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CAPITOL INSIGHT Train Wreck by Randall Hagar Director of Government Relations The US House of Representatives in May was finally able to achieve a vote and passed an amended version of the American Health Care Act AHCA Then two weeks later the non partisan Congressional Budget Office released a report of scored costs for the proposal passed two weeks earlier which by that time had been transmitted to the US Senate This is backwards costs should be available to evaluate a proposal before voting on it That would be good government But the report showed that the amended version of AHCA did not move the needle significantly in reducing the numbers of citizens losing health insurance compared to the previous version which could not be brought to a vote because of those numbers So the amended version instead of causing 24 million people to lose health care as the prior version would improved that to only 23 million Why bother Well apparently improving the projected uninsured rate by 1 million made it possible to vote on it But they didn t know when they voted what the new numbers forecast a million or ten million Confused Me too And that s just the broad strokes the essential benefits covering mental health and substance use treatment are no longer required under the bill that passed the House which allows a state to opt out Medicaid Medi Cal in California is slashed severely along with about a dozen other patient protections which states may also opt out of lose coverage in staggering numbers over the next decade Remember these names of the eight Representatives who voted for AHCA Representative Doug LaMalfa Randall Hagar Richvale Representative Tom McClintock Elk Grove Representative Jeff Denham Atwater Representative David Valadao Hanford Representative Kevin McCarthy Bakersfield Representative Steve Knight Palmdale Representative Darrell Issa Vista Representative Mimi Walters Laguna Niguel All but one represent competitive districts which means those districts are roughly composed of even numbers of Republicans and Democrats Those districts will be in play in the November 2018 mid term elections Something to think about Meanwhile in the US Senate At press time conflicting statements emanated from various Senators about a Senate version of the AHCA with the Majority Leader Senator Mitch McConnell saying that there was an agreement in principle to expect legislative text soon and a vote before the end of June Others opined that they didn t think there could be agreement In finally bringing it to a vote eight California Republi given the differences between various factions of Senators can members of Congress some of whom pledged early Details are cloaked in complete secrecy Stay tuned on to vote against it others who were clearly on the fence Meanwhile back in California voted for it thereby assuring passage Congressional districts in the Central Valley report 30 50 of constitu In related news because it s a direct California response ents receiving expanded Medi Cal under the Affordable to the AHCA after climate change and infrastructure the Care Act These are first time insureds who would likely biggest topic in the state Capitol is Single Payer SingleVolume 32 Number 1 Summer 2017 921 11th Street Suite 502 Sacramento CA 95814 916 442 5196

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Capitol Insight 2 Payer as a concept is simple do away with the middlemen in health care i e insurers create a California government run health plan in the place of a private insurance market That sounds enticing particularly if you treat patients with private insurance The administrative burden may decrease substantially for your practice For patients no copays or deductibles in fact few if any up front costs Californians overwhelmingly poll as liking the concept until the prospect of raising taxes becomes a consideration Still those may all in the final analysis be solvable problems Never let it be said that California doesn t dream big Estimates by the California Senate Appropriations Committee peg costs for Single Payer at 400 billion a year One estimate comes in lower at around 330 billion yet another at 365 billion To put these figures in context the entire budget for the state of California totals approximately 180 billion The success of the proposal SB 352 Lara Atkins rests on several assumptions one that the federal government would grant California waivers of Medicare and Medicaid requirements so that funds currently flowing into California from those entitlement programs could be used in a Single Payer system It is ironic given current attempts to repeal it that the ACA specifically allows states to establish alternative healthcare financing systems Meanwhile back in California Part 2 Assuming the federal government in its largesse grants waivers to produce a laboratory for government run health care taxes in California would have to provide an additional 200 billion a year Would you pay 15 of your income on top of what you already pay in taxes to bridge the funding gap A payroll tax of that magnitude is one proposal for meeting the funding gap The proposal would meet high public resistance to raising taxes on the order of magnitude needed to fund Single Payer and it would require a 2 3 vote of both houses of the California Legislature both very steep ascents Even if these hurdles were overcome there are flaws concerning SB 562 as it now stands There is no guarantee of parity between mental health or substance use and other health services There is no guarantee of timely access to services There is no guarantee for timely access to specialty care There is no guarantee of network adequacy private concierge practice would be allowed opening the question of where providers of health services would choose to land Finally government has a concerning habit of setting reimbursement rates to physicians and other health care providers at abysmally low levels SB 562 Passed the California Senate on a vote of 23 14 on June 1 and is now in the California Assembly where it will be acted on this summer Note at press time the California State Budget negotiations are nearing a close with no report of a deal on financing Single Payer which there surely must be for it to be a viable proposal Stay tuned California Psychiatric Association sponsored bills have run the table in a remarkable show of bi partisan support for a diverse CPA 2017 legislative agenda What I mean by run the table is that each was voted by relevant committees and voted off the floor of their respective legislative houses without so much as a single NO vote being cast against them Each bill having passed out of their houses of origin must now begin the very same process of review in their second house Jail Medications An inside look at how a bill is made AB 720 Eggman fills a tragic gap in providing involuntary medications to jail inmates with severe mental illness Currently there are procedures for sentenced inmates who refuse treatment and are dangerous to themselves or others or gravely disabled But no such procedure exists for inmates who are awaiting arraignment trial or sentencing The obvious solution at the time AB 720 was introduced seemed to simply define inmate as either sentenced or pre sentenced and use procedures defined in current law for sentenced inmates It turned out that the Los Angeles Sheriff s Department LASD custodian of the largest mental health institution in the United States in the Twin Towers jail was also working on this problem The CPA and LASD joined forces to become co sponsors However it turned out to be more complicated than simply redefining inmate Who knew The Disability Rights California DRC and the American Civil Liberties Union s ACLU opposition quickly emerged against AB 720 Disability Rights California cited a number of concerns in opposition First it objected to jails as treatment facilities and opined that community treatment facilities are preferred Agreed although there is universal recognition that an inventory of inpatient psychiatric beds is insufficient to meet the needs of patients generally much less those in jails Second the DRC

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Capitol Insight 3 maintained that people will not be afforded due process because of the possible short time they may be in custody i e jails may be tempted to give short shrift to due process procedures Not making much sense as a direct response to the problem the DRC proposed a 30 day medication order in place of the current order which remains in effect for one year for sentenced inmates We countered with 180 days because that period though nothing shorter was more clinically supportable Third if inmates were released for any reason or moved to another facility the uncertainty of continued access to medication raises continuity of care issues Our response was that CPA and the LASD were as much concerned about continuity of care as they were But how could a facility based intervention guarantee access to community resources which are very limited CPA offered amendments to the effect that a discharge plan would be created for each inmate Fourth the DRC asserted that an inmates ability to participate in the defense of their active criminal case may be adversely affected by medications This seems counter intuitive particularly since CPA members who work in jails opined that stabilization through medication helps inmates participate meaningfully in their court processes Fifth the bill affects poor people disproportionality with bail reform pending in the legislature this made at least a little sense but again nothing practical could be done within the scope of the bill to address that concern Finally the claim that the bill would treat differently situated individuals in very dissimilar positions the same when different procedures are appropriate Still scratching my head on that tient treatment options for inmates while at the same time recognizing the unavailability of community beds and shortages of slots in community programs for those purposes They further objected to AB 720 because they preferred a priority be made to invest in more community resources No arguments from CPA on either point They continued to argue though that with bills like AB 720 California would never invest in these critical resources and patients would never receive appropriate care because appropriate care could never be provided in jails CPA made several gestures in the form of small language changes in response to these and other concerns without damaging the original intent of the bill Again committee staff were very supportive of our efforts but the ACLU was not They too showed up in committee and testified in opposition We had a series of meetings with the DRC in which we tried in good faith to address these concerns and offered concessions and amendments without damaging the heart of our effort to provide treatment to a neglected population Committee staff were very pleased that we had gone so far in trying to work out objections and approved of our efforts with the opposition and our amendments to address concerns raised by them But when it came time to be heard in Committee this time the Assembly Judiciary Committee the DRC still showed up unsatisfied in opposition The basic problem is that the DRC has a basic philosophical problem with the idea of involuntary treatment involuntary medication and jails being de facto mental health treatment facilities We agreed on the last point AB 1136 Eggman Psychiatric Bed Registry ACLU opposed AB 720 too because it preferred outpa This bill too has opposition the California Hospital Association The CHA says this will be expensive and it The above negotiations took roughly 5 weeks and all of the effort and straining to find common ground with the opposition was worth it the Assembly Judiciary Committee like the Assembly Public Safety Committee a month earlier on a 7 0 vote voted 10 0 with one abstention to approve over the objections of the ACLU and the DRC Three weeks later on May 22 the full Assembly 80 members voted on the bill and there too it passed 75 0 again with opposition from the ACLU and the DRC AB 720 was sent to the Senate where a hearing of the Senate Public Safety Committee on it has been set tentatively for June 20 We have had equal success with the two other CPA sponsored bills A brief recap is below AB 1136 requires a grant application to the federal government for funds to set up an online real time registry of available inpatient crisis and residential beds for both mental health and substance use treatment If you consider the complexity of operations conducted in cyber space in order to make an app like Uber or Lyft work simply and quickly for the person desiring a ride you ll get some sense of what CPA is aiming at The next best thing to making more of these kinds of beds available is to assure that once openings are available they are able to be found quickly Funds are available for a grant program provided by the 21st Century Cures Act passed by Congress last December

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Capitol Insight 4 won t work because it hasn t worked in other states Not Votes on SB 374 Note there were no NO votes the complete story but CPA intends to make certain it Senate Health Committee March 29 7 0 does work Senate Floor April 24 39 0 Votes on AB 1136 Note there were no NO votes Keep your fingers crossed for action in the second houses Assembly Health Committee April 25 15 0 for each of these bills Assembly Appropriations Committee May 26 16 0 Assembly Floor May 31 75 0 SB 374 Newman Parity Enforcement This bill simply assures that the California Insurance Commissioner and the California Department of Insurance have authority to enforce the federal Mental Health Parity and Addiction Equity Act of 2008 in all segments of the California health insurance market While this bill is very important it did not attract opposition In fact health insurers have promised to support the bill when it appears in the Assembly after a nominal tweak to its language Key Contact Sign Up and Update Name ____________________________________________ Home Address _____________________________________ City State Zip _____________________________________ Home Phone ______________________________________ Home FAX ________________________________________ Note Home address information is needed because it s where you are registered to vote We match you with your legislative representative this way It is held in strict confidence Office Address _____________________________________ City State Zip _____________________________________ Office Phone ______________________________________ Office FAX ________________________________________ California Psychiatric Political Action Committee PAC E Mail Address _____________________________________ 921 11 Street Ste 502 Sacramento CA 95814 Is your FAX a confidential line ______ or in a multidisciplinary office ______ check one th Please fill out the requested information below required by state campaign reporting laws Name ________________________________________ Is it confidential ______________ Do you personally know a California legislator or her his spouse Yes _____ No _____ If so whom _________________________________ Employer ________________________________________ As a Key Contact I would be willing to Address ________________________________________ _______ Write letters to my state legislators Home Phone ________________________________________ _______ Meet with legislators Office Phone ________________________________________ _______ Work on a campaign Fax ________________________________________ _______ Participate in public events District Branch ________________________________________ _______ Author a newspaper opinion piece or letter to the editor To pay online via PAYPAL http www calpsych org cppac fund _______ Other please specify _________________________ Make checks payable to Please feel free to write down any suggestions you may have to help strengthen our Key Contact System __________________ CPPAC 921 11th Street Suite 502 Sacramento CA 95814 o Charge my circle one Visa MasterCard Amount ___________________________ Credit Card Number ____________________________ Expiration Date ____________________________ Thank you for your contribution Contributions not deductible on Federal Income Tax __________________________________________________ If you know who your legislator is please make note of it here Assemblymember ___________________________________ Senator ___________________________________________ We can find your representative for you Please call the California Psychiatric Association s toll free number 800 772 4271 Please FAX completed form to 916 442 6515