financing piece, the discussion will turn to “how the pie gets sliced up.”
o “The next 5 weeks will be the most strenuous and there is no inevitably.” We’re pushing the agenda, but it’s a huge ask. The only way this is going happen is by achieving consensus (state, CMS, plans, stakeholders). Must be some unification. If not, we can just stall and try again next year.

III. Budget Neutrality (Toby Douglas)
- Goal: construct budget neutrality (BN) that brings in most federal funds
- BN based on a few components:
1. Coverage Expansion: with health reform, states can begin on coverage of childless adults through a state plan amendment (SPA). Instead, CA is requesting to do so under the waiver. If we’re permitted to do so, we want to count this expansion outside of BN requirements.
2. Public Hospital Spending: making the assumption/assertion that had CA not entered the last Public Hospital waiver, we would have seen massive growth in cost (8.5%) for Public Hospital expenditures through 2015. Therefore, with a large trend line absent a waiver, there’s a lot of room for BN.
3. Implementation of Organized Delivery Systems of Care for Special needs Populations: absent this waiver, expenditures for this program will grow much faster. With better coordination, we will reduce the trend rate
4. Longstanding recipient of funding under the LA County waiver. Continuing to carry that forward should be counted with a BM gain.
5. Also $360m per year we just received, added in 5th yr of waiver; we should continue to receive that in the new waiver.
- If all 5 pieces receive CMS approval, CA will be able to draw down $10 billion over 5 years.

IV. Waiver Financing (Toby Douglas)
- Overall Point: no state general funds. Plus, MOE under ARRA and PPACA. So, need to look for other opportunities:
o Expanding state-only programs being claimed under waiver (currently 6 programs) to more programs: workforce money, MRMIP high risk pool (prop 99 funds should be claimed under waiver), parolees assistance, IMDs, and over-night hospital stays in corrections.
o Global Payment Process for Public Hospitals – set limit of funding that they have to live within, then they have to try to allocate care and promote prevention. Payments would be above cost.
o Improvement pool – through IGTs, allow public Hospitals to invest in deliver systems through improved flow of patients through out patient system.
o IGTs for non-contract Hospitals – allowing for IGT above cost, supplemental payments for that group, to help private safety net systems.

V. Preparing for Implementation (Greg Franklin)
- Some preparation for the waiver being done now, especially with the SPD Transition.
o Provider cross-walk takes Fee-For-Service (FFS) providers and cross walked it with plan providers, continued to build providers for SPD populations.
o Aggregate data: number of Medi-Cal only population by aid code provided to plans in June. Will be posted to website by Aug/Sep.
o 2009 Paid Claims Raw Data for FFS service, county specific – this has been shared with plans.
o County Alternative Model – those Counties that are interested due back Aug 15.
o Outreach and Education Work
• SPD sensitivity training.
• Western University of Health Sciences developing it, will be developed with stakeholder input, conducted in Jan 2011 for everyone (one in Nor Cal, one in So Cal)… trainers for plans, train-the-trainers, DHS managed are staff, community organizations, etc.
• Informing Materials and Presentations
• UC Berkeley will be developing pre-enrollment notifications and other materials, in all threshold languages and alternative formats
• Starts no later than Nov. 1,
• Revising facility site review tool.

As you know, California’s existing §1115 Medicaid waiver expires on August 31st, and the state is currently in the process of applying for its renewal. In June, DHCS submitted an initial waiver proposal to CMS, and the two entities are currently engaged in negotiations regarding the eventual scope of the waiver and the ultimate financial contribution from the federal government. If all goes well, DHCS will submit a final waiver application no later than September 1st.

To help you better understand the state's initial 70-page waiver proposal, ITUP has just produced a document entitled Summary, Thoughts, and Analysis that highlights potential opportunities for various stakeholders within the coverage expansion component of the waiver and includes a plethora of ITUP recommendations. Be sure to check it out.

In addition, earlier this month DHCS published a Vision Document that describes how the components of the waiver proposal will help the state make significant strides in implementing health reform, including coverage expansion to the newly eligible Medicaid populations, expansion of Medicaid benefits for new and existing populations, delivery system reform, administration simplification, and payment reform. Also a great read.

Both documents are useful tools to help one make heads-and-tails of the waiver.

I'm working on a piece on health information technology with Kiwon but wanted to provide loyal ITUP blog readers with a preview that summarizes the final meaningful use rule released last week by CMS. Eligible professionals and hospitals must abide by these requirements in order to demonstrate 'meaningful use' of an electronic health record product and thus receive incentive payments (up to $44,000 for Medicare providers and $63,750 for Medicaid providers over 5 years) for the adoption of an EHR.

Check out our meaningful use table on objectives and outcome measures for the details.

The Patient Protection and Affordable Care Act has provisions for state exchanges to extend grants to “navigators” in order to assist and guide participants in purchasing reliable health care through the complexities of the insurance market.

Below is a quick summary of what we know now (which is very little). And/or, you can read the law for yourself.

Navigator duties can/may include:
• Public education;
• Distributing fair and impartial information;
• Assisting in Exchange enrollment;
• Providing culturally and linguistically appropriate information;
• Referring grievances;and
• Providing general health insurance consumer assistance.

In order to be eligible to serve as a navigator, candidates CAN be:
• a member of trade/industry/professional associations;
• a member of fishing/ranching/farming organizations;
• a community group;
• a chamber of commerce or unions;
• resource partners of small businesses; and/or
• licensed insurance agents and brokers capable of demonstrating having existing relationships or the feasibility of establishing relationships with employers, employees, consumer or self-employed individuals likely to be qualified for the Exchange.

A Navigator CANNOT be a health insurer or entity receiving direct consideration from a qualified health provider offering insurance.

Though concern exists regarding the addition of navigators to a field that is saturated with specially trained insurance-savvy brokers and agents, the role of the navigators seems to be concentrated on a more local and community level, thus giving special assistance to those who are first-time insurance buyers.

Only time will tell if their role is redundant, but with the establishment of California’s Health Benefits Exchange on the horizon, many may find it comforting to have local patterns to help with the novel and potentially complex insurance health plan options in the Exchange.

Much more to discuss as details emerge...

In Sacramento, as in many state capitols across the country, elected officials are bracing themselves for what could be more bad budget news.

Some background... In the 2009 federal stimulus package, Congress issued assistance to the states ($11 billion to California alone) in the form of increased federal Medicaid spending. The funding was intended to soothe the vast expansion of program utilization due to the recession. Yet the federal assistance was not indefinite; it is set to expire on Dec. 31, 2010.

Earlier this year, it appeared Congress would continue the assistance for an additional six months in an “extenders bill” (HR 4213) that also included a continuation of unemployment benefits. Thirty states, including California, already accounted for the extra funding in their budgets and budget proposals. However, the “extenders bill” – and the $24 billion in extra Medicaid funding it contained – was filibustered and did not pass out of the Senate last month.

Failure to receive the additional federal Medicaid aid – $1.5 billion of the $24 billion is expected to come to the Golden State – would mean California faces even an even larger budget crisis. Entire programs could be eliminated (as is evident in the Governor’s May Revise proposal to completely eliminate CalWORKs).

There’s an irony that many states are experiencing: without the federal assistance, states may have to cut essential safety net programs while simultaneously gearing up to implement health reform, including an expansion to Medicaid that will cover more than 16 million Americans starting in 2014. Many states are hoping Congress can find away to pass the Medicaid extension before the August recess in hopes of preventing significant cuts to programs and jobs.

It is unclear whether Congress will pass a Medicaid assistance provision this year. If so, it could ensure that essential state programs are kept alive. If not, California’s budget woes are looking that much more woeful. Stay tuned...

On Tuesday, ITUP staff joined a discussion with HHS Secretary Kathleen Sebelius as she offered insight about the nation’s new investment in preventive care, "marking a fundamental shift from treatment to prevention." As you can read in the blog post immediately below, starting September 23rd new health plans will be required to cover preventive services at no additional cost to individuals.

Here’s some of the pertinent Q-and-A with Secretary Sebelius:

Disease and Prevention
Q: Will patients with chronic diseases be considered to be seeking preventive care or treatment for their illness?
A: That would not be preventive care; that would be considered medical management, and thus, left up to the health plans.

Q: In the area of colorectal screenings, in which there are at least three different screening options, is there anything that ensures that insurers won’t simply steer patients in one direction, but rather leave the decision to physicians and their patients? Is there any protection involved?
A: No, I don’t believe there is any protection involved. I know this might be an issue, but I’m not aware of any problems in this area.

Benefits of Prevention
Q: Which preventive benefits are included in the new provisions, and will there be a cap?
A: The regulation has tables that list vaccinations and benefits that are included. (See this list). There is no technical cap on the benefits.

Budget for Preventative Services
Q: What percentage of the overall legislation is being devoted to preventive care? I think this needs more priority.
A: The new law aims at ensuring a comprehensive approach in which prevention is an important part. We have allotted $15 billion over the next 10 years in a fund for prevention and public health.

Q: Will there be any financial incentives for plans to participate? Is this something that we should be encouraging, or is there a disconnect in this area?
A: I don’t think there is a disconnect. We are trying to give more Americans access to the preventive services that have usually been typical of large employer health plans.

Wellness
Q: Many people have made reference to wellness; can you speak about grants that will be awarded to small businesses in terms of that?
A: That is an ongoing discussion with Congress, so we don’t currently have a timeline for when this will happen. However, for follow-up information, feel free to reference the newly-launched health reform website.

Q: We are looking to develop a community wellness program. We have seen many benefits in the modified behaviors treatment. Is there any care that specifically addresses this? Do you see anything coming that speaks specifically to modified behaviors?
A: Services have been recommended for body mass index consultations, nutritional counseling, etc. The preventive services page on the health reform website can provide a more comprehensive list for you.

Q: Pesticides have been documented as unhealthy; what will be the reimbursement for services in this area?
A: Part of the recommended services come from the “bright future” guidelines. So we will leave this discussion to doctors and their patients, but we are certain that environmental health will come up in their discussions.

Yesterday, HHS Secretary Kathleen Sebelius announced new rules under health reform that will require health plans to provide preventive services with no-cost sharing for enrollees so long as in-network providers deliver them. The requirements apply only to new health plans that start providing coverage after September 23, 2010 or existing plans who make substantial changes after the date.

For individuals in those plans, there will be no co-payments, deductibles, and out-of-pocket charges for a list of services in line with recommendations provided by the U.S. Preventive Services Task Force. The intention is to increase the utilization of preventive services for Americans, who currently use less than half the services recommended by their physicians.

With a list that includes cancer screenings, routine vaccinations and wellness visits for children, Sebelius predicts that the new requirements will extend benefits to 31 million U.S. residents who are newly covered through their employer and 10 million residents who sign-up for new individual plans.

For more, see yesterday's California Healthline.

Certainly, this is a huge step towards offering Americans more comprehensive care in tough economic times. We’d love to hear your comments!

As you know, the federal reform law requires states to have fully functioning exchanges by January 1, 2014. It specifies that the exchanges offer coverage for individuals and small businesses, and that the exchanges be operated by a government agency or non-profit entity. Health plans must adhere to the exchange guidelines in order to offer subsidized coverage through the Exchange. Purchase of insurance through the exchanges will be available for U.S. citizens and legal permanent residents. The exchanges will also contain new consumer protections that health plans must adhere to in order to take advantage of the new market.

While states will be obliged to adhere to those federal requirements, the law leaves a majority of the construction of the exchanges to the states.

Some of these large questions include:
• Should the state establish its own pool or be part of the federal pool?
• Should the exchange be statewide or a regional consortium of neighboring states?
• Should the entity be a public agency, public-private partnership, or a private non-profit organization?
• Should the exchange be a web-portal, like E-Insurance or an active price and coverage negotiator?
• Should a board govern the exchange? If so, how? Make-up? Selection?
• What will be the relationship between the exchange, private insurance and public programs?
• Should Medi-Cal and Healthy Families be a part of the Exchange? If so, should the Exchange be authorized to do Medi-Cal and Healthy Families eligibility determinations and redeterminations?
• Should there be a separate small employer pool or should individuals and small employers buy as part of the same pool?
• Can there be a public option in the exchange?
• How do we maximize participation and outreach?
• How will the Navigator grants operate and who will be eligible for them?
• What will be the roll of brokers? CAA’s?

One of the two exchange bills moving rapidly in the legislature this summer, AB 1602 (Perez) and SB 900 (Alquist & Steinberg), will likely pass this year and become law. It will begin to set the framework for California's Health Benefits Exchange and include initial answers to many of these key questions.

If you have thoughts on any of these topics, or suggestions for how they might be actualized and implemented, NOW is the time to speak up. Reach out to your legislature, comment on this blog, contact me (cliff @ itup.org), and make your voice heard!

To assist you, be sure to check out our new side-by-side comparison of the Exchange bills.

Legislative Update: The two pieces of exchange legislation, AB 1602 (Perez) and SB 900 (Alquist & Steinberg), recently passed out of the opposite houses' Health Committees and are now awaiting hearing in the opposite houses' Appropriations Committees.

While the bills are very similar (they would both, if passed, establish the Exchange and set forth its foundation and scope), they do contain notable differences. ITUP has recently posted a side-by-side comparison of the Exchange bills. Check it out!

In June, the Department of Health Care Services (DHCS) submitted an initial waiver proposal to the federal Centers for Medicare and Medicaid Services (CMS). CMS is currently reviewing the proposal and will offer feedback to DHCS who will then submit a final waiver application no later than September 1, 2010.

Concurrently, our elected officials in Sacramento are moving forward with legislation that will make the necessary changes in law so that the state implements the new waiver once it receives CMS approval. Two identical bills, AB 342 (Perez) & SB 208 (Steinberg), were recently amended to comport with the requests made in the June proposal to CMS.

Legislative Update: Both bills recently passed out of the opposite houses' Health Committees and are now awaiting hearing in the opposite houses' Appropriations Committees. The bills will likely be amended multiple times before their final passage as California’s waiver proposal gets more refined, advocates’ requests are incorporated, and CMS offers further guidance and parameters.

New Waiver Material: We have recently posted a 2-page Outline of the Waiver Bills. Soon we will be publishing an easy-to-read outline of the state's 70-page proposal to CMS.

Check 'em out!

The Obama Administration recently announced requests for public comment on a few health reform related regulations. If you can, you are encouraged to provide HHS your perspective and suggestions.

In particular, the Departments of HHS, Labor, and Treasury released several regulations to implement the new Patients’ Bill of Rights. The regs relate to:
* the prohibition of discrimination based on pre-existing conditions for children;
* the ban on lifetime limits on coverage;
* the ban on unfair rescissions of coverage;
* the restriction of cost-sharing for emergency services; and
* other patient protections.

Information on the rules is available on the HHS website.

Comments on the regs are due by August 27, 2010 and the rules go into effect September 23, 2010.

You can comment directly to HHS on line.

Below are links to a series of new HHS brochures and materials related to the implementation of the Affordable Care Act.
 
· Patient Protections & Insurance Reforms
· Poster: Are You Eligible for the Pre-Existing Condition Insurance Plan?
· The Affordable Care Act — What it Means for Those with Pre-Existing Conditions
· Medicare and the New Health Care Law — What it Means for You
· Closing the Prescription Drug Coverage Gap

For questions or comments on any of these, you can email HHSIGA @ hhs.gov.

Yesterday, MRMIB's Deputy Director of Legislative and External Affairs Jeanie Esajian made a few announcements regarding the state's new high risk pool.

MRMIB submitted two documents to CMS Thursday. The first details how MRMIB will run the new pool. The second is to solicit responses from plans who may want to participate in the pool.

MRMIB will hold a conference for potential vendors on July 12th, and it hopes to get proposals in by July 21st.

Ultimately, the Agency hopes to begin taking patient applications by the end of the summer and sees the new pool up-and-running by September.

For more, see today's California Healthline article.