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How Will Health Care Reform Affect San Diego?

How Will Health Care Reform Affect San Diego?
The health care reform bill passed by Congress will transform the health care system in San Diego, and throughout the nation. We discuss the biggest changes that will result from the historic legislation, and which elements of the bill still need more clarity.

GLORIA PENNER (Host): I’m Gloria Penner and I’m joined by the editors at the roundtable These Days in San Diego. Today, we focus on the local impact of two major national initiatives, the federal healthcare overhaul legislation just signed into law, and the Obama administration’s expected pursuit of immigration reform. And then we will turn to San Diego County’s Board of Supervisors and their decision to cut their own discretionary funds, plus their vote to not build the controversial Merriam Mountain housing development. The editors with me today are John Warren, publisher and editor of San Diego Voice & Viewpoint. John, it’s good to see you again.

JOHN WARREN (Editor/Publisher, San Diego Voice & Viewpoint): Thank you, Gloria.

PENNER: Alisa Joyce Barba, Western bureau chief for NPR News. Welcome back, Alisa.


ALISA JOYCE BARBA (Western Bureau Chief, National Public Radio News): Good morning, Gloria.

PENNER: Good morning. And David Rolland, editor of San Diego CityBeat. Always a pleasure to see you, David.

DAVID ROLLAND (Editor, San Diego CityBeat): Hello, Gloria.

PENNER: Hello there. Our call in number is 1-888-895-5727, 895-KPBS. And, as you could hear from David’s voice, this is going to be a fun show. So, as the world knows, President Obama signed historic healthcare legislation into law this week, and he’s going to sign a second companion bill in the next few days, this after some tough negotiations with resistant congressional Democrats and with no support from Republican Representatives. But Republicans have not entirely capitulated. They have mobilized to block the measure in the courts and tried to stall its implementation with a variety of political procedural devices to no avail. So while all this played out, folks in California and San Diego were figuring out what the new law will bring. And, John, a major goal of the reform was to cover the uninsured. What does this translate into in California?

WARREN: Well, in California we have 7,000 – in San Diego County alone, 7,000 doctors. We have over 500,000 people who are not insured with 20 regional hospitals and just like under 100 clinics. So clearly, we’re not going to see an immediate increase in the number of facilities or the number of doctors. We have small businesses trying to figure out what does this mean for them because most of the small businesses covered by the new law are for employers of 50 or more people, and most of those small businesses in California, or in San Diego County in particular, employ less than 50 people. And so there are penalties for people not being insured. I guess there’s a glimmer of hope when you look at some of the highlights of the bill. Children under – or young people up to the age of 26 can stay on their parents’ policies, insurance companies can no longer drop people with illnesses, and they can no longer refuse to insure people because of preexisting conditions. Beyond those things, we’re waiting for the other pieces to kick in, and so it’s a time of great uncertainty for a bill that has 2400 pages and will cost us $900 billion dollars over the next 10 years.


PENNER: And what I heard on an NPR report, Alisa, was that when the regulations are all written down, because different departments are going to have to come up with their own rules and regulations, that that 2400 page bill is going to seem like a postcard because it’s going to be such a huge amount of verbiage.

BARBA: Yeah, there’s no question that this is like the beginning of a very complex and complicated bureaucracy. I don’t think anybody’s really sorted out what it’s going to mean. I mean, there are some implications. We know that there’s – this bill is going to increase the number of people who have access to insurance. This bill is going to make – increase the need for primary care providers, for nurse practitioners, for people who have to take care of people at a very primary level. It is going to decrease Medicare, Medicaid payments to primary care physicians and to specialty physicians. So there’s some things that we know are coming down the pike but I think that the real fear – I mean, what I’ve heard the most, as you said, 95% of small business owners in San Diego hire – employ under 50 people, which means they will not be subject to a lot of the regulations here so it may not affect them as much as they think but there’s a tremendous amount of fear, I think, in the business community about what this is going to mean.

PENNER: And I would like to ask our listeners about that. Are you looking forward to having some advantages from this bill or don’t you know? Do you feel as though it’s been hyper-promoted as something that is just manna from heaven and that you think maybe it’s not. I’d like to hear your reaction to the legislation, the historic law that has been passed. It’s not just legislation. It’s being referred to as historic. You know, the insurance companies really resisted this. At first, they were onboard, David, and then they started resisting it, they started putting up all their complaints about it. But despite all those complaints, won’t the insurance industry actually benefit because millions more paying customers will be driven their way?

ROLLAND: Oh, sure, they – I mean, they’re certain – like as John mentions, you know, there are new and very necessary regulations on insurance companies. But, like you say, they – millions of new customers can’t be all bad for the insurance industry. So, you know, I don’t know how that’s all going to wash out for them. You know, I think that they’re probably, you know, crunching those numbers now but, you know, the good thing is that they will not be able to cherry pick the healthiest people to insure anymore. They’re going to have to take care of everybody, so that’s a good thing. I mean, I – This bill is funny because I – I’ve never been so euphoric about the passage of a bill that I hated so much.

PENNER: Why do you hate it?

ROLLAND: Because I was one of the – you know, I’m one of the millions of progressives in this country who preferred…

BARBA: Ooh, that’s a naughty word, remember?

PENNER: Nah, nah.

ROLLAND: Not to me, it’s not. Who wanted the true overhaul and government takeover of the healthcare or at least the insurance industry that the Republicans are saying this – falsely saying this is. You know, I wanted the insurance industry completely taken out of the mix.

PENNER: You’ve sort of preempted a thought that I had and I was going to ask you that, David, so I’m going to ask it now. Do you think the public option is totally off the table? Or could that in some way return?

ROLLAND: Well, it’s off the table for now. But, you know, Timothy Noah from – a writer from wrote an interesting piece comparing and contrasting the education part of this bill, the student loan, you know, basically taking the private sector out of the student loan business. He compared that to the healthcare part of it and said – and followed the trajectory of the student loan component over the decades and how that has slowly gone from the private sector back to the public sector, and he makes some interesting comparisons, saying, well, if that can happen over time, if the public can be fine with the government takeover of student loans, could it possibly – could the country possibly get into the idea of, you know, of more of a government role in the provision of healthcare?

PENNER: Have we seen no resistance at all to the government getting into the student loan business and taking it away from private industry?

ROLLAND: There’s been a little bit. I mean, we heard – if listeners were listening to NPR before the show, they probably heard a piece on that and heard some complaints from Lamar Alexander, you know, worried that the interest rates were going to be too high for students and this was going to be bad for everybody but – So, yeah, there is resistance but it was completely drowned out by the hysteria surrounding healthcare.

PENNER: Before I go back to the panel, we have many people who want to talk to us about this so let’s start with Pam in Normal Heights. Hi, Pam, you’re on with the editors. Welcome.

PAM (Caller, Normal Heights): Well, thank you, and good morning to you, David. I share your euphoria and pain. And what I observe, it’s just amazing that the president keeps speaking honestly about what has been passed, truly historic, but it’s health insurance reform. And it’s – we’re quite a ways from healthcare reform. For one thing, there are no…

PENNER: Pam. Excuse me, Pam, your phone – your phone is breaking up and so we’re having a little trouble hearing you. I have the feeling that your question probably has to do with whether this is real reform, and I’m going to paraphrase it for you because your phone’s not behaving itself. John, is this real reform?

WARREN: Oh, yes, this is real reform. I think we have to realize, as the president said in Iowa, you know, we didn’t get everything we want. He said we didn’t get the public option but we didn’t get it because we couldn’t get it. But when you look at the gamut of things that are being changed, it’s significant. And I – The statement was made on the floor of the House and the Senate that we shouldn’t throw out what we can get for delusionary perfection that’s not obtainable in terms of moving with this thing. So I think we will see the benefits but the fear that’s been created by the Republicans, it’s gotten to the point that it’s no longer a matter of the merits of the bill. It’s just a political divide. The 13 attorney generals (sic) going to court to sue, the constitutional challenges, the death threats being made on people who voted against it, all of this is just a knee jerk panic reaction to a tremendous propaganda campaign that outlaws and ignores 32 million Americans being covered and coverage reaching up to 95% of people in the next four or five years.

PENNER: Alisa.

BARBA: Yeah, I think there’s – Let’s look at the physician community. Typically, one would expect that given what is likely to happen, the outcome of what’s going to happen with this bill, what we think it’s going to likely result in a cutback in benefits to many, a cutback in pay and a cutback in reimbursements to many physicians. But I think if you look across the gamut, what most of them are saying is that something had to change. The system was broken. Clinton tried, nothing happened. Nothing happened under the Bush administration. I think among many physicians, there’s this reluctant admission that something had to change, this wasn’t perfect, this is going to come with a lot of pain, but it’s the first step and I think that what John’s talking about, there’s kind of a – there’s an acknowledgement that there’s been a philosophical shift in healthcare policy as if the ship—the ship—had kind of shifted its direction a little bit, and I think that scares the bejesus out of half the country that doesn’t like where that shift is turning.

PENNER: Well, let’s talk a little bit about the doctors. The executive director of the San Diego County Medical Society says that the decline of primary care doctors will stop. We – They only have about one-third of all doctors in San Diego County are primary doctors because many people like to go and do the higher paying specialties. So why would that happen? Why would we find the decline stop and that we might even see more primary care doctors come through?

BARBA: Well, there’s – I mean, written into the bill there’s increased reimbursements for primary care physicians. There’s going to be an increased demand for primary care physicians because of the millions of uninsured people who are suddenly going to have insurance, going to be able to go into the health clinics and get the most basic medical care.

PENNER: Well, I think, however, on the other hand, we have Chris Van Gorder who is the president and CEO of Scripps Health and he says that if you’re insured now, he guesses it’s going to cost more and will be getting less because insurance companies will be pressured to reduce cost. They may need to cut reimbursements and raise premiums. So how does that fit into this? If they cut reimbursements, how will doctors get better paid if they’re primary care?

BARBA: Well, I think primary care probably is reimbursed at the lowest level compared to specialty care right now. And if you get – You know, if you’re a primary care physician and you’re getting 20 patients a day, you’re going to be getting 30 patients a day. Ultimately, your reimbursements are going to go up even if costs per patient goes down ultimately.

PENNER: So will the lines get longer and will the waits get longer?

BARBA: I think in the short term it definitely will until we increase the flow of people into those jobs. I mean, that’s what – A friend of mine is a nurse practitioner and she was saying that, you know, there’s just – there’s not enough clinics, there’s not enough, you know, raw facilities in place in San Diego County or anywhere in the nation, I think, to meet the demand that’s going to come. There’s going to be building…

PENNER: Okay, John.

WARREN: Well, the big change in the law is that it will reduce the payments to the specialists…

BARBA: Umm-hmm.

WARREN: …and that reduction to the specialists will be transferred to the primary care, which should be an incentive to bring more physician practitioners and – into the business so that’s where the shift is being made. But the doctors will tell you that they’re still suffering right now…


WARREN: …with loss in payments.

PENNER: All right. Well, we’re going to come back to this and take your calls. We are talking about the new healthcare law and we would love to speak with you as well. This is the Editors Roundtable. I’m Gloria Penner.

PENNER: I’m Gloria Penner. We are talking about landmark healthcare reform that is now the law of the land. We’re getting your reaction to it and we’re, of course, talking to our magnificent panel here. I always say that at the beginning, the beginning of the second part of the show, keep up their enthusiasm and they are enthusiastic today. Alisa Joyce Barba is with us from NPR News and John Warren from San Diego Voice & Viewpoint, and from San Diego CityBeat we have David Rolland. And you, of course. So let’s go right to the phones and hear from Cory in North Park. Cory, you’re on with the editors.

CORY (Caller, North Park): Good morning. How you doing?

PENNER: Good morning. Just fine. What’s going on?

CORY: I just wanted to say, you know, I agree we need change and I actually don’t know a whole lot, like most people, on my level at least, but I am particularly concerned at the precedence (sic) that the requirement to purchase healthcare is – that has been included in the bill. It’s unprecedented with anything that has ever existed in the country, like even car insurance. If you don’t drive, you don’t have to get it. But this is saying that everybody has to do it. But they’re not calling it a tax and so that must mean there’s something different about the way they’re requiring people to pay for it, and that’s of particular concern just, you know, given constitutional history, so forth and so on.

PENNER: Well, Cory, thank you so much for that point. And let’s hear what David Rolland has to say about that. Thanks, Cory.

ROLLAND: Yeah, I would – Initially, I would have the same concerns about a requirement to purchase insurance, especially when you have to purchase insurance or purchase, you know, the product of an industry that has behaved badly so you have to give them money. But then when you analyze, you know, what the reason for that is and that is because we’re all in this together and you’ve got to have – you really have to have healthy people in the system to make the finances work. Everybody has got to kick in, everybody’s got to take care of everybody else. And there are subsidies. You know, whether or not those subsidies are at the right level, you know, to make it work for everybody, you know, remains to be seen but there are subsidies to help people afford it. Again, I wish it weren’t – the money wasn’t going – I’d rather the money go to the government rather than insurance industry but you have to have healthy – young healthy people paying into the system to make it work.

PENNER: But you raise a very good point, David. We think of low income Californians getting enrolled in public programs such as MediCal but how will those who don’t qualify for MediCal that are just earning a little bit more and yet they can’t afford insurance be helped? John.

WARREN: Well, it gets to be complicated because we’re covering 32 million people, leaving about 24 million uninsured. But of that 24 million, 12 million of those are undocumented people in the country and then the group that Cory is talking about falls into the other 12, which has a minimal cost associated with their nonparticipation, almost like a fine. So it’s not – In the end, it’s 95% of coverage. And I think for many people, you’re talking about in California, there will be some additional – initial tax credits which will translate into cash payments that will help people move toward insurance that can’t afford it.

PENNER: It – Go ahead, Alisa.

BARBA: So in other words, if you don’t qualify for MediCal and you can’t afford, you know, a regular type of insurance, you will either pay a fine or take the tax credit that you get and go to these – what are they called? An exchanges?

WARREN: Exchanges, yes.

BARBA: They’ll be these kind of pools where people, low income people, will be able to pool their money together and have the most basic form of coverage.

PENNER: Okay, thank you, Alisa. Ron in Tierrasanta’s with us now. Hi, Ron, you’re on with the editors.

RON (Caller, Tierrasanta): Yes, good morning, and thank you for taking the call. I am just terribly concerned with what’s going on around the healthcare bill. The spitting on United States Representatives, the death threats. If we’ve learned one thing in this country it’s that death threats sooner or later turn into deaths. We have the most heavily armed radical rightwing since Germany in the 1920s, there’s just no question about that. And when and, God forbid, if it happens then I suspect that the five Supreme Court Justices who decided that every fanatic is entitled to his own gun will join in expressions of heartfelt regret.

PENNER: Okay, well, thank you very much. That’s kind of a down note, John. Does Ron have a point?

WARREN: Well, Ron has a point but I think there’s something missing. In America, people want all the freedoms in the world and they want them without responsibility. Today, if you visit Capitol Hill, it’s not the Capitol Hill that I knew 30 years ago where people walked the grounds freely. You got barriers, you got officers with M-16s and flak vests and the whole scenario. It’s because people are different in terms of their moral values and so this is a part of it because we keep wanting to legislate based on our personal, immediate interests and we’re no longer thinking in terms of a collective national concern which was the basis of the laws and the Constitution and the whole foundation that we have. And we can’t pull up this and be constitutional at an instant and then go back to being self-centered. It doesn’t work that way.

PENNER: Alisa.

BARBA: Also, you know, the gray areas of politics seem to be disappearing. I mean, it’s black and it’s white. You’re Republican or you’re Democrat. And then increasingly, these horribly divisive issues like abortion, I mean, that – what happened, I think, and what the caller’s referring to is that there’s been death threats, there have been threats made against people who voted in favor of this healthcare reform bill, specifically the group of what they call pro-life Democrats, who were holding out. They weren’t going to vote for the bill because they didn’t like language in the bill that they thought would provide federal funds for abortion. In the end, President Obama agreed – he issued an executive order saying none of the funding in this will provide – help go to provide abortion, so the pro-life Democrats, the so-called pro-life Democrats went along with the bill and that’s what pushed it over the edge. That group of people, in particular, reportedly have been the subject of death threats. And, you know, as we know, there have been vigilantes out there who have killed abortion providers, who’ve gunned – so, again, the level of vitriol and the huge chasm that seems to divide the two camps have led to, I think, just an amazing amount of ugliness in the debate.

PENNER: Okay, briefly, please, David.

ROLLAND: Yeah, everybody has a right to be angry and, you know, I’ve been angry at government policies my entire adult life. It’s funny to be kind of finally on the side, you know, of people that are on the receiving end of the anger. So everybody has a right to be angry but what makes this different is that the Republican Party seems to be egging on the anger and actually, you know, basically it’s – we’re in a room full of, you know, open gas cans and sticks of dynamite laying around and the Republicans seem to be throwing, you know, a lit match into the room. That seems to be what is different for me.

PENNER: Said in his normally unbiased manner. Thank you very much, David. We’ll hear from Frank in Balboa Park now. Hi, Frank.

FRANK (Caller, Balboa Park): Hi, Gloria?


FRANK: Good morning. I’m – Just an observation. I’m taking pictures of the flamingos in Balboa Park, just…

PENNER: Yes? Is that all you wanted to tell us?

BARBA: I guess so.

PENNER: I guess Frank is gone. Okay. Well…

ROLLAND: It sounds nice.

PENNER: …on that note, that’s kind of a happy picture considering what we’ve just been talking about, so I think I’m going to end this segment there. And, Frank, I really appreciate you giving us such a lovely conclusion. Let us move on.