California Healthline

As California lawmakers attempt to tighten the rules on childhood vaccinations, they’re getting pushback from unexpected quarters: high-profile officials who support vaccines.

Choreograph/Thinkstock

In the past few weeks, Democratic Gov. Gavin Newsom and the members of the Medical Board of California have questioned a bill that would give the California Department of Public Health authority to decide whether a child can skip routine vaccinations.

Anti-vaccine activists have capitalized on these moments, plastering Facebook pages and social media with praise for the officials’ statements.

But those officials are not against vaccinations. In fact, they have made clear they’re committed to vaccines, and to dealing with the problem the bill is supposed to fix — doctors providing kids with medical exemptions for reasons that don’t meet federal standards.

“Having been in public health for a long time, I am a huge supporter of vaccines,” said Michelle Bholat, MD, a family medicine physician in Santa Monica and until recently a member of the medical board, which has oversight over physicians and their licenses.

What concerns her, she said at a late-May meeting of the board, was the measure’s potential effect on doctor-patient relationships and the particulars of who would qualify for a medical exemption.

Pediatrician and State Sen. Richard Pan (D-Sacramento) introduced the bill to address a spike in the number of children who have been granted what he calls “fake” medical exemptions from vaccinations; more than five times as many kids have medical exemptions this past school year than in 2015-16.

SB 276 would give the final say on medical exemption applications to the state public health department, which would be required to follow guidelines established by the Centers for Disease Control and Prevention. Any exemptions provided by doctors would be subject to approval — or denial — by the department.

The only other state that gives control of vaccine exemptions to a public health agency is West Virginia.

The measure passed the state Senate in May and is awaiting consideration in the state Assembly.

The debate over the measure comes as new state data show that the percentage of kindergartners who had all their recommended shots fell for the second straight year, largely due to an increase in medical exemptions written by doctors.

During the past school year, the share of fully vaccinated kindergartners dropped to 94.8%, down from 95.6% in 2016-17, putting the state in potentially dangerous territory — officials recommend 90%-95% coverage for community immunity.

And as vaccination rates dip, measles is spreading nationwide. In the largest outbreak since 1992, more than 1,000 people have been infected across the country this year through June 5, including 51 in California.

Nearly 3 years ago, California enacted a law by Sen. Pan that bars parents from citing personal or religious beliefs to avoid vaccinating their children. Children could be exempted only on medical grounds if the shots were harmful to their health.

That ban improved vaccination rates, though progress has been slipping.

Today, many of the schools that had the highest rates of unvaccinated students before the law took effect still do. Doctors have broad authority to grant medical exemptions from vaccination; some wield that power liberally and sometimes for cash, signing dozens or hundreds of exemptions for children, sometimes in far-off communities.

Sen. Pan’s bill would crack down on this practice and has the strong support of the medical establishment. It was cosponsored by two powerful doctor associations, the American Academy of Pediatrics, California, and the California Medical Association.

“We want to make sure unscrupulous physicians aren’t making medical exemptions for money,” said David Aizuss, MD, president of the California Medical Association. “The idea of the bill is to protect a real personal medical exemption, where kids are on chemotherapy or have an immunological response.”

But it has its critics — and this time, they extend beyond the small but fervent group of people who continue to question the extensive scientific evidence that shows vaccines are safe. And although raising concerns is typical in the legislative process, their criticisms take on outsize importance with a subject as explosive as vaccines.

The biggest name among the new critics is Gov. Newsom, who said he’s worried about interfering with the doctor-patient relationship. “I like doctor-patient relationships. Bureaucratic relationships are more challenging for me,” he said at the state Democratic Party convention in early June.

“I’m a parent; I don’t want someone that the governor of California appointed to make a decision for my family.”

State Sen. Ben Allen (D-Santa Monica), a cosponsor of Sen. Pan’s previous legislation, abstained from voting on the new measure last month, saying he’d made commitments during the previous fight to leave medical exemptions to the discretion of doctors.

Last month, the Medical Board of California offered just lukewarm support, and only to portions of the bill, after listening to 200 members of the public speak against it for more than 2 hours.

The board members called on Sen. Pan to address a variety of concerns, from the potential oversight role the state public health department might play, to the proposed guidelines for medical exemptions.

They agreed on one thing: It should be easier for the board to investigate complaints of questionable medical exemptions. To look into complaints, the board needs to see medical records. To get those records, it generally needs permission from patients or their guardians, something parents who have sought medical exemptions are often unwilling to provide. The bill would give the board access to these records.

One physician, Bob Sears, MD, in Orange County, a well-known opponent to vaccine mandates, was put on probation in 2018 for writing an exemption for a 2-year-old without taking any medical history. Since 2016, at least 173 complaints against physicians for inappropriate exemptions have been filed with the state medical board, with more than 100 currently under investigation, the board said.

Medical exemptions for California kids are clustered in certain communities and schools. In Humboldt County, 5.8% of kindergartners have medical exemptions from shots, according to the new state data. In Nevada County, the rate is 10.6%. All told, nearly one-third of the state’s counties have fallen below 95% immunity from measles.

Dr. Aizuss of the California Medical Association said the organization is working with Gov. Newsom’s office and the medical board, among others, to update the bill so that it will be “workable, effective, and supported by the governor.

“I think that our goal is the same,” he said. “The idea of the bill is to protect ... the sanctity of the true physician-patient relationship, as opposed to a relationship where physicians were granting the medical exemption for a fee, which is not a true physician-patient relationship.”
 

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. California Healthline reporter Ana B. Ibarra contributed to this report.

As California lawmakers attempt to tighten the rules on childhood vaccinations, they’re getting pushback from unexpected quarters: high-profile officials who support vaccines.

Choreograph/Thinkstock

In the past few weeks, Democratic Gov. Gavin Newsom and the members of the Medical Board of California have questioned a bill that would give the California Department of Public Health authority to decide whether a child can skip routine vaccinations.

Anti-vaccine activists have capitalized on these moments, plastering Facebook pages and social media with praise for the officials’ statements.

But those officials are not against vaccinations. In fact, they have made clear they’re committed to vaccines, and to dealing with the problem the bill is supposed to fix — doctors providing kids with medical exemptions for reasons that don’t meet federal standards.

“Having been in public health for a long time, I am a huge supporter of vaccines,” said Michelle Bholat, MD, a family medicine physician in Santa Monica and until recently a member of the medical board, which has oversight over physicians and their licenses.

What concerns her, she said at a late-May meeting of the board, was the measure’s potential effect on doctor-patient relationships and the particulars of who would qualify for a medical exemption.

Pediatrician and State Sen. Richard Pan (D-Sacramento) introduced the bill to address a spike in the number of children who have been granted what he calls “fake” medical exemptions from vaccinations; more than five times as many kids have medical exemptions this past school year than in 2015-16.

SB 276 would give the final say on medical exemption applications to the state public health department, which would be required to follow guidelines established by the Centers for Disease Control and Prevention. Any exemptions provided by doctors would be subject to approval — or denial — by the department.

The only other state that gives control of vaccine exemptions to a public health agency is West Virginia.

The measure passed the state Senate in May and is awaiting consideration in the state Assembly.

The debate over the measure comes as new state data show that the percentage of kindergartners who had all their recommended shots fell for the second straight year, largely due to an increase in medical exemptions written by doctors.

During the past school year, the share of fully vaccinated kindergartners dropped to 94.8%, down from 95.6% in 2016-17, putting the state in potentially dangerous territory — officials recommend 90%-95% coverage for community immunity.

And as vaccination rates dip, measles is spreading nationwide. In the largest outbreak since 1992, more than 1,000 people have been infected across the country this year through June 5, including 51 in California.

Nearly 3 years ago, California enacted a law by Sen. Pan that bars parents from citing personal or religious beliefs to avoid vaccinating their children. Children could be exempted only on medical grounds if the shots were harmful to their health.

That ban improved vaccination rates, though progress has been slipping.

Today, many of the schools that had the highest rates of unvaccinated students before the law took effect still do. Doctors have broad authority to grant medical exemptions from vaccination; some wield that power liberally and sometimes for cash, signing dozens or hundreds of exemptions for children, sometimes in far-off communities.

Sen. Pan’s bill would crack down on this practice and has the strong support of the medical establishment. It was cosponsored by two powerful doctor associations, the American Academy of Pediatrics, California, and the California Medical Association.

“We want to make sure unscrupulous physicians aren’t making medical exemptions for money,” said David Aizuss, MD, president of the California Medical Association. “The idea of the bill is to protect a real personal medical exemption, where kids are on chemotherapy or have an immunological response.”

But it has its critics — and this time, they extend beyond the small but fervent group of people who continue to question the extensive scientific evidence that shows vaccines are safe. And although raising concerns is typical in the legislative process, their criticisms take on outsize importance with a subject as explosive as vaccines.

The biggest name among the new critics is Gov. Newsom, who said he’s worried about interfering with the doctor-patient relationship. “I like doctor-patient relationships. Bureaucratic relationships are more challenging for me,” he said at the state Democratic Party convention in early June.

“I’m a parent; I don’t want someone that the governor of California appointed to make a decision for my family.”

State Sen. Ben Allen (D-Santa Monica), a cosponsor of Sen. Pan’s previous legislation, abstained from voting on the new measure last month, saying he’d made commitments during the previous fight to leave medical exemptions to the discretion of doctors.

Last month, the Medical Board of California offered just lukewarm support, and only to portions of the bill, after listening to 200 members of the public speak against it for more than 2 hours.

The board members called on Sen. Pan to address a variety of concerns, from the potential oversight role the state public health department might play, to the proposed guidelines for medical exemptions.

They agreed on one thing: It should be easier for the board to investigate complaints of questionable medical exemptions. To look into complaints, the board needs to see medical records. To get those records, it generally needs permission from patients or their guardians, something parents who have sought medical exemptions are often unwilling to provide. The bill would give the board access to these records.

One physician, Bob Sears, MD, in Orange County, a well-known opponent to vaccine mandates, was put on probation in 2018 for writing an exemption for a 2-year-old without taking any medical history. Since 2016, at least 173 complaints against physicians for inappropriate exemptions have been filed with the state medical board, with more than 100 currently under investigation, the board said.

Medical exemptions for California kids are clustered in certain communities and schools. In Humboldt County, 5.8% of kindergartners have medical exemptions from shots, according to the new state data. In Nevada County, the rate is 10.6%. All told, nearly one-third of the state’s counties have fallen below 95% immunity from measles.

Dr. Aizuss of the California Medical Association said the organization is working with Gov. Newsom’s office and the medical board, among others, to update the bill so that it will be “workable, effective, and supported by the governor.

“I think that our goal is the same,” he said. “The idea of the bill is to protect ... the sanctity of the true physician-patient relationship, as opposed to a relationship where physicians were granting the medical exemption for a fee, which is not a true physician-patient relationship.”
 

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. California Healthline reporter Ana B. Ibarra contributed to this report.

As California lawmakers attempt to tighten the rules on childhood vaccinations, they’re getting pushback from unexpected quarters: high-profile officials who support vaccines.

Choreograph/Thinkstock

In the past few weeks, Democratic Gov. Gavin Newsom and the members of the Medical Board of California have questioned a bill that would give the California Department of Public Health authority to decide whether a child can skip routine vaccinations.

Anti-vaccine activists have capitalized on these moments, plastering Facebook pages and social media with praise for the officials’ statements.

But those officials are not against vaccinations. In fact, they have made clear they’re committed to vaccines, and to dealing with the problem the bill is supposed to fix — doctors providing kids with medical exemptions for reasons that don’t meet federal standards.

“Having been in public health for a long time, I am a huge supporter of vaccines,” said Michelle Bholat, MD, a family medicine physician in Santa Monica and until recently a member of the medical board, which has oversight over physicians and their licenses.

What concerns her, she said at a late-May meeting of the board, was the measure’s potential effect on doctor-patient relationships and the particulars of who would qualify for a medical exemption.

Pediatrician and State Sen. Richard Pan (D-Sacramento) introduced the bill to address a spike in the number of children who have been granted what he calls “fake” medical exemptions from vaccinations; more than five times as many kids have medical exemptions this past school year than in 2015-16.

SB 276 would give the final say on medical exemption applications to the state public health department, which would be required to follow guidelines established by the Centers for Disease Control and Prevention. Any exemptions provided by doctors would be subject to approval — or denial — by the department.

The only other state that gives control of vaccine exemptions to a public health agency is West Virginia.

The measure passed the state Senate in May and is awaiting consideration in the state Assembly.

The debate over the measure comes as new state data show that the percentage of kindergartners who had all their recommended shots fell for the second straight year, largely due to an increase in medical exemptions written by doctors.

During the past school year, the share of fully vaccinated kindergartners dropped to 94.8%, down from 95.6% in 2016-17, putting the state in potentially dangerous territory — officials recommend 90%-95% coverage for community immunity.

And as vaccination rates dip, measles is spreading nationwide. In the largest outbreak since 1992, more than 1,000 people have been infected across the country this year through June 5, including 51 in California.

Nearly 3 years ago, California enacted a law by Sen. Pan that bars parents from citing personal or religious beliefs to avoid vaccinating their children. Children could be exempted only on medical grounds if the shots were harmful to their health.

That ban improved vaccination rates, though progress has been slipping.

Today, many of the schools that had the highest rates of unvaccinated students before the law took effect still do. Doctors have broad authority to grant medical exemptions from vaccination; some wield that power liberally and sometimes for cash, signing dozens or hundreds of exemptions for children, sometimes in far-off communities.

Sen. Pan’s bill would crack down on this practice and has the strong support of the medical establishment. It was cosponsored by two powerful doctor associations, the American Academy of Pediatrics, California, and the California Medical Association.

“We want to make sure unscrupulous physicians aren’t making medical exemptions for money,” said David Aizuss, MD, president of the California Medical Association. “The idea of the bill is to protect a real personal medical exemption, where kids are on chemotherapy or have an immunological response.”

But it has its critics — and this time, they extend beyond the small but fervent group of people who continue to question the extensive scientific evidence that shows vaccines are safe. And although raising concerns is typical in the legislative process, their criticisms take on outsize importance with a subject as explosive as vaccines.

The biggest name among the new critics is Gov. Newsom, who said he’s worried about interfering with the doctor-patient relationship. “I like doctor-patient relationships. Bureaucratic relationships are more challenging for me,” he said at the state Democratic Party convention in early June.

“I’m a parent; I don’t want someone that the governor of California appointed to make a decision for my family.”

State Sen. Ben Allen (D-Santa Monica), a cosponsor of Sen. Pan’s previous legislation, abstained from voting on the new measure last month, saying he’d made commitments during the previous fight to leave medical exemptions to the discretion of doctors.

Last month, the Medical Board of California offered just lukewarm support, and only to portions of the bill, after listening to 200 members of the public speak against it for more than 2 hours.

The board members called on Sen. Pan to address a variety of concerns, from the potential oversight role the state public health department might play, to the proposed guidelines for medical exemptions.

They agreed on one thing: It should be easier for the board to investigate complaints of questionable medical exemptions. To look into complaints, the board needs to see medical records. To get those records, it generally needs permission from patients or their guardians, something parents who have sought medical exemptions are often unwilling to provide. The bill would give the board access to these records.

One physician, Bob Sears, MD, in Orange County, a well-known opponent to vaccine mandates, was put on probation in 2018 for writing an exemption for a 2-year-old without taking any medical history. Since 2016, at least 173 complaints against physicians for inappropriate exemptions have been filed with the state medical board, with more than 100 currently under investigation, the board said.

Medical exemptions for California kids are clustered in certain communities and schools. In Humboldt County, 5.8% of kindergartners have medical exemptions from shots, according to the new state data. In Nevada County, the rate is 10.6%. All told, nearly one-third of the state’s counties have fallen below 95% immunity from measles.

Dr. Aizuss of the California Medical Association said the organization is working with Gov. Newsom’s office and the medical board, among others, to update the bill so that it will be “workable, effective, and supported by the governor.

“I think that our goal is the same,” he said. “The idea of the bill is to protect ... the sanctity of the true physician-patient relationship, as opposed to a relationship where physicians were granting the medical exemption for a fee, which is not a true physician-patient relationship.”
 

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. California Healthline reporter Ana B. Ibarra contributed to this report.

Some states could keep their federally funded insurance exchange with consumer protections intact under a proposal unveiled Monday by two Republican U.S. senators.

Sen. Bill Cassidy (R-La.) and Sen. Susan Collins (R-Maine) said their proposed legislation would allow states that embraced the Affordable Care Act to keep operating under many of the current federal rules.

Another option is for states to pursue a less-regulated alternative to Obamacare under the Patient Freedom Act. Or they could reject federal dollars completely in favor of a new state solution for health coverage.

“We give states the option,” Sen. Cassidy said at press conference Jan. 23.

Some health law supporters say the Cassidy-Collins proposal, one of several in the GOP-controlled Congress, could represent a lifeline for states such as California that have invested heavily in expanding coverage under the ACA.

But many Democrats at the state and national level criticized the plan as potentially harmful to millions of Americans who rely on the health law because it does not promise sufficient funding and consumer protections.

“It provides a somewhat illusory option to stay in the ACA without the guarantee of federal assistance necessary to allow states to maintain the level of coverage they are currently providing,” California Insurance Commissioner Dave Jones, an elected Democrat, said in an interview.

California fully implemented the health law by expanding Medicaid coverage to millions of low-income people and creating its own insurance exchange, which ultimately covered 1.3 million enrollees. Supporters have held the state up as proof that the health law can work as intended – and as a counterpoint to Republican contentions that Obamacare is collapsing nationally.

Sen. Cassidy said his legislation promotes the Republican doctrine of states’ rights while avoiding the one-size-fits-all approach from Washington.

Sen. Collins echoed that sentiment, saying she favors letting states that had success with the health law maintain the status quo. She described it as “reimplementation of the ACA” in those states.

“If a state chooses to remain covered by the ACA, exchange policies will continue to be eligible for cost-sharing subsidies and advance premium tax credits,” she said in a Senate floor speech Jan. 23. “The insurance market will still be subject to ACA requirements, and the individual mandate and employer mandate will also remain in place in that state.”

Sen. Cassidy and Sen. Collins acknowledged that details of their bill haven’t been worked out, nor is it clear how it will mesh with other proposals. Competing plans in Congress don’t envision these state options, and it’s unclear what approach President Donald Trump and his nascent administration will take in crafting a replacement plan.

Still, some industry experts and analysts say the Cassidy-Collins proposal is intriguing.

“The advantage to a state like California is we could protect what we have accomplished already,” said Howard Kahn, former chief executive of L.A. Care Health Plan, an insurer on the Covered California exchange. The large managed care plan serves patients in Medi-Cal, the state’s Medicaid program.

“Cassidy’s proposal could work for California better than other alternatives in the short term. The question is whether they maintain federal funding for the longer term,” Mr. Kahn said. “My feeling is you do have to engage with the rational Republicans who are trying to find something that doesn’t tear it all apart.”

Federal funding is a key issue for states. In a summary of the bill posted by Sen. Collins, it said states choosing to retain Obamacare or pick the Republican alternative could receive “funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion.”

Dylan H. Roby, of the department of health services administration at the University of Maryland School of Public Health, College Park, said “California would still have to absorb a 5% cut, at least, in the premium tax credits and cost-sharing subsidies.”

Republicans will need 60 votes in the U.S. Senate to pass a full replacement for the ACA. Sen. Cassidy said his compromise approach is designed to win over some Democrats and reach that 60-vote majority.

In her speech on the Senate floor, Sen. Collins said children could still stay on their parents’ health plans until they are 26 years old. There would be no discrimination against preexisting conditions and no caps on annual or lifetime coverage, she said.

Other key features of the legislation include a provision allowing states to automatically enroll eligible people in health plans unless they opt out. The plan also promotes health savings accounts and price transparency requiring hospitals and other providers to disclose costs so consumers can shop around for the best price.
 

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Some states could keep their federally funded insurance exchange with consumer protections intact under a proposal unveiled Monday by two Republican U.S. senators.

Sen. Bill Cassidy (R-La.) and Sen. Susan Collins (R-Maine) said their proposed legislation would allow states that embraced the Affordable Care Act to keep operating under many of the current federal rules.

Another option is for states to pursue a less-regulated alternative to Obamacare under the Patient Freedom Act. Or they could reject federal dollars completely in favor of a new state solution for health coverage.

“We give states the option,” Sen. Cassidy said at press conference Jan. 23.

Some health law supporters say the Cassidy-Collins proposal, one of several in the GOP-controlled Congress, could represent a lifeline for states such as California that have invested heavily in expanding coverage under the ACA.

But many Democrats at the state and national level criticized the plan as potentially harmful to millions of Americans who rely on the health law because it does not promise sufficient funding and consumer protections.

“It provides a somewhat illusory option to stay in the ACA without the guarantee of federal assistance necessary to allow states to maintain the level of coverage they are currently providing,” California Insurance Commissioner Dave Jones, an elected Democrat, said in an interview.

California fully implemented the health law by expanding Medicaid coverage to millions of low-income people and creating its own insurance exchange, which ultimately covered 1.3 million enrollees. Supporters have held the state up as proof that the health law can work as intended – and as a counterpoint to Republican contentions that Obamacare is collapsing nationally.

Sen. Cassidy said his legislation promotes the Republican doctrine of states’ rights while avoiding the one-size-fits-all approach from Washington.

Sen. Collins echoed that sentiment, saying she favors letting states that had success with the health law maintain the status quo. She described it as “reimplementation of the ACA” in those states.

“If a state chooses to remain covered by the ACA, exchange policies will continue to be eligible for cost-sharing subsidies and advance premium tax credits,” she said in a Senate floor speech Jan. 23. “The insurance market will still be subject to ACA requirements, and the individual mandate and employer mandate will also remain in place in that state.”

Sen. Cassidy and Sen. Collins acknowledged that details of their bill haven’t been worked out, nor is it clear how it will mesh with other proposals. Competing plans in Congress don’t envision these state options, and it’s unclear what approach President Donald Trump and his nascent administration will take in crafting a replacement plan.

Still, some industry experts and analysts say the Cassidy-Collins proposal is intriguing.

“The advantage to a state like California is we could protect what we have accomplished already,” said Howard Kahn, former chief executive of L.A. Care Health Plan, an insurer on the Covered California exchange. The large managed care plan serves patients in Medi-Cal, the state’s Medicaid program.

“Cassidy’s proposal could work for California better than other alternatives in the short term. The question is whether they maintain federal funding for the longer term,” Mr. Kahn said. “My feeling is you do have to engage with the rational Republicans who are trying to find something that doesn’t tear it all apart.”

Federal funding is a key issue for states. In a summary of the bill posted by Sen. Collins, it said states choosing to retain Obamacare or pick the Republican alternative could receive “funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion.”

Dylan H. Roby, of the department of health services administration at the University of Maryland School of Public Health, College Park, said “California would still have to absorb a 5% cut, at least, in the premium tax credits and cost-sharing subsidies.”

Republicans will need 60 votes in the U.S. Senate to pass a full replacement for the ACA. Sen. Cassidy said his compromise approach is designed to win over some Democrats and reach that 60-vote majority.

In her speech on the Senate floor, Sen. Collins said children could still stay on their parents’ health plans until they are 26 years old. There would be no discrimination against preexisting conditions and no caps on annual or lifetime coverage, she said.

Other key features of the legislation include a provision allowing states to automatically enroll eligible people in health plans unless they opt out. The plan also promotes health savings accounts and price transparency requiring hospitals and other providers to disclose costs so consumers can shop around for the best price.
 

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Some states could keep their federally funded insurance exchange with consumer protections intact under a proposal unveiled Monday by two Republican U.S. senators.

Sen. Bill Cassidy (R-La.) and Sen. Susan Collins (R-Maine) said their proposed legislation would allow states that embraced the Affordable Care Act to keep operating under many of the current federal rules.

Another option is for states to pursue a less-regulated alternative to Obamacare under the Patient Freedom Act. Or they could reject federal dollars completely in favor of a new state solution for health coverage.

“We give states the option,” Sen. Cassidy said at press conference Jan. 23.

Some health law supporters say the Cassidy-Collins proposal, one of several in the GOP-controlled Congress, could represent a lifeline for states such as California that have invested heavily in expanding coverage under the ACA.

But many Democrats at the state and national level criticized the plan as potentially harmful to millions of Americans who rely on the health law because it does not promise sufficient funding and consumer protections.

“It provides a somewhat illusory option to stay in the ACA without the guarantee of federal assistance necessary to allow states to maintain the level of coverage they are currently providing,” California Insurance Commissioner Dave Jones, an elected Democrat, said in an interview.

California fully implemented the health law by expanding Medicaid coverage to millions of low-income people and creating its own insurance exchange, which ultimately covered 1.3 million enrollees. Supporters have held the state up as proof that the health law can work as intended – and as a counterpoint to Republican contentions that Obamacare is collapsing nationally.

Sen. Cassidy said his legislation promotes the Republican doctrine of states’ rights while avoiding the one-size-fits-all approach from Washington.

Sen. Collins echoed that sentiment, saying she favors letting states that had success with the health law maintain the status quo. She described it as “reimplementation of the ACA” in those states.

“If a state chooses to remain covered by the ACA, exchange policies will continue to be eligible for cost-sharing subsidies and advance premium tax credits,” she said in a Senate floor speech Jan. 23. “The insurance market will still be subject to ACA requirements, and the individual mandate and employer mandate will also remain in place in that state.”

Sen. Cassidy and Sen. Collins acknowledged that details of their bill haven’t been worked out, nor is it clear how it will mesh with other proposals. Competing plans in Congress don’t envision these state options, and it’s unclear what approach President Donald Trump and his nascent administration will take in crafting a replacement plan.

Still, some industry experts and analysts say the Cassidy-Collins proposal is intriguing.

“The advantage to a state like California is we could protect what we have accomplished already,” said Howard Kahn, former chief executive of L.A. Care Health Plan, an insurer on the Covered California exchange. The large managed care plan serves patients in Medi-Cal, the state’s Medicaid program.

“Cassidy’s proposal could work for California better than other alternatives in the short term. The question is whether they maintain federal funding for the longer term,” Mr. Kahn said. “My feeling is you do have to engage with the rational Republicans who are trying to find something that doesn’t tear it all apart.”

Federal funding is a key issue for states. In a summary of the bill posted by Sen. Collins, it said states choosing to retain Obamacare or pick the Republican alternative could receive “funding equal to 95% of federal premium tax credits and cost-sharing subsidies, as well as the federal match for Medicaid expansion.”

Dylan H. Roby, of the department of health services administration at the University of Maryland School of Public Health, College Park, said “California would still have to absorb a 5% cut, at least, in the premium tax credits and cost-sharing subsidies.”

Republicans will need 60 votes in the U.S. Senate to pass a full replacement for the ACA. Sen. Cassidy said his compromise approach is designed to win over some Democrats and reach that 60-vote majority.

In her speech on the Senate floor, Sen. Collins said children could still stay on their parents’ health plans until they are 26 years old. There would be no discrimination against preexisting conditions and no caps on annual or lifetime coverage, she said.

Other key features of the legislation include a provision allowing states to automatically enroll eligible people in health plans unless they opt out. The plan also promotes health savings accounts and price transparency requiring hospitals and other providers to disclose costs so consumers can shop around for the best price.
 

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.