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...

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!

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.

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.

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!

Along with the tumult and flux that will invariably come with the implementation of health reform, the next few years offers California an opportunity to reexamine existing health care systems and structures. Reform implementation, therefore, brings with it the possibility of better designing the way health coverage and health care are administered and delivered in our state.

At ITUP, we'll be exploring those possibilities, particularly focusing on four areas, among others:
(1) The California Health Benefits Exchange;
(2) Medi-Cal Eligibility and Enrollment Simplification;
(3) Stability in Payment and Reimbursement Reform; and
(4) Creating an Integrated Safety Net and System of Care.

For instance, on number (2), we have already begun thinking and writing about opportunities for Medi-Cal Modernization.

To further the conversation on number (4), the Robert Wood Johnson Foundation (RWJ) has provided a two-year grant to examine well-functioning safety nets that provide low-income patients affordable access to comprehensive care.

The recipient of that grant, Mark Hall, Professor of Law and Public Health at Wake Forest University Medical School, has recently released five in-depth case studies examining the costs and adequacy of better functioning safety net systems in Asheville NC, Boston MA, Denver CO, Flint MI, and San Antonio TX.

For those interested in how we in California may one day provide more effective, coordinated care, be sure to read Professor Hall's case studies.

Amid all the movement in Sacramento around the High Risk Pool, Section 1115 Waiver Renewal, Health Benefits Exchange, and even the Single Payer bill, it is easy to forget about the state budget. If you recall, the state is currently in a $19.1 billion budget deficit (in a total budget of +/-$100 billion).

As you know, the Constitutional deadline has come and gone, and we're now 7 days into the new fiscal year without a budget. While we're still a long way from the record (the 2008-09 budget was signed on Sep. 23rd - 85 days past the deadline), with all the other business in the Capitol, including the broiling minimum wage fight and the fast-approaching mid-term elections, it looks to be another long, hot summer on the budget in Sacramento.

As a quick refresher... in May, Governor Schwarzenegger released his revised budget proposal. The Governor's proposal includes some dramatic cuts and changes to Medi-Cal, Healthy Families, and the mental health safety net. For more, be sure to read ITUP's summary and analysis.

Just last month, the Democratic majorities in the state Senate and Assembly responded to the Governor, announcing their Principles for Finalizing Budget.

Some highlights:
• No further erosion of the critical services for vulnerable children, the disabled, the elderly, and the ill, including proposals that call for elimination of CalWORKs, child care, community mental health, and the draconian reductions in IHSS and Medi-Cal.
• Funding schools in accordance with Prop 98.
• Now is not the time to implement major new programs or to implement new tax breaks.
• Closing loopholes, like the oil drilling loophole, and maintaining existing tax rates that will not negatively impact the economy.
• Reject the scapegoating of state employees.

How and when all of this will unfold, and how the final budget may or may not affect the implementation of reform in California, is almost impossible to say at this point. Stay tuned to the Blog as the saga unfolds...

Attention counties and community-based organizations!

The Blue Shield of California Foundation (BSCF) is accepting grant proposals to help counties position themselves to respond to the opportunities in the pending Section 1115 Medi-Cal waiver. Proposals for the first of two funding phases are due Friday, July 9, 2010 at 12:00 pm.

Background: if the waiver is implemented as currently envisioned, the 10 county Health Care Coverage Initiatives (CIs) will be expanded throughout the state. The waiver would (1) allow existing CI counties to enroll more people, (2) enable any county that can identify local match and meet other program requirements to create a new CI, and (3) encourage counties to create a County Alternative Option that would be a locally-organized system of care as an option for providing care to Medi-Cal-eligible seniors and persons with disabilities.

BSCF is currently considering funding county governments or regional collaboratives of counties to develop strategies to expand coverage options for the uninsured and/or create an organized system of care for Medi-Cal eligible seniors and persons with disabilities.

Efforts that are eligible for funding consideration include:
* Expansion of an existing local CI;
* Creation of a CI in a county or counties without one; and
* Development of a County Alternative Option to provide care to seniors and persons with disabilities under the terms of the next Section 1115 Medi-Cal waiver.

To learn more and to submit a proposal, visit the BSCF website or contact Richard Thomason at richard.thomason @ blueshieldcafoundation.org.

First, some background... When President Obama signed the American Recovery and Reinvestment Act (aka the federal stimulus) early in his presidency, states got a fiscal boost due to an increase in FMAP. FMAP is the ratio that the federal government pays towards states' Medicaid programs.

For instance, prior to the stimulus, the FMAP for Medi-Cal was 50%. That is, for every $1 spent on our Medi-Cal program in California, the federal government covered 50 cents. After the stimulus, the federal share went up to 61.59%. This resulted in billions of dollars of savings for the state.

Yet, the new matching rate is set to expire on December 31. If it does, states in deep fiscal holes, like California, would be forced to make up the difference elsewhere -- either in cuts to other programs/services or increased revenue.

On May 28th, the House of Representatives approved an "extenders" bill for various programs, but omitted the FMAP extension provision in an effort to secure enough votes for passage.

Here's the good news... Today, California Health Line is reporting that the Senate plans to restore FMAP extension in the bill. This would mean California would receive the $1.5 billion in increased federal aid that Gov. Arnold Schwarzenegger assumed in his May revise proposal.

This is by no means a done-deal, but it is a promising sign for our state budget. Stay tuned...

Below is our summary of the Governor’s proposed May revisions to the FY2010-2011 budget as it pertains to health care. Notable changes include large increases in premiums for hard working, low wage Healthy Families subscribers; significant copays for Medi-Cal patients with incomes at or below poverty; the elimination of CalWORKs that pays for food and shelter for the poorest families; drastically reduced IHSS care that allow low income seniors and the disabled to stay out of nursing homes; severe cuts in child care that enables low wage families to go to work; and the reduction of community mental health services that prevent institutionalization of the mentally ill and untold harm to themselves and others. Also included are a few suggestions on what should be done to compensate for these cuts.

California Budget May Revision

The Revised Budget was released today, with deficit reductions absent of new revenue and performed solely through program cuts. While major cuts to Healthy Families and Medi-Cal were avoided thanks to federal reform's Maintenance of Effort (MOE) provisions regarding state health programs, both programs will be subject to new caps/cost sharing requirements and numerous other social services are either eliminated (CalWORKS) or reduced (IHSS, mental health, and others). We will have a more comprehensive summary in the coming days.

New numbers released by the state indicates that January was the worst on record for joblessness in California at a rate of 12.5%, with eight counties experiencing at least 20% unemployment. Yesterday the Senate passed the "American Workers, State, and Business Relief" Act, which will bring some much needed help to California and its fifth highest unemployment rate (behind Michigan, Nevada, Rhode Island, and South Carolina). The bill:

-Extends the 65% COBRA subsidy from the stimulus act to the end of 2010, saving unemployed beneficiaries in California $720/month

-Extends the enhanced federal matching rate for Medicaid (FMAP) for 6 months to June 2011, providing California $1.5-2B for the 2010-2011 budget

-Delays the scheduled 21% SGR payment rate cut for providers treating Medicare patients

In health reform news, the Senate Parliamentarian ruled as expected today that the reform bill must become law before a Reconciliation bill can be moved. The CBO and legislative language are expected as early as tomorrow, and numerous sources point to the final process starting on Monday, where the House Budget Committee will begin marking up the reconciliation bill. As for the question of Senate support, peruse this letter sent to minority leader Mitch McConnell today from Harry Reid.

...is what we spent on health care in the United States in 2009 ($2.5 trillion in total) says the Office of the Actuary, Center for Medicare and Medicaid Services (CMS) in a Health Affairs paper released today. The short piece is required reading for anyone interested in where current/future health care dollars come from and go to. You can read some of the major findings below:

-In 2009 the health share of gross domestic product (GDP) is expected to have increased 1.1% to 17.3%—the largest single-year increase since 1960.

-Slow growth in private market spending (3.0%, $1.5 trillion total) reflects the toll of the recession, while public spending increased markedly (8.7%, 1.2 trillion total) as a result of higher unemployment (9.9% increase in Cobra spending) and Medicaid enrollment (6.5% increase). See below:

-The share of health care dollars paid by government will increase to the 50% milestone by 2012, and 52% by 2019. See below:

-The effects of population growth and the changing age-sex mix are expected to be minor, contributing 0.9% and 0.4%, respectively, to annual growth for 2009–2019.

-By 2020 over 19% of the GDP will be dedicated to health care, about one in five dollars spent in the U.S. totaling $4.5 trillion annually at an annual growth rate of 6.1% (almost 2% faster than inflation).

This trajectory is clearly unsustainable, unless we choose to spend an increasingly larger portion of our economy on health care (without any apparent benefit to actual health outcomes) while also cutting public benefits/raising taxes to keep up....or Congress can pass the health reform bill that begins to address these problems while also providing health security to millions.

Broad consensus surrounds the viable path that should now be taken in Congress: Pass the Senate Bill and Fix it Through Reconciliation. Paul Krugman lays it out quite bluntly , and 47 of the nation's leading health policy experts have signed on, as well. Below are our thoughts for your reference, and a reminder of what will occur if Congress falters:

Weighing the Options in Federal Reform
Op-Ed on How to Restore California to Greatness

The Consequences of Reform Failure

From the White House Council of Economic Advisers:

-Health care expenditures would likely rise from their current level of 18 percent of GDP to 28 percent in 2030 and 34 percent in 2040
-The number of uninsured people in the United States would rise from 46 million in 2007 to 72 million in 2040
-Essentially all of the rise in average employee compensation due to increasing productivity over time would go to health insurance, and essentially none would go to take-home wages
-Steeply rising Medicare and Medicaid spending will be amplified by a 65% increase (25 million people) in the 65+ population resulting in unsustainable increases in the budget deficit

From the Urban Institute Health Insurance Policy Simulation Model:

-The amount of uncompensated care would more than double in 45 states
-Every state would see Medicaid/CHIP spending rise by 75%
-Every state would see the employer-sponsored insurance (ESI) population degrade
-27 states would see ESI premiums double, and 46 states would see employer costs increase by 60%
-The number of uninsured would increase by more than 30% in at least 27 states

The House reconvened on Capitol Hill today, with a promising development that may reconcile the differences in reform financing between the House high-income tax and the Senate excise tax on high-cost insurance. For the first time, lawmakers are considering extending the Medicare payroll tax to go beyond the pay-stub and now include dividends and other investment income for high-income earners.

The current law imposes a 1.45%/1.45% tax on employer/employee, and the Senate bill raises the worker contribution to 2.35% for individuals making more than $200,000 a year and couples making more than $250,000 a year. The compromise will extend the tax to sources such as capital gains, stock dividends, and interest (while excluding pensions and retirement accounts). The Finance Committee briefly considered the idea, finding that 80% of the funds would come from the top 5% of income earners and 64% of the funds from the top 1%. If this idea holds, the compromise will most likely also scale back the limits of the excise tax (though not remove it) and possibly eliminate the high-income tax so as to keep all mechanisms within the health care system.

Following up on yesterday's Health Insurance Exchange resources, I thought I would include some experienced words from the newly elected California Congressman John Garamendi in a press call today, expressing his (and my) preference for a nationally regulated Exchange:

"Under health reform, 30 million people will buy their insurance through the Exchanges. I spent years as insurance commissioner in California, chasing after the insurance company scoundrels. You’re going to toss 30 million Americans to these sharks unless there is a real strong regulatory environment [like the House's Exchanges]...

State governments vary in their ability to enforce regulations, and insurance company influence also varies. You can wind up with a commissioner in a state that has no interest in protecting consumers. To deal with that, you need a broad based Exchange that’s strong enough to overcome the insurance companies. That’s the role of the federal government. To make sure the insurance sold is valuable, claims will be paid, and companies will play by the rules."

Here are three pieces recently put together by the ITUP team:

-A Summary of Differences between the House and Senate bills (including sticking points like the structure of the Health Insurance Exchange...head here for more useful materials on this topic), and where we think the final legislation should be heading.

-An Open Letter assessing our regional constituents' thoughts on how best to transition to a 'reform ready' state using the 1115 Medicaid Waiver.

-A brief overview of the Budget Proposal put forth by Governor Schwarzenegger, highlighting the vast cuts to Health and Human Services programs like Medi-Cal in order to close the state's budget gap.

...three votes to go. Late last night, the Senate voted along party lines (60-40) to break a Republican filibuster and limit debate on the Manager's Amendment. Below you can find some important resources on the legislation including:

Highlights of the Manager's Amendment (pdf)
The Manager's Amendment (full text)
CBO Score of the Patient Protection and Affordable Care Act, Incorporating the Manager's Amendment (pdf)
CBO Score (blog)

Here are some provisions reflecting the updated Senate bill:
-Overall cost: $871B
-Expands insurance to 31 million uninsured Americans
-Reduces the federal deficit by $132B over 10 years, and by $1.3T over twenty years
-Immediate barring of coverage denial for pre-existing conditions in children
-Free choice provision allowing employees under 400% FPL paying between 8-9.8% of their income to obtain a voucher for purchase of individual insurance through Exchange
-National nonprofit health plans to be managed by the Office of Personnel Management (OPM), the same entity that manages health plans of federal employees
-Expanded tax credits for small businesses, beginning 2010
-Increases payroll tax for high-income earners from 0.5% to 0.9%
-Eliminates 'botox' tax and institutes 10% indoor tanning services tax
-Reduces minimum medical loss ratio to 80% for small group market, retains 85% threshold for large group market

Here is a nice visual aid by Igor Volsky: