Policy Perspectives

October 9, 1997
Sacramento, California






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Program Summary

By Julianna S. Gonen, PhD

Helen Rodriguez-Trias, co-director of the Pacific Institute, introduced the program by noting the importance of having this final program converge on policy, for if the work being done on womens health does not help to shape services actually being delivered it is not of much use. She also added her hope that todays discussion and the ones prior will provide input to the ongoing Governors Task Force on managed care. Martha Romans, director of the Jacobs Institute, recapped for the attendees the topics and findings of the earlier seminars in the series, including consumer voices, views of various stakeholders, and Medi-Cal managed care. Sarah Samuels, an associate of the Pacific Institute, outlined the days program and introduced the speakers.

The President's Commission

Sylvia Drew Ivie, Executive Director of T.H.E. Clinic in Los Angeles and a past board member of the Jacobs Institute, was the programs first speaker. Ms. Ivie is serving on the Presidents Advisory Commission on Consumer Protection and Quality in the Health Care Industry, and it was on the activities of the Commission, whose final report is due at the end of January 1998, that she focused her remarks. She noted that womens health issues have gotten little attention at the Commission thus far and that she needs the help of those in attendance at todays seminar to help move the focus to women. She exhorted attendees to write and lobby members of the Commission, because "everyone else is doing it" and womens health concerns also need to be heard. The Commissions charge is to advise the President on how best to promote and assure consumer protection, and the broad membership of the 32-member Commission represents "every constituency in the land." These include institutional and individual health care providers, insurers, purchasers, consumers, representatives of state and local government, unions, etc. The Commission is divided into four subcommittees, including one charged with developing a consumer bill of rights. Unlike the previous federal health care task force, the activities of this Commission are open and over 40 experts have testified thus far.

Ms. Ivie observed that the business and purchaser communities are taking the stance of asserting that they too are "consumers" and that they are concerned with costs to purchasers and providers; these interests are striving to ensure that the Commissions work not be a "runaway consumer panel." This has created a significant amount of tension. As the body operates by consensus it is experiencing difficulty in reaching agreement, as various groups are "digging in" to protect their interests. Progress has been made, however, on the subcommittee charged with drafting a consumer bill of rights, which Ms. Ivie hopes will find its way into federal legislation. Elements on which there has been agreement include: a timely internal appeals process in health plans; the existence of an external appeals option and ombudsman services; respect and non-discrimination (something critical to women); the right to information about health insurance products; the importance of choice when possible; the right to confidentiality (an area in which further work is needed in the areas of reproductive health issues for women and mental health and substance abuse services); the right to participate in decisions; and emergency room access and payment.

The Governor's Task Force

Next the audience heard from Margaret Laws, who is a staff member working with the California version of the federal Commission, the California Managed Health Care Improvement Task Force. The Governors Task Force has 30 members, including Helen Rodriguez-Trias of the Pacific Institute for Womens Health. Like the federal effort, Ms. Laws noted that womens health concerns have not received considerable attention at the Governors Task Force meetings, and that external help from womens health advocates is much needed. The five groups that are equally represented on the Task Force include health care service plans (including one Medi-Cal plan), employers/purchasers, health plan enrollees, providers, and consumer groups. The Task Force was divided into four expert resource groups in order to produce necessary background reports and develop specific legislative recommendations in fifteen distinct areas, including dispute resolution, provider incentives, expanding consumer choice, managed cares impact on vulnerable populations, and new quality information development.

While women were not initially identified as one of the explicit areas of focus for the Task Force, this was changed due to the efforts of Rodriguez-Trias and others. The Task Force has commissioned a paper on womens health and the coordination and integration of care, which will be presented on November 21st.

Like its federal counterpart, the Governors Task Force comprises many different interests and constituencies, which again poses a challenge to achieving consensus. Ms. Laws encouraged attendees to provide input into the work on womens health that the Task Force is undertaking. The most difficult part of the task is to determine how to recommend that government make needed changes to ensure that managed care serves womens health needs well.

A Local Medi-Cal Initiative

The next speaker was Irene Ibarra, Chief Operating Officer of the Alameda Alliance for Health, who is "in the trenches" trying to make managed care work for low-income and uninsured women in the Alameda County Medi-Cal program. Alameda is one of the counties that has adopted the Two-Plan model, where Medi-Cal beneficiaries are served either by a local, non-profit health plan (the Alliance) or a commercial competitor (Blue Cross). The Alliance has been in operation since January of 1996. Ms. Ibarra stressed the importance of the local initiative due to its community base and focus. The plan has 600 primary care sites, 800 specialty contracts, community health centers, and other providers in its network. She described several of the programs target areas, including prenatal care, diabetes, asthma, and immunizations. While there are men enrolled in the plan, many of its programs tend to focus on women and children because they are the majority of enrollees. In the area of prenatal care, access to services had been identified as a major barrier, and so the plan provides free transportation for prenatal care visits. Utilization, however, has been lower than expected; it is not yet clear whether this is due to less need than had been anticipated, or other access barriers. The goal is to get women into prenatal care as early as possible. The plan conducts a risk assessment that includes medical and social factors, and maintains a referral network to link enrollees to case management and support services. Another target was a diabetes project, and the plan is conducting a pilot project on the effectiveness of intensive case management programs for women at risk for or with diabetes, which is very important for women in their childbearing years. The program attempts to link members to providers other than their primary care providers, such as health educators and nurses, and the goal is to work with women at home, in their own environments. A third program area is asthma, which is a leading cause of hospitalization, and in this program children are a major focus as well. The program includes informing primary care providers of emergency room visits and distributing asthma kits and educational materials in at least four different threshold languages spoken within the county. The final program that Ms. Ibarra described was childhood immunizations, an area in which Alameda County had not been performing well. This program includes provider incentives and immunization reminder cards to parents that include the name and phone number of the primary care provider.

Ms. Ibarra then went on to provide a profile of the women in their plan. Women comprise a majority in every age group, particularly in the 21 to 44 group. The AFDC-related Medi-Cal categories of beneficiaries were enrolled in managed care mandatorily, while others (SSI, medically indigent, etc.) could do so voluntarily, and some have. Three quarters of the plans enrollees fall into three ethnic groups: white, African-American and Hispanic, but if all Asian ethnic groups are combined they number more than Hispanics. The most frequent service request received by the plan is for a specialty referral by a female enrollee, and women request more referrals than men and have higher hospitalizations rates (even when excluding obstetrical care). The most commonly utilized pharmacy benefits are pain medication, asthma medication and contraceptives. The plan is experiencing a birth rate of 20-35 per 1,000 women enrolled, which is lower than expected; the average age of women delivering is 25, which belies the notion that women in the Medi-Cal program tend to deliver babies as teenagers. The plan is hoping to improve its rate of prenatal care initiation within the first trimester, an area in which it has not done well thus far; indeed, utilization of preventive services in general needs to improve. The most frequent procedure requested by women is abortion, and the average age of those receiving abortions matches the average delivery age at 24. The most frequently used dial-in audio recording, as well as the most frequently asked question of call-in nurses, is diagnosing pregnancy.

Ms. Ibarra outlined several areas in which health plans could voluntarily improve service, including increasing preventive screening services (including pap smears), where underutilization remains a problem. Plans should also do more physician training and provide better access to ancillary and community services, which can have significant impact on health. Greater access is needed through mechanisms such as after-hours care, and ethnically targeted disease case management is critical, particularly in a multi-cultural state such as California. This needs to include early diagnosis and active involvement of the plan members. Overall, Ms. Ibarra stated a concern with expansion of health coverage, noting that recent efforts to expand coverage to more children is laudable but does not address the needs of their mothers, or their fathers. Affordable alternatives do not currently exist for low-income working populations; perhaps subsidized low-cost insurance is an option that should be explored. Welfare reform is also of concern, as it is likely that those moving off public assistance are going into jobs without health insurance. Extension of public health benefits after leaving public assistance, as some states have done, should be considered. Prenatal care should be provided to all women in the state, regardless of immigration status. Different approaches are needed for uninsured women; many are eligible for Medi-Cal but have not enrolled, due to many access barriers. The application process should be simplified and de-stigmatized. Managed care can work for low-income women and their families, with the necessary policy reforms to ensure that women have access to care.

Older Women's Health Needs

Consultant Deborah Reidy Kelch then addressed the seminar on issues for older women in managed care, noting that the diversity of women and their needs must be emphasized to policy makers and the private sector. Women are not homogeneous across the gender and age spectrum, and even within the sub-group of older women there are many differences among women and they have a broad range of interests and needs. Reasons for focusing on older women include their different health profiles and experiences as they age, the fact that they access a different mix of health services (men use more hospitals, women more prescriptions, for example), they have fewer resources to pay for care (and the services women use more tend not to be the ones covered in insurance plans), and they have been underrepresented in health research, leaving the medical community underinformed about their health needs. Physicians tend to pursue less aggressive treatments for older women. Many health problems of older women are preventable (through lifestyle changes or early screening and detection) but are often undiagnosed or misdiagnosed, and either untreated or undertreated.

Older women are particularly vulnerable and disabled as a group, and due to the limited amount of available information on outcomes in managed care, it is important that there be careful monitoring of the care given to them in managed care plans. But managed care has the potential to overcome some of the failings of the fee-for-service system, particularly with its emphasis on prevention and because of its more comprehensive benefits. The challenge is how to make that potential real for older women. Older women are more likely to live in poverty than older men. Older women also often have multiple chronic conditions, so while they tend to live longer than men they do so with more disabling conditions. Heart disease is the leading cause of death for both older women and men, but women are more likely to die after a heart attack and they receive less aggressive treatment from physicians for heart disease. Perceptions still persist, however, that heart disease mainly affects men. Cancer is the second leading cause of death in older women, particularly lung and breast cancer, and treatments tend to be different for older women. Women 65 and over in HMOs are more likely to receive cancer screening than those in fee-for-service; however a recent study revealed negative outcomes for HMO breast cancer patients once diagnosed. Because older women tend to be on multiple medications they are more vulnerable to adverse drug interactions and medication errors. Older women take an average of 6 prescription and 3 over-the-counter medications at the same time.

Traditional Medicare provides better coverage for the acute illnesses of men than for the chronic illnesses of women. Older women are more likely than men to have lower incomes, higher drug expenditures and long-term care costs, which are not covered by Medicare. Women are therefore more likely to spend out-of-pocket for health care.

Currently there are approximately 1.5 million Medicare enrollees in HMOs in California, about 38% of the total in Medicare in the state; 56% of Medicare managed care enrollees are women. The penetration of Medicare managed care varies significantly by county, from as low as 1% to over 50%. The age distribution within Medicare HMOs is similar to the distribution in Medicare overall, which belies a belief that HMOs tend to enroll only the younger beneficiaries. There are also over 100,000 people over 55 in the states Medi-Cal system, which enrolls low-income elderly, and 65% of those are women, reflecting womens lower socioeconomic status. Medi-Cal serves several essential roles for older women, including paying for Medicare co-payments and deductibles for the low-income elderly, covering services that Medicare does not (such as drugs), and covering long term care.

Currently there is limited and conflicting information on the impact of Medicare managed care on the elderly and disabled. HMOs have little experience with these groups and may be insensitive to their needs. The complexities of managed care may serve as barriers to care for the chronically ill and disabled who have special care needs. With conflicting notions of how to measure quality, it may be a while before we truly know what the impact of managed care is and what the outcomes are.

In terms of policy implications, Ms. Kelch stressed that as we focus on managed care we must not lose sight of the larger problem of inadequate funding of the long-term care system. Medicare does not cover long term care, and Medicare HMOs are not required to do so either; this is a serious flaw and fundamental inadequacy of the Medicare program, with a disproportionate impact on women, that continues into Medicare managed care. In terms of Medicare managed care policy, she advocated reasonable and enforceable standards that would apply to all plan types, including provider-sponsored organizations and other newly-evolving models, but that allow sufficient regulatory flexibility to ensure that a degree of choice among alternatives remains in the system. We must avoid setting standards that result in the disappearance of alternative providers and options, particularly as women are more likely to use such providers. Government should play a vital role in creating consistent quality standards and reporting across plans to facilitate consumer education and comparisons among competing plans. We should also learn from effective programs, such as those in managed care plans that integrate acute and long-term care services by looking at both the health and social needs of members and do it in a patient-centered way. But instead, Medicare enrollees are being placed in plans that only focus on medical needs and do not take this more holistic approach. The Department of Health Services and Corporations should develop strict guidelines and quality measurements for managed care plans serving the elderly and disabled, similar to those developed for low-income women and children. When quality information is collected, it must be with a recognition of the various sub-groups within populations (such as age and ethnicity sub-groups). There need to be provider training standards (for all providers, not just those in managed care plans) so that they have knowledge in detection and treatment of the health problems of older women. Managed care plans are uniquely situated to communicate new research findings and treatments to their providers that can improve care to older women. Women themselves also need to be involved in decisions about policy and their care. This should occur throughout womens life spans; women should be given tools, beginning at an early age, to be active participants in their own health care.

Reproductive Health

The final panelist was Kathy Kneer, Chief Executive Officer of Planned Parenthood Affiliates of California, who began her remarks by noting that many of the challenges in womens health have not changed throughout our history, and we will always be fighting a political battle over reproductive health. She referenced data from the Alan Guttmacher Institute on the lack of contraceptive coverage by private insurance plans, and cited this as one example of a general bias in health care favoring men that causes women to pay more out of pocket for care. She also noted the discrimination against women in medical research that has contributed to both under- and over-treatment of women. She echoed other speakers in asserting that women must be politically active as health care consumers. Ms. Kneer observed that the legislative turnover in the California Assembly caused by term limits has disrupted long-standing relationships that womens health advocates had with sympathetic legislators. She then commented that historically, the Medi-Cal program has often led the way in making changes in insurance coverage, changes which the private market then follows. But now, with the transition to Medi-Cal managed care, the state is often buying services from private plans. These private plans, she noted, have generally not done well in caring for adolescents, a group that needs greater attention to its health needs. Unintended pregnancies, however, are not just a problem of teens, as is often perceived. She pondered how to achieve increased utilization of contraceptives in a system that is designed to reduce utilization of services overall. She stated that insurance companies and purchasers have coalesced to oppose expansions of benefits, and stressed that "our side" needs to similarly work together to advocate for womens health needs. The Governors Task Force was created to bring some sense to the changes underway, but if we are not careful it could instead serve as a barrier to reforms. The insurance industry views government involvement in health care delivery as an egregious encroachment, virtually equating it with the advent of communism. Consumer and womens health advocates must therefore work in unison to bring about needed changes. Everyone in attendance today should leave with the commitment to lend their individual and organizational voices to the important issues discussed throughout the program, to "end the silence," particularly around critical issues of health care for adolescents.

Open Discussion

The program was then opened up to questions from the audience. Shannon Perry, Director of the School of Nursing at San Francisco State University inquired about the presence of nurses on the two commissions that were described at the outset of the discussion; Sylvia Ivie responded that the president of the American Nurses Association serves on the federal commission, and Margaret Laws noted that Ellen Severoni, a nurse who runs California Health Decisions, is on the California task force. Ms. Laws also noted that the task force has heard testimony from several nurses and nurses organizations. Helen Rodriguez-Trias added that there needs to be more of a focus on the health care work force in general, and on the viability of providers whose services are not seen as remunerable under current delivery systems, and on the role of nursing in primary care. The same questioner also asked how the consumer bill of rights slated to emerge from the federal effort will differ from similar efforts in the past. Ms. Ivie responded that the major difference is that this one is likely to wind up in legislation.

Terry Temkin from Hadassah (and who is also a geriatric nurse practitioner) observed that we have yet to see the full "fall-out" of women being encouraged into Medi-Cal managed care plans and the resulting health implications, and that we must be vigilant about both the risks and the opportunities in these health plans. She cited recent data that enrollees in Medicare MCOs had poorer outcomes following hip fractures than those in fee-for-service Medicare. Deborah Kelch responded by noting that she too believes that managed care holds potential for the elderly, and that elderly women in particular have clear incentives to enroll in MCOs due to the high out-of-pocket costs that they bear under fee-for-service. We dont yet know, however, what the overall health implications of the movement into managed care are. Fortunately the federal Health Care Financing Administration is taking these concerns seriously and has launched several important quality initiatives which should generate additional information.

Shawna Hecker from Feminist Womens Health Centers noted the value of hearing Irene Ibarras experiences in Alameda County, as they have learned in Sacramento County about what has not worked as well. The problem is that the valuable messages from these lessons are not reaching the Task Force. Managed care is having an impact on the viability of safety net providers in the county, and one has recently shut down. Medi-Cal enrollees are being defaulted into managed care plans without their consent, ostensibly under federal waiver provisions, and HCFA has not responded to inquiries about the constitutionality of this practice. In Sacramento Medi-Cal beneficiaries have become the "prey" of seven private managed care plans which do not have experience meeting the needs of this population. This privatization effort occurred without a definition of what constituted family planning services, and although one now exists it does not include abortion. This concern is relevant at the federal level as well. There was also no community or county involvement in the designing of the plan in Sacramento County, a fatal flaw which has led to major enrollment and informed consent problems. Many women dont even know that they are in a managed care plan until they need to seek care for a child or themselves.

Ella Kelly of the Pacific Institute for Womens Health noted that even well-educated women still only tend to think of health insurance as a necessity to have in the eventuality of illness, and do not consider it an investment in their health. When it comes to maintaining their health, women turn to friends and non-medical/alternative therapies for which they pay out of pocket (acupuncture, herbalists, etc.) How do we get these women, who otherwise would be on the front lines of policy advocacy, to become engaged with more long-term health policy questions?

Dorothy Stowell, an InterGovernmental Senior Advocate, added that many people do not know or understand what services they have through their health plans, and consumers need to be educated about the services available to them and how to access them.

Mary Campbell Bliss, a perinatal nurse specialist with Sutter Memorial Hospital, commented that several of the most important issues for the population with which she deals have not yet been addressed, such as coverage of and education about lactation services. Violence is another critical issue and ways must be found to address it in a managed care environment. Sylvia Ivie encouraged her to write the Presidents Commission on those very important issues, and went on to raise the notion of a basic benefits package as a right. Those primarily concerned with costs reject this outright, and she would like to hear from those who favor a basic standard benefits package. Kathy Kneer added that the issue of violence goes beyond advocating for a safer environment and includes discrimination that victims of domestic violence have faced, primarily in the indemnity insurance world which has viewed domestic violence as a preexisting condition and refused women coverage.

Peggy Brandt from the University of California - Berkeley School of Public Health, where they are conducting research on managed care and perinatal services, echoed Ms. Blisss advocacy of more attention to lactation services, which appear to be falling through the cracks at most health plans and medical groups. Few are tracking the training, coverage and quality of these services.

Catherine Bergstrom from the office of Assemblywoman Alquist commented that domestic violence and sexual assault need much more attention; 70% of California counties have no services for women who are victims of violence. Mental health services also need greater attention.

Another audience member observed that health education, particularly for children and adolescents, is still lacking, leading to problems such as teen pregnancy (California has the highest rate in the nation). There needs to be a way to demonstrate to health plans that investments in health education are cost-effective and will save them money in the long run. Kathy Kneer said that much of the initial impetus for managed care was cost containment, which is to some extent giving way now to more of a focus on quality and health outcomes. This impetus is coming largely from employers. The problem is that disease management is being viewed as the route to better health outcomes, which leaves out critical areas like reproductive health, which is not a disease. Also, the short-term view that many health plans take of their enrollees discourages them to emphasize preventive care and health education. Deborah Kelch stressed that although we should continue to push health plans to adopt more of a preventive and health education approach, fundamentally they are by design based on a medical model and we must look to other avenues of educating women about their health in addition to what can be accomplished through the plans.

Holly Mitchell, Director of the California Black Womens Health Project, added that it is really the underserved populations (women of color, older women, poor women, etc.) to whom we must outreach because they are the least empowered to advocate for their own health care to managed care plans, as they struggle daily with mere survival. It is the women in this room and other health advocates that must push to have these womens needs recognized, as managed care plans do not view these women as a market. Traditional health education models must be adapted in creative ways to be meaningful to this population of women. Ms. Ivie concurred and noted the importance of retaining traditional community providers even as more and more enrollees move into managed care. It is in these settings that women will come, even in groups, to learn about health and staying healthy.

Monica Hart from Golden Gate University raised the issue of mental health benefits, stating that some psychiatric hospitals use electro-convulsive treatment (ECT) for patients who do not (or cannot) comply with psychotropic medication regimens. She noted that mental health disorders often manifest as physical ailments, making mental health benefits critical. Ms. Kelch again noted that this is another manifestation of what is wrong with relying exclusively on the medical model of health care. Seniors, for example, may suffer from confusion as a result of medications that they are taking (or not taking), or because of depression or substance abuse or abuse in the home. A well-organized system would look to all possible sources of a presenting problem. Ms. Hart also added that under managed care, primary care providers are eager to prescribe anti-depressants or to refer patients on to psychiatric or community mental health facilities, as they say they cannot spend the requisite time with these patients under managed care. Sarah Samuels added that the common practice of "carving out" mental health services from other care delivered in managed care plans may exacerbate some of these problems.

Dale Kelly Bankhead from the office of Assemblywoman Carole Migden noted that one advantage of term limits is that more women are now in the legislature, and she encouraged audience members to come and talk to them and indicate what they can do on behalf of women. The bad news is that much legislation that would aid womens health, such as one mandating independent medical review for coverage denials for bone marrow transplants for breast cancer and another designating ob-gyns as primary care physicians for women, is facing a gubernatorial veto, under the rationale that the Governors Task Force must weigh in first. While the work of the Task Force will undoubtedly be beneficial, some of these issues dont need such extended consideration and are too pressing to wait.

Helen Rodriguez-Trias asked the panelists and attendees to comment on opportunities for better integration of mental health services as a result of the federal parity mandate, and on the recent consumer rights document released by Families USA and several large HMOs. Sylvia Drew Ivie explained that Kaiser Permanente, Group Health Cooperative of Puget Sound, and HIP of New York had indeed joined Families USA and the AARP to create an 18-point consumer rights package, which is an important development since it marks one of the first time some health plans have broken ranks with the rest of the industry and sided with consumers. She said she hoped it would push the Presidents commission to be more progressive. Kathy Kneer noted that it has been virtually impossible to get the health plans in California to "break ranks" this way, and they have collectively advocated only the "least common denominator" in terms of quality standards. Deborah Kelch stated that opportunities will emerge, as some of the more intelligent plans are beginning to hear the messages they are being sent and will respond to public opinion.

Betty Perry from the Older Womens League of California applauded the friendliness of todays forum to older women, and to all womens health concerns. She criticized the health insurance industry for depicting health care as a commodity and refusing to discuss their compensation arrangements with physicians, and asked Margaret Laws how next year would be different in terms of the viability of various legislative remedies following the work of the Governors task force. Ms. Laws conceded that there was some frustration involved in working to devise recommendations when similar ones have already been proposed and are not being heard. One part of the task forces agenda has been to be as specific as possible when formulating recommendations. Ms. Ivie added that at the federal level, the message needs to be heard that there will be a price to pay if womens interests are neglected in the work of the Presidents Commission, as the current sentiment is to ensure that business interests remain satisfied and at the table.

Catherine Camp from the California Mental Health Directors Association commented that the federal mental health parity legislation was disappointingly limited but important. Most importantly it eliminates lifetime caps on mental health benefits, but it does not require insurance companies to offer mental health benefits. There is legislation moving forward in California (AB 1100) that would require parity for serious mental illness for adults and children, but it has not been pushed through the final legislative stages out of fear of facing the same veto as other pending health care legislation. It will be revisited in 1998 when it will need all of the support possible from advocates. There has been some support for the bill from some Republicans and even unexpected support from several managed behavioral health companies. Ms. Camp also observed that mental health services for Medi-Cal beneficiaries are carved out from other medical services, which has both good and bad implications. The positive effect is that it allows mental health services to be delivered outside of a medical model and in a way that integrates with other community systems that people use for support. In both the public and private sector, purchasers that carve out mental health services tend to allow for more flexible benefits. The problem is the difficulty in coordinating care and getting the medical and mental health systems to work well together.

Address by Assemblywoman Liz Figueroa

Following the seminar, attendees heard a luncheon address from Assemblywoman Liz Figueroa, who chairs the Assemblys Committee on Insurance. She noted that managed care impacts women the most because women use most health care services. The problem is that the goal of most HMOs is to run a profitable business, leading to a tension between cost-cutting and quality care. It is the role of the legislature to step in to provide the appropriate balance, as the pendulum has swung too far to the side of the HMOs profits. The result has been an unacceptable burden on womens health, in the form of reduced hospital lengths of stay following childbirth and mastectomies, and barriers to contraceptive access and breast cancer treatment. Assemblywoman Figueroa told the audience that over 80 managed care-related bills had been introduced during the past legislative session, and while some of the criticism of piecemeal or "body-part" legislation is valid, some immediate problems need to be addressed when broader reform is not forthcoming. The political will for larger change will not be there until enough specific problems have surfaced and been addressed.

One of the bills put forth during this past session, sponsored by Figueroa, would move jurisdiction over HMOs from the Department of Corporations to the Department of Insurance, due to discontent over the formers oversight. The Department of Insurance is where consumers "naturally go to complain about health insurance," and the Insurance Commissioner is an elected official and thus at least in theory responsive to the people. Another of her bills (AB 794) would forbid an HMO from overruling a treatment decision of a physician unless it was done by another physician.

Governor Wilson has promised to veto many of these bills, as he is waiting for the results of his Health Care Improvement Task Force. The problem, said Figueroa, is that the Task Force is appointed rather than elected and is not the appropriate genesis for legislation. It is also not fully addressing womens health needs, such as hospital stay following mastectomy, direct access to gynecologists, bone marrow transplants, and contraceptive issues, and delay in awaiting its report and subsequent legislation will put off needed changes too long. The marketplace does not protect womens health from HMOs cost-cutting efforts, whose profits increase when they spend less on care. Health care is not an industry in which CEOs should be reaping billion-dollar salaries. The legislature must step in to ensure that women and all consumers are given quality health care, and the Governor should address womens health concerns with both specific and broad reforms. Because of the Governors reluctance to act, a power vacuum has been created in which there is no force to counterbalance the market pressures that favor HMO cost-cutting. Assemblywoman Figueroa applauded the efforts of CEWAER and others in highlighting these issues, and encouraged people to contact the Governor to exert pressure for action to improve the health of California women.

A questioner from the audience asked which bills in particular were awaiting the Governors approval and should be referenced in any lobbying efforts. Ms. Figueroa indicated SB 70 (the mastectomy bill which empowers physicians to determine the appropriate length of hospital stay), SB 794 (prohibiting HMOs from overruling physicians treatment decisions), 760 (breast cancer/bone marrow treatment).

Sarah Samuels asked what those in attendance today could do to help Figueroa and other legislators move legislation like this in the upcoming session. The Assemblywoman encouraged people to ensure that organizations to which they belong are aware of the important bills and to send letters of support to the legislature and to newspaper editors.

Another questioner asked how to remedy the damage inflicted by the passage of recent legislation barring undocumented immigrants from receiving prenatal care through Medi-Cal. Ms. Figueroa indicated that there are reform efforts underway in several of the legislative caucuses that will need the support of advocates such as those assembled today.

Lessons Learned

Womens voices need to be heard in policy forums such as the Presidents Advisory Commission on Consumer Protection and Quality in the Health Care Industry and the Governors Managed Health Care Improvement Task Force.

Community input is important in ensuring that health plan practices adequately meet the needs of those they enroll.

Women are not homogeneous across the gender and age spectrum, and even within the sub-group of older women there are many differences among women and they have a broad range of interests and needs. When quality information is collected, it must be with a recognition of the various sub-groups within populations (such as age and ethnicity sub-groups).

Traditional Medicare provides better coverage for the acute illnesses of men than for the chronic illnesses of women. Managed care has the potential to overcome some of the failings of the fee-for-service system, particularly with its emphasis on prevention and because of its more comprehensive benefits. Currently, however, there is limited and conflicting information on the impact of Medicare managed care on the elderly and disabled.

With conflicting notions of how to measure quality, it may be a while before we truly know what the impact of managed care is and what the outcomes are.

Government should play a vital role in creating consistent quality standards and reporting across plans to facilitate consumer education and comparisons among competing plans. In terms of Medicare managed care policy, reasonable and enforceable standards should be implemented that would apply to all plan types, including provider-sponsored organizations and other newly-evolving models, but that allow sufficient regulatory flexibility to ensure that a degree of choice among alternatives remains in the system. Standards should not result in the disappearance of alternative providers and options, particularly as women are more likely to use such providers.

Historically, the Medi-Cal program has often led the way in making changes in insurance coverage, changes which the private market then follows. But now, with the transition to Medi-Cal managed care, the state is often buying services from private plans.