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How Will House Health Care Bill Affect San Diego?

An audio recording of this interview will be posted here within a few hours of the live broadcast. A transcript will also be added within 24 hours. Thank you for your patience.

MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. The House of Representatives took a big step toward overhauling America’s health insurance system this weekend. In a squeaker vote late Saturday night, the House approved HR-3962, called the Affordable Healthcare for America Act. Even those who were cheering the passage as a major achievement acknowledge that healthcare reform legislation still has major hurdles to cross in Washington. It’s unclear when the Senate will vote on its own version of a healthcare bill and then the two versions need to be reconciled and approved before the president can sign the bill into law. But we thought it reasonable to ask what might happen to healthcare in San Diego if a bill similar to the House bill gets signed into law. Here to help answer that question is my guest Gary Rotto, Director of Health Policy for the Council of Community Clinics. And welcome to These Days, Gary.

GARY ROTTO (Director of Health Policy, Council of Community Clinics): Thank you. Good to be here, Maureen.

CAVANAUGH: And we’d like to invite our listeners to join the conversation. What would you like to see included in healthcare reform? And do you think we’ll see healthcare reform legislation become law by the end of the year? Give us a call with your questions and comments. Our number is 1-888-895-5727, that’s 1-888-895-KPBS. Well, as I said, the bill was passed, the House bill was passed this Saturday night. I’d like to get your thoughts, some – an overview of your thoughts about this legislation.


ROTTO: Well, I mean, as the health centers and the community clinics look at this bill, the most important thing for us is access, access to the healthcare system. And what you see in that bill, even its predecessors, and even in the bills that are the Senate versions, very similar as far as coverage in the number of uninsured who will now be eligible for coverage. So, for example, working with the Insure the Uninsured Project in the UCLA Center for Health Policy Research, using some of their numbers and their metrics, you know, in San Diego County there’s 556,000 uninsured individuals. If this bill passes the Senate, 360,000 of those people will now receive coverage. They’ll either be eligible for coverage under Medicaid or, in this state, MediCal or they’re going to receive subsidies to be able to buy the private insurance.

CAVANAUGH: I see. So the limitations on MediCal or Medicare will be expanded, is that correct?


CAVANAUGH: And what will happen to – I can’t do the math that quickly but about 200,000 of the people who are uninsured will stay uninsured?

ROTTO: More than likely. They’re not eligible for any number of reasons, whether it’s that they’re – their citizenship status, whether it’s income and they’ve just elected to not be eligible. But, you know, and then there’s the other part that this bill, what I think everybody champions and talks about, is shared responsibility, that the government’s going to make sure that prices are reasonable for people to buy in at any level, that the individual must maintain insurance and that they will still have an employer-based system that will be built around it but with an understanding that we need to help support small businesses as they try to provide this and continue to provide coverage to their employees.


CAVANAUGH: What are some of the other elements of the House plan that you like?

ROTTO: Well, of course, you know, the plan recognizes the integral role of the medical home and how successful that is and that’s what the community clinics are built upon, that concept that you come for your primary care and that you know your doctor, you know your medical team and they’re going to be following and working with you through whether you’re healthy or whether you have a preexisting condition. Maybe it’s asthma, maybe it’s hypertension, maybe it’s diabetes, any number of different conditions. And they’ll be helping you to stay healthy. There’s a additional impetus for folks to enter the workforce. Healthcare workforce has such a shortage at all different levels and especially in urban settings and in rural settings. It’s so important to attract doctors, young doctors, in particular, into the field. There’s incentives in there to do that and for them to be a part of the health center community. I mean, those are some very key essential elements that will help us to transform our system to build upon what we have and make it even better.

CAVANAUGH: I’m speaking with Gary Rotto. He’s Director of Health Policy for the Council of Community Clinics here in San Diego. And we’re talking about the bill that was passed by the House of Representative – Representatives, that is, this past weekend, the Affordable Healthcare for America Act. And we’re taking your calls at 1-888-895-5727. Now, of course, this House bill does include, as you’ve already mentioned, a government run insurance option. Currently, we refer to it as the public option. A lot of people call it a lot of different things. It was one of the most controversial elements of the plan. What do you think about including the public option? What kind of changes does that create?

ROTTO: Well, it kind of keeps the system honest. We enjoy a market-based system in America and what this does is, it sets up a kind of a – almost a benchmark. It makes sure that the private insurance companies are – continue to be competitive and not try to game the system. There – My understanding is that the public option will not be subsidized. It’s got to stand on its own. It’s got to pay for itself off its own premiums and off its own expenses very much like the private system.

CAVANAUGH: And as a representative of community clinics, do you think that the public option is going to be a significant factor in bringing medical prices down, in bringing prices down all across the board?

ROTTO: I think it’ll be a factor. It’s probably not going to be the sole factor. I mean, there’s another concept in the bill which radically changes how we think about insurance payments. Right now, it’s very fee-based. So hospitals, doctors, clinics are paid for when people are sick. And there’s a lot of folks that say why shouldn’t we be keeping people healthy? The incentive should be on prevention and on wellness. And maybe there should be a shared system for if you have great benchmarks of quality and of keeping people healthy, that maybe that’s how we ought to be paying for services. And so there’s something called an accountable care organization which Robert Wood Johnson Foundation and Medical School in New Jersey’s going to be testing starting in January and which we think – we’re starting to look at on the local level. We think that it has potential, great potential in San Diego.

CAVANAUGH: And I’m wondering, you know, there is a huge price tag that comes with this particular piece of legislation. The bill proposes to spend over a trillion dollars over, I think it is, a ten-year period. And there’s a tax that’ll be, if indeed this does become law, on the highest earners, the top .3% of earners in the United States. When people hear that price tag, over a trillion dollars, they get very nervous, Gary, and I’m wondering how do you reconcile spending that much money to overhaul America’s healthcare system?

ROTTO: Well, what you have to do is you – Vince Mudd from San Diego Office Interiors, I believe, was on the show back in August. He’s a small businessman, very active in the community, active with the Chamber of Commerce, and he tells a story that his insurance premiums for his employees went up 18% last year, I think 17% the year before, and what he points out is he didn’t have anybody who was pregnant and delivered and didn’t have any major surgeries amongst his employees and yet there’s still double-digit increases in the premiums for employers. A small business can’t continue to sustain itself on those increases year after year. We have to do something to bring that down. So, yes, there is a cost and if you break it out over the ten years, sure a trillion dollars sounds incredible but if you break it out and what the cost is per year and that over time, that over that ten-year period, the federal deficit will actually go down because we’ll be able to bring what’s called the cost curve down instead of this trajectory that keeps going straight up. Think about now what they call bending the curve and that if you can do that, you’re going to be saving a tremendous amount of money for small businesses and in our economy.

CAVANAUGH: I’m speaking with Gary Rotto. He’s Director of Health Policy for the Council of Community Clinics. And we’re talking about the healthcare reform legislation that passed the House of Representatives last weekend. And we are taking your calls at 1-888-895-5727. Let’s go to Gayle who’s calling us now from Alpine. Good morning, Gayle, and welcome to These Days.

GAYLE (Caller, Alpine): Good morning, Maureen. Thank you so much for your program. There’s something – there’s a part of this health program that I think people are not – maybe not aware of or it’s being overlooked. When you go to Europe, you find that there are a lot of – a lot more protection from the toxins that are included in the products that we all use. Things like makeup, things like household cleaning products, all sorts of things that are allowed in this country that are not allowed in Europe. And when people are asked about that, it boils down to the fact that when government has a vested interest in your health and the health of the public, they’re rather more aware about the products that you use.

CAVANAUGH: I see, and so you think we’re going to be seeing more regulation on our products and our makeup and our food items because there might be a government run option in a new healthcare system?

GAYLE: I would definitely like to think that the products I buy are not going to be poisoning me.

CAVANAUGH: Okay. I agree with you, Gayle. Thank you for the phone call. I don’t know that we have any information about the idea of government regulation increasing because of a new healthcare – because they’ll be involved in providing some more coverage to people.

ROTTO: You know, I haven’t heard that, Maureen, but there’s an underlying principle that Gayle’s talking about and that is an educated consumer, and that’s one of the things that’s so important in healthcare today, that we continue to be educated consumers. You know, with the health insurance exchange that will be initiated with the passage of healthcare reform, that’s one of the goals of that exchange is to be able to set up comparisons that are apples to apples, oranges to oranges so that people can make an informed decision about the type of insurance product that’s best for them.

CAVANAUGH: Let’s take another call now. Lavar is calling from San Diego. Good morning, Lavar. Welcome to These Days.

LAVAR (Caller, San Diego): Good morning. How are you doing?

CAVANAUGH: I’m doing great. Thank you for calling.

LAVAR: I had a question about a couple of requirements that I understand to be included in the plan but I’m not sure, so I was hoping that the speaker could confirm them.

CAVANAUGH: Okay, let’s see. We’ll try.

LAVAR: They both pertain to requirements. One, I – One thing that I heard was that people who are employed will be required to buy healthcare from their employers. And that it’s a overall general requirement for everyone to have healthcare. Just my thought on the first, that doesn’t sound like it’s going to be the same as the option that’s – we’ve had in the past, so that’s a change when I heard that from the folks, that there was going to be no change. And the second, it sounds like that such requirement will be the first thing that the government has ever done requiring everyone in the country to do, and so I was looking for some clarity on that. Thank you.

CAVANAUGH: Well, thank you, and thank you for the call. What do we know about that, Gary?

ROTTO: Well, again, it goes back to the concept of the shared responsibility between the government, the individual and the employer. It’s not unlike in California when we passed a proposition a number of years ago that required if you drive a car, you have to have automobile insurance in order to drive. So what this is doing is, it’s requiring that, yes, you have to have insurance, you have to have healthcare coverage. It does require employers to provide health insurance to employees or to make a contribution to help fund affordable health insurance. Individuals are required to obtain insurance or they pay a fee based upon their adjusted income.

CAVANAUGH: I see. And the government run option is supposed to make it more – easier for people to actually be able to afford health insurance.

ROTTO: Exactly, that they can be, as an individual, if their company doesn’t offer it…


ROTTO: …or let’s say they’re a sole practitioner, they have their own company and it’s a, you know, independent contractor position, that they can go through this exchange and become part of a larger group because we know that when you have – when you buy in bulk, when you buy in volume, your costs go down. That’s the principle behind the health insurance exchange.

CAVANAUGH: Now, I want to, of course, interject a caveat here because we are talking about the legislation passed by the House of Representatives. We have no idea what the final healthcare reform bill, if, indeed, there is one that becomes law, will look like. And I would imagine for the community clinics, you guys must be scrambling a little. You don’t know really what’s coming down the pike, do you?

ROTTO: Well, you’re trying to read our – trying to read the crystal ball or the tea leaves out there. Yeah, we look at the different versions of the bills…


ROTTO: …whether it’s the Senate Health Committee bill, the Senate Finance Committee bill. Up to this point on Saturday, there were – it was through the three different House committees. Now we have one bill that passed to look at and compare and say what are the provisions that are consistent between all of those that seems to be non-controversial. We certainly hear about the controversial portions, one of which is the public option but as far as those that apply to the clinics themselves, the recognition of the medical home, the recognition of the clinics as the safety net in our community, those are all very consistent, so feel very, very comfortable with those provisions, that those will carry through in any final bill.

CAVANAUGH: Let me just check in on how the community clinics are doing. During this recession, have you seen the number of people at the clinics increase?

ROTTO: Most definitely. The numbers of uninsured have gone just depends on the particular clinic or clinic organization, gone up 20 to 50% year over year of people who were formerly employed, no – aren’t employed any longer and, therefore, have lost their coverage, partially because they couldn’t afford the Cobra payment, you know, be able to pay to continue your coverage that’s no longer employer subsidized. Or what you’re starting to see is those companies that are starting to go into their new enrollment year, November, December, you start to have your new benefits plans rolled out and there are companies that are trying to be very loyal to their employees and not cut back because they recognize the value of the employee so they may have to cut back on the level of health insurance, of the care, of the coverage. It may mean that it’s a higher premium that – co-pay that people have to pay when they go to the – go for medical care. It may be their monthly premium, they have to pay a larger share versus what their employer is paying. Or that their deductible has gone up greatly. And those are squeezing folks and so we’re starting to see some of those folks also that can’t afford it because they may have an extremely high deductible and they figure that the best place to go that you’re still going to get high quality care at a reasonable price is going to be your community clinic.

CAVANAUGH: Now I know the community clinics are different from a doctor’s office or going to a hospital in the sense that they are the safety net but as you speculate on the provisions in these various healthcare bills, how do you think it’s going to change your operation at the community clinics? I mean, as opposed somebody comes in now and perhaps they don’t have insurance, will you start checking for insurance and – what do you think the scheme is going to be for patients to the clinics?

ROTTO: Well, I think when folks walk through the door it’s not really going to change because we do that already. We try to help folks with their coverage, whether they’re covered by a private insurer through their business or a individual plan or whether they’re eligible for another plan. It could be that they’re eligible for Medicare or they’re eligible for MediCal or the kids are eligible for Healthy Families or any number of different ways they can be covered. Last resort, of course, not covered at all, you have the sliding fee scale, which is applied based upon income.

CAVANAUGH: Okay, were you finished?

ROTTO: I was just going to say that I think that there’ll be fewer of those folks because you’re going to now have, as we were talking about, so many more people who will be eligible for some type of coverage.

CAVANAUGH: Let’s take another phone call. Jeff is calling from Encinitas. Good morning, Jeff, and welcome to These Days.

JEFF (Caller, Encinitas): Yeah, happy to participate. I had always been led to believe that emergency room visits by those who could not afford healthcare were driving up the costs for everybody. In other words, not just uninsured but those maybe who were under the poverty line or illegal immigrants, you name it, and that emergency rooms were duty bound to serve those clients. And I’ve never heard the details of how the proposed plans would address those who are not legally employed or otherwise able to cover their premium of a mandated health insurance coverage plan.

CAVANAUGH: Thank you for that question, Jeff. And I’m going to go to you, Gary, and do you understand what Jeff is asking?

ROTTO: It sounds like there’s two parts there. One is if you elect not to have coverage and you’re going to pay in, you’re still personally responsible and you have to have proof of coverage. It’ll be very similar to how you, in my understanding, how you send in your – is it the W-2 form at the – when you file your taxes? There’ll be a little certificate you’re going to have to mail in, it seems to me, is what folks will have to do to show that they’re covered or pay this kind of excise tax, so to speak. I don’t know if that’s the right term but…


ROTTO: …you know, an extra tax for not being able to prove coverage that will go into the pool, into the system to help defray the cost for everybody.

CAVANAUGH: Right, and the income limits on those eligible for, one could say, free government healthcare, in other words in being able to participate in one of the government programs like Medicare and so forth, are – those income limits are going to be, I don’t – raised or lowered, I can’t figure it out, and more people are going to be included in those programs, is that correct?

ROTTO: Yeah, 150% federal poverty level is the cutoff…


ROTTO: …where folks will be eligible for MediCal.


ROTTO: Which is still not a whole lot of money on an annual basis for a family of four.


ROTTO: I’ve forgot what that is, $20,000–25,000, something like – very, very nominal amount that one is making.


ROTTO: And above that there will be the subsidies that will be offered and they’ll be phased out when you get to what’s called 400% of the federal poverty level.

CAVANAUGH: I see. Let’s take another phone call. Aaron is calling from San Diego. Good morning, Aaron. Welcome to These Days.

AARON (Caller, San Diego): Good morning. Thanks for taking my call.

CAVANAUGH: Yes, how can we help you.

AARON: Well, I have three major issues with the healthcare plan as it seems to stand now and I do recognize that this isn’t final law and that this isn’t, you know, necessarily binding in any important, final way. But my issues – my problems with this are, number one, I think is the most basic one, is that the United States is still the richest country in the world and I believe we still have more billionaires within our borders than any other country in the world and last time I looked at that particular statistic it wasn’t even close. So that, you know, I would tie that in with somebody that I don’t remember who said it but I think a philosopher once said you that you can judge a culture by how it treats the poorest, the sickest and the animals?

CAVANAUGH: Yes, I remember that.

AARON: And so what I’m thinking is if we have more money in this country than any other country in the world and all of the other countries who aren’t even close have already had a free healthcare system for everyone for years, then why can’t we have one? That’s my first issue.

CAVANAUGH: Well, Aaron, I’m afraid we’re going to have to sort of make it the only issue because we’re kind of running out of time. But I appreciate your phone call and so many people have brought up that issue. I think the whole idea of people who have lobbied so hard for the single payer system that we’ve heard so much about, that really is just not on the table this time around, is it, Gary?

ROTTO: No, it’s not. And it was very, very early on but that went away rapidly. The Obama administration, you know, in reading how – reading the urgency of the need to create healthcare reform, made a strategic decision and said rather go with the public option than to push single payer. You know, Aaron was talking about a philosopher and philosophy, really part of our American culture is this rugged individualism as we learned about in, you know, middle school history, and that still permeates our society. So that may be what is helping underlying, you know, how we look at healthcare reform or any number of issues, the market driven system that we have and the idea of individualism but still coming together on behalf of the community, how you blend those together.

CAVANAUGH: Now I don’t want to leave this particular topic without talking about the issue that was a shocker to many people when this Affordable Healthcare for America Act passed last Saturday, and that was the last minute change to the bill that restricts insurance companies offering abortion coverage. And, Gary, could you tell us a little bit about what you know about that.

ROTTO: You know, I’m not the expert on that because it really is not – does not really impact the community clinics…

CAVANAUGH: Right, yes.

ROTTO: …because we provide reproductive health services but those are more for folks that need, you know, education about themselves, their bodies, the family planning, you know, how do you go about family planning? How do you – you know what are the different services for a woman to stay healthy.

CAVANAUGH: Right. I understand.

ROTTO: And that’s really where our clinics focus.

CAVANAUGH: Now, that issue is one of the many issues that face this bill as it goes on into the Senate and you’ve been following this, I know, rather closely. Do you think that we’re going to see something passed and signed by the end of the year? Or is that cutting it rather close?

ROTTO: It’s going to be cutting it close.


ROTTO: The question is when will the Senate take it up. And, of course, the next step is, once the Senate does pass the bill, whatever it looks like, then it has to go to Conference Committee and we’re going to have to reconcile, those in the House in particular, who say there must be some type of public option versus if the Senate acquiesces and says we’re not going to have public option on the table. That’s probably going to be the biggest Conference Committee discussion that there will be. There’ll be other elements but that will be it. How quickly can the Conference Committee then produce the bill and get it to the president, probably after the first of the year would be my personal guess.

CAVANAUGH: Probably faster than Washington usually works.

ROTTO: Very true.

CAVANAUGH: Well, thank you so much for talking with us today.

ROTTO: Oh, it’s a pleasure. Thank you so much for inviting me in, Maureen.

CAVANAUGH: I’ve been speaking with Gary Rotto. He’s Director of Health Policy for the Council of Community Clinics. And if we didn’t get a chance to take your call on the air, please do post your comments at And coming up, recycling enters a new phase in San Diego and it’s all about food scraps. That story’s next as These Days continues here on KPBS.