A California Budget Project report released today predicted that the California Health Benefit Exchange, designed to insure small businesses employees and individuals without employer coverage could enroll as many as 8 million Californians when it launches in 2014, Because most Californians -- 55 percent -- receive health care coverage through their employers, they are unlikely to be affected by a requirement that all Americans maintain a minimum level of coverage.

Through subsidies for low- and middle-income families, increased Medi-Cal eligibility and employer incentives, ACA could reduce the number of uninsured Californians by two-thirds, or 4.7 million individuals, the independent fiscal and policy analysis group concluded.

Tangible Benefits in First Year

One year after it was signed into law, the Affordable Care Act (ACA) has provided tangible benefits to millions of Californians. The ACA has started to close the gap in prescription drug coverage for seniors and it offers up to 300,000 Californians who have been denied coverage due to pre-existing conditions an opportunity to sign up for affordable coverage through a temporary insurance pool. Young adults can be covered by their parents' plan up to age 26.

"As California works to swiftly and effectively implement a significant restructuring of our health care system, it is important that policy makers and insurance consumers have the basic facts own what the law means for our state," Budget Project executive director Jean Ross said in a news release. "The ACA is already providing clear benefits to California's seniors, young adults and individual consumers."

Sacramento Business Journal

The Health Debate Is Far From Over; Will Be Cornerstone Issue In 2012

The curious incident of the dog in the night was the crucial clue for Sherlock Holmes in solving the mystery in "Silver Blaze." The guard dog simply did not bark -- the absence of what one might have expected, being the most revelatory event.

This is much the position we find ourselves in today monitoring Americans' attitudes toward health care reform. Being asked to assess differences following the passage of federal health care legislation is revealing for what is absent -- a change in attitudes. Our latest opinion research data almost a full year post passage looks eerily similar to the data immediately following the law's enactment.

Health Law Anniversary

A majority of Americans (52 percent) continue to tell us they oppose the new health care law that was enacted by the Obama administration and Congress in 2010. Dating back to the summer of 2009 and continuing through passage our polling has demonstrated net negatives for the health care plan.

Also striking in its consistency is the intensity of antipathy toward the health care legislation. Two-in-five voters (40 percent) strongly oppose this law, compared to only 22 percent who strongly support it. Importantly, a majority (53 percent) of the all important Independent voters who tend to decide elections oppose the new law -- another consistency in our tracking over the last year.

As always in the world of politics, it is this intensity difference which is driving the debate. A whopping 73 percent of Republicans strongly oppose the new law. However, support among the Democratic base is not intense enough to act as a counterbalance to GOP repugnance of the law. Only 43 percent of Democrats strongly support the law one year later - a 30 point intensity gap.

The president's health care plan has sat at the center of a national debate over federal spending and the role of government, which played a crucial role in the overwhelming Republican victories last November. Nearly seven of ten voters who participated in that election told us on election night that they recalled seeing advertising during the campaigns about the federal health care reform legislation. Stunningly, among these voters, 70 percent said the ad was negative about the plan, while only eight percent (8 percent) said the ads they saw were positive about the new health care law. Given that ratio, it is not surprising that 45 percent of 2010 election voters said they wanted their vote to be read as a signal to oppose the law, while only 28 percent indicated their vote was supportive of the law.

Granted, many Americans tell us they like key features of the new law. Specifically, they rate coverage for pre-existing conditions, the expansion of coverage, and children staying on their parent's plan until they are 26 years old as reasons to keep the law intact. However, these positive features are being swamped by concerns about the impact on the federal debt (55 percent say it will make the federal budget deficit larger); the perception government will be too involved in health care decisions (54 percent say it will lead to too much government involvement; 9 percent say not enough government involvement in the health system) and a concern that the law does not address the escalating cost of health care (55 percent say the cost of their health care will increase as a result of the law).

One new "dog" that has barked in our polling is the impact of news reports about the decisions by federal judges on whether the individual mandate is constitutional or not. When given the opportunity to provide a rationale for their opposition to the law, voters increasingly point to their belief that the government does not have the right to force people to buy insurance coverage and/or an assertion that the law is unconstitutional because of this provision.

An issue to be on the lookout for as the debate emerges -- if insurers do begin to pull out of markets, then the debate could morph into one of anxiety over losing current coverage, which voters overwhelmingly like (72 percent say the current health system is meeting their needs and the needs of their family). This emerging concern is likely coming much sooner than when health exchanges come on line in 2014.

What else is ahead? The politics of repeal are difficult to predict. Still, one thing is certain. The Republican nominee for president will support repealing this legislation.

In our firm's congressional polling in 2010 in Republican primaries, the top testing statement about why to vote for a candidate was his or her opposition to the Obama health care plan. Today, 82 percent of Republicans and 82 percent of those who identify themselves as supporters of the Tea Party Movement also support repeal. Independents and swing voters may waiver in their views of this law, but the nominating wing of the Republican Party has shown no signs of changing. There is no way a Republican will win the nomination without being actively and vocally in support of repeal.

Campaigns are about differences. There could not be a more fundamental difference between President Barack Obama's championing of this law and the eventual Republican nominee's likely disdain for it. Therefore, as any sleuth might deduce upon examination of this data, we believe the debate over health care is far from over and will in fact be a cornerstone of the 2012 campaign. That prediction is really quite elementary.

By Bill McInturff and Lori Weigel
Bill McInturff is a partner and co-founder of Public Opinion Strategies, a political and public affairs survey research firm. Lori Weigel is a partner

Kaiser Health News

Despite Deep Divisions, Health Law Will Eventually Win Over Public

It may be difficult to see from here, but there is little doubt that the Patient Protection and Affordable Care Act (ACA) will eventually take its rightful place alongside the most cherished social programs such as Social Security and Medicare. Yes, it must first pass judicial review and get fully funded and implemented. And based on the current divisions in the country over the law, it has a ways to go before it achieves this exalted status. But the law's passage is a tribute to the perseverance, leadership and courage of those who worked to pass it -- especially then Speaker Nancy Pelosi, D-Calif., who found a way to herd enough cats to secure passage.

The federal health law traveled a rocky road just to get where it is today. Prior to the law's passage, there were some early message battles that were clearly lost. Advocates started out talking about the right values and principles behind the reform effort such as keeping your insurance if you like it and ending denials based on pre-existing conditions -- all of which have always been immensely popular with the public. But once the attacks began, they were difficult to counter because there was no specific bill to which advocates could point. And there were always deep divisions about the law between those with health care insurance and those lacking coverage.

Health Law Anniversary

Many of these first-wave attacks were false, misleading or even outrageous, including those based on "death panels," cited by PolitiFact as the 2009 political lie of the year, and the claim that the law would cut Medicare when in fact it strengthens the traditional program and saves taxpayers billions by reducing excessive private insurance profits in Medicare Advantage. Seniors were always among the most skeptical demographic groups because they were fearful that any health system change would impact Medicare. These lies, though, achieved their desired end of reducing support for reform among older Americans and women. In April 2010, a GWU Battleground Poll found just 39 percent of seniors supported the bill, while a majority, 56 percent, opposed it.

Once the House drafted a bill, there was a perilous waiting period between House and Senate action that lasted for months. Having three separate bills also had a negative impact on public support. It served to foster even greater confusion about the substance of health care reform legislation and made it difficult to push back on attacks made against the reform effort.

Once the health overhaul finally passed, advocates could point to what the law would actually do for regular Americans, especially for the 80 percent who already had health insurance coverage. In the past year, the measure got a critical boost from several key early implementation milestones, including extending coverage for young adults; eliminating pre-existing conditions for children; the down payment it made on the closing of the Medicare prescription drug doughnut hole; coverage of preventive health services for seniors; prohibiting arbitrary insurers from canceling coverage when a consumer gets sick; eliminating secret limits on lifetime and annual caps; and enacting small-business tax credits. Polling during the latter half of 2010 showed a small but significant bump in support for the law as awareness of these real benefits began to increase. Slowly, more Americans are coming to understand the law's valuable patient protections, and they will oppose having those taken away.

Support for the law was also hurt by insurance company decisions to raise rates when what most people wanted from the law was to reduce costs and premiums. Fortunately, the law's provisions provide additional powers to states to further regulate insurance company premium increases -- an idea firmly supported by public opinion. These provisions have already served as a check against the most egregious rate increases, as insurance companies abandoned some of their plans once they received negative press on the issue. Another recent shot in the arm for the law came with the announcement of $4.3 billion in savings from a crackdown on Medicare fraud and waste, which has become an important populist proof point for advocates in an era of deficits and concerns about government spending.

ACA Challenges

In the near future, the law still faces significant challenges. The House this year cast a symbolic vote to repeal it and is threatening its funding through the budget process -- despite the fact that a recent Kaiser Family Foundation tracking poll found that 64 percent of Americans oppose cutting off funding for the law, and just 30 percent support ending its funding. (Kaiser Health News is an editorially independent program of the foundation.) If Republicans take back the Senate and the White House in 2012, they may be able to fully repeal it. Equally pressing, within the next year or so it is widely anticipated that the U.S. Supreme Court will review the law in the wake of the various lower court decisions that have been handed down. In the meantime, some individual states have taken it upon themselves to drag their feet on implementation of the law and have gone so far as to reject federal funds earmarked for that purpose. This flies in the face of the will of the American public, fully half of whom want to expand the law (30 percent) or keep it as it is (20 percent), while fewer Americans want to repeal it and replace it with a Republican alternative (18 percent) or repeal it and not replace it at all (21 percent).

But if the health law survives this gamut, by 2014 it will help tens of millions of Americans in myriad ways. It will eliminate all denials for pre-existing conditions, fully close the Medicare prescription drug doughnut hole and use health exchanges to provide affordable coverage to those who currently lack it. Furthermore, the provisions that change the health care system -- though not well understood by the public -- also have very significant potential to empower patients while helping the system to deliver higher quality care at lower costs. If given the opportunity, these reforms and protections will eventually make the Affordable Care Act politically unassailable.

By Celinda Lake, David Mermin and Dan Spicer
Celinda Lake is the president of Lake Research Partners, a public opinion and political strategy research firm. David Mermin is a partner and Dan Spicer is a senior analyst

Kaiser Health News

Paul Fearer and his three colleagues are waiting for the fifth and final appointee to the California Health Benefit Exchange so the board can set policy in motion in preparation for the exchange's start-up in 2014. He joins California Health and Human Services Secretary Diana Dooley, former California HHS Secretary Kim Belshé and former Schwarzenegger administration chief of staff Susan Kennedy on the exchange board.

Fearer indicated that he is particularly focused on improving quality while constraining costs. "Affordability and quality are not in conflict," he said. "The right care at the right time is the most affordable care.".

Fearer earned his stripes at now defunct PacAdvantage, a statewide health insurance purchasing pool for small business, which he chaired for seven years. Fearer said he learned a lot from PacAdvantage -- about what works and what does not." The risk profile of the population being served has to be reasonable to avoid adverse risk selection, a fatal weakness," he said. "Participating plans in PacAdvantage had become the insurers of last resort, making it economically unfeasible to underwrite individuals.

"You also need a competitive offering; efficient, reliable and accurate operations; and customer service addressing underserved communities. That population is most in need of education and information on eligibility and plan choices, which are complicated issues," Fearer said.

Finally, he said the exchange must provide transparent information about plans, providers and coverage options and a robust set of alternatives for individuals so that they can access appropriate care at the right time.

Although the Affordable Care Act sets guidelines for the development of exchanges, Fearer is confident there will be room for tweaking. "The broad range of standards don't preclude innovation," he said. "Over time, operations developed by the exchange will influence the health care delivery system in California."

Fearer will join four others to lead the implementation of new state insurance exchange

California State Assembly Speaker John Pérez (D-Los Angeles) named Paul Fearer, Senior Executive Vice President and Director of Human Resources of UnionBanCal Corporation and Union Bank, and Chairman of the Board at the Pacific Business Group on Health* (PBGH), to the California Health Benefit Exchange Board. The board will be responsible for implementing what will likely become the largest health insurance exchange in the nation and the first of its kind, created under the health care reform law of 2010.

Paul Fearer has served as Director of Human Resources of UnionBanCal Corporation and Union Bank, N.A. since April 1996. Prior to joining Union Bank in 1990, Mr. Fearer spent 14 years in human resources at Stanford University, including service as Deputy Director of Human Resources Services. He is Chairman of the Board for the Pacific Business Group on Health, where he has played a leadership role for over 13 years. For six years, Fearer also served on the Board of Pacific Health Advantage, a statewide health insurance purchasing pool for small businesses in California that was operated by PBGH.

"Given his long-time strategic roles with Pacific Health Advantage and PBGH, Paul understands the real world challenges of improving the quality and affordability of health care," says David Lansky, President and CEO of PBGH. "He has governance experience with an insurance exchange and a longstanding commitment to improving health care for the people of California."

Other exchange board members include: former Schwarzenegger Chief of Staff, Susan Kennedy; former Secretary of Health and Human Services Kim Belshé; and current head of California Health and Human Services Diana Dooley.

"This is an important opportunity to take what we know about improving quality and moderating costs, and make higher quality, affordable health care a reality for more Californians, " says Fearer. "I am excited to begin this new role."

* About the Pacific Business Group on Health

Founded in 1989, Pacific Business Group on Health (PBGH) is one of the nation's leading non-profit business coalitions focused on health care. PBGH helps leverage the power of its 50 large purchaser members who spend 12 billion dollars annually to provide health care coverage to more than 3 million employees, retirees and dependents in California alone.