Posts Tagged 'Medi-Cal'

Healthcare Crisis: Not Enough Specialists For The Poor, but Calif to Cut Medi-Cal Spending

Healthcare Crisis: Not Enough Specialists For The Poor

LA Times, December 15, 2012

With months-long waits for Medi-Cal patients to see specialists, some turn to emergency rooms — exactly what healthcare reform is banking on avoiding.

By Anna Gorman, Los Angeles Times

The blurry vision began early last year. Roy Lawrence ignored it as long as he could. But after falling off a ladder at his construction job, he knew he had to see a doctor.

He went to a community health clinic in South Los Angeles, where doctors determined he had diabetes and cataracts. The clinic could manage his illness but referred him early this year to the county health system for eye surgery.

Nearly a year later, Lawrence, a Jamaican immigrant without insurance, still is waiting for the operation. His vision has deteriorated so much he is considered legally blind.

PHOTOS: Waiting in vain to be seen

“I want to see again,” he said. “I’ve been waiting a long time.”

Lawrence, 49, and patients like him are posing a critical challenge for the planned overhaul of the nation’s healthcare system. Federal officials are investing billions in community health centers like the To Help Everyone (T.H.E.) Clinic, where Lawrence’s problem was diagnosed, with the hope that they can keep more patients out of high-cost emergency rooms.

But a dearth of specialists available to low-income patients presents one of the bigger hurdles facing the country as it tries to bring spiraling healthcare costs under control. Doctors say meeting new government mandates to keep patients healthy and out of hospitals — a linchpin in reducing medical spending — will be virtually impossible without the ability to make timely patient appointments with specialists.

By the end of the decade, the nation will be short more than 46,000 surgeons and specialists, a nearly tenfold increase from 2010, according to the Assn. of American Medical Colleges. Healthcare reform is expected to worsen the problem as more patients — many with complex and deferred health needs — become insured and seek specialized treatment.

Many of the newly insured will receive Medi-Cal, the government plan for the needy as administered through the state of California. Clinics already struggle to get private specialists to see Medicaid patients because of the low payments to doctors. Last week, an appellate court decision that authorized the state to move forward with 10% cuts in Medi-Cal reimbursement, which could make finding doctors for those patients even more difficult.

“Specialists are paid so poorly that they don’t want to take Medi-Cal patients,” said Mark Dressner, a Long Beach clinic doctor and president-elect of the California Academy of Family Physicians. “We’re really disappointed and concerned what it’s going to do for patient access.”

The healthcare overhaul includes initiatives aimed at reducing shortages of general medicine professionals but does little to increase the availability of specialists.

In Los Angeles County, the sheer volume of poor or uninsured patients needing specialist services has long overwhelmed the public health system, creating costly inefficiencies and appointment delays that can stretch as long as a year and half.

Patients’ conditions often must be dire for them to see a neurologist, cardiologist or other specialist quickly. Community clinics try to bypass the backed-up formal government referral system by pleading, cajoling and negotiating to get less critically ill patients like Lawrence moved up on waiting lists.

“Where needs are absolutely critical, we are able to work out special arrangements,” said Rise Phillips, chief executive of T.H.E. Clinic. “That is not the norm. That is, rather, the exception.”

At times, clinic staff members are forced to work against one of their key missions by sending patients to emergency rooms to increase the odds of their seeing a specialist more quickly.

The challenge can be seen in Belinda De Leon’s cubicle in a small, windowless back corner of T.H.E. Clinic. A referral specialist, De Leon spends her days trying to speed up appointments for the center’s clients — and fielding calls from patients wanting to know how much longer they have to wait. At any given time, she’s juggling more than 1,000 pending referrals.

One involves uninsured housekeeper Juana Barrera. Barrera, 45, has been waiting since April 2011 to see a gastroenterologist and get a colonoscopy. She has had bleeding off and on and recently started having pain in her stomach.

On a recent visit, she told De Leon she is scared to wait any longer. But she can’t afford to pay for the test out of pocket. “I’m hoping it’s not anything like cancer,” she said.

De Leon promised to update Barrera’s referral paperwork to indicate she is experiencing pain. “Hopefully that will help,” she said.

Waits for specialist appointments vary dramatically, depending on the type of specialist needed. Patients willing and able to travel across L.A. County to specialty clinics may be able to see a doctor within a month or two. Others who lack transportation and must go to a nearby facility can wait up to a year for a dermatologist or neurologist and up to 18 months for a cardiologist or ophthalmologist.

The county is trying to make the system more efficient, reduce wait times and ensure that those who don’t need more advanced care don’t overburden the system, said Mitch Katz, head of the L.A. County Department of Health Services. County officials risk losing newly insured patients, along with government funding, if they can’t find ways to reduce the bottleneck.

One focus is using technology to improve communication and better screen patients. A pilot program, for example, is allowing primary care doctors at community and public clinics to quickly transmit patients’ medical information via computer to a public health specialist for a consultation.

The electronic consults are streamlining referrals and helping clinic doctors make better treatment choices, said Louise McCarthy, executive director of the Community Clinic Assn. of Los Angeles County.

During an August visit to T.H.E. Clinic, Lawrence saw nurse practitioner Sandeep Lehil for the first time. He told her he was controlling his diabetes with medication and a modified diet. But his vision wasn’t getting any better.

“My eyes are really bad,” he told Lehil. “I can barely see.”

Lawrence’s medical record showed that he wouldn’t be seeing an ophthalmologist for many months.

“That’s a long time to live with blurry vision,” Lehil said.

“By that time, I’ll be blind maybe,” Lawrence responded.

Lawrence, who has a soft voice, an accent and a lanky frame, arrived in the U.S. nearly 20 years ago to pick apples, and overstayed his visa. He can’t work or drive, and he relies on others to cook meals to avoid burning himself. His immigration status prevents him from getting health insurance or unemployment benefits. He lives with a friend, spending most days listening to a television he can barely see. When the phone rings, he lifts it almost to his nose to see who is calling.

In mid-October, Lawrence was back at the clinic and saw a different, fill-in doctor who knew nothing about his situation, nor when his surgery would be scheduled. “You haven’t received any notice?” asked physician David Hwang. “No, not yet,” Lawrence answered, adding that he checks his mailbox every day.

De Leon, the referral clerk, later gave Lawrence unwelcome news: The wait to see an ophthalmologist at the county’s Harbor-UCLA Medical Center was still about a year. She said she was trying to get him an appointment elsewhere sooner.

Weeks later, Lawrence took matters into his own hands. With the help of a friend, he took three buses to reach the emergency room at Los Angeles County/USC Medical Center northeast of downtown. He waited several hours but finally saw an emergency room physician, who managed to get him an appointment the next day with an eye doctor.

“You have to do what you have to do,” Lawrence said.

At the medical center’s specialty clinic, ophthalmologist Simon Bababeygy told Lawrence his cataracts probably were caused by his diabetes, high blood pressure and high cholesterol.

He described the surgery he would perform, on one eye at a time. And he spoke the words Lawrence had been waiting for: He should be seeing much more clearly by the end of the year.

Preparing for the surgery, doctors got an abnormal result on a heart test. Now, Lawrence has to wait to see a county cardiologist before going back to Bababeygy to schedule the eye operation. He has no idea how long that could take.

“Every time, it’s something else,” he said. “My eyes are getting worse. And now it’s my heart.”

Times staff writer Anna Gorman reported aspects of this story while participating in the California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism.

Copyright © 2012, Los Angeles Times

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LA Times, December 13, 2012

Court Ruling Could Cut California Spending On Medi-Cal

A 9th Circuit appeals panel decides California can reduce its Medi-Cal reimbursements to doctors, pharmacies and others. Providers say the doctor shortage will worsen.

By Maura Dolan and Chris Megerian, Los Angeles Times

SAN FRANCISCO — In a potential windfall for the state, a federal appeals court decided unanimously Thursday that California may cut reimbursements to doctors, pharmacies and others who serve the poor under Medi-Cal.

A three-judge panel of the 9th Circuit U.S. Court of Appeals overturned injunctions blocking the state from implementing a 2011 law that slashed Medi-Cal reimbursements by 10%. Medi-Cal, a version of Medicaid, serves low-income Californians.

The ruling could make it harder to find doctors for as many as 2 million new patients who could become eligible for Medi-Cal under President Obama’s healthcare law — a possible 25% expansion of the program. California already provides one of the lowest rates of reimbursement in the nation for medical services to the poor, and there is a shortage of doctors to serve those patients.

Lynn S. Carman, an attorney for a group of pharmacies, said the decision would be costly for providers, worsen the doctor shortage and would be appealed.

“If this decision stands it will not only destroy the Medicaid program in California, but it will destroy the Obamacare program for millions of Americans who are now being shoved into the Medicaid program under the Affordable Care Act,” Carman said.

“They will not be able to obtain quality healthcare or access to services because providers cannot provide services at less than what it costs to furnish them,” Carman said.

The ruling could make it considerably easier for the state to close its budget gap.

The state is facing a $1.9-billion deficit next year, although Proposition 30’s temporary tax hike and an improving economy are projected to shift the state back into surpluses in the near future.

Medical providers said Thursday that the cutback should be lifted now that the state’s fiscal outlook has improved. The ruling can be applied retroactively to June 1, 2011.

“Now that the state has money, it would be like Scrooge for Gov. Brown not to pass a bill to eliminate at least the retroactivity part of it,” Carman said.

For the governor, Medi-Cal cuts could serve one policy aim at the expense of another.

Balancing the budget has been Brown’s first priority since taking office, and cutting healthcare — the state’s second-biggest cost after education — has been key to his fiscal goal.

But at the same time, he has wanted California to be out front in healthcare reform, and lead the country in efforts to put the federal law into place.

A spokesman for Gov. Brown released a statement Thursday that implied that Brown was inclined to put his budget priorities first, and was not likely to rescind the cuts.

“Today’s decision allows California to continue providing quality care for people on Medi-Cal while saving the state millions of dollars in unnecessary costs,” the spokesman wrote.

In a ruling written by Judge Stephen S. Trott, appointed by President Reagan, the panel said the lower court injunctions were unwarranted because the federal government had approved the cuts.

“Neither the State nor the federal government ‘promised, explicitly or implicitly,’ that provider reimbursement rates would never change,” Trott wrote.

California has estimated that the 10% cut to medical providers and pharmacies would save the state $50 million a month.

Medi-Cal typically covers families and disabled Californians. The federal law will extend its coverage to single, childless adults beginning in 2014.

The California Medical Assn., which joined dentists, pharmacists, medical suppliers and medical response companies in trying to block the cutbacks, urged Brown to repeal them.

Dr. Paul R. Phinney, president of the doctors’ association, said the cuts shrink the number of providers who could afford to serve both existing Medi-Cal patients and the new ones who could become eligible for coverage in 2014.

“We need to ensure that health insurance isn’t just an empty promise for these patients,” Phinney said.

According to the California HealthCare Foundation, Medi-Cal patients already have difficulty finding doctors.

A foundation study published in July 2010 said 25% of physicians provided care to 80% of Medi-Cal patients.

Although 90% of physicians told the foundation they were accepting new patients, only 57% said they were taking on new Medi-Cal patients.

Dr. Ted Mazer, a San Diego ear, nose and throat surgeon, said he had to stop taking fee-for-service Medi-Cal patients several years ago because the reimbursements didn’t cover his costs and Medi-Cal patients were inundating his practice.

“So few doctors will see Medi-Cal patients that I was seeing them from the Mexican border to Riverside County to Orange County,” said Mazer, an officer of the California Medical Assn. “The reimbursement costs are so poor they don’t even cover costs, let alone pay for the administrative hassle. I can only see so many until I go under.”

Chris Perrone, deputy director of the foundation, said Thursday’s ruling will make it harder to block rate cuts in the future.

“The hurdles for people who want to block these rate cuts are little higher,” said Perrone.

Dolan reported from San Francisco and Megerian from Sacramento.

Times staff writer Anna Gorman contributed to this report.

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Obama shields states cutting Medicaid doctor payments

Bipartisan attack on Medicaid, healthcare for low-income children, seniors and workers.
  • The GOP’s justly-hated Ryan Plan puts states’ Medicaid programs on an ice floe, because it caps federal payments to states regardless of states’ needs (“block-granting”), and also gives states the rights to cut their Medicaid programs in defiance of federal standards of of who must be eligible and what services must be covered. 
  • But Democrats have also attacked Medicaid, beginning with the Clinton administration, which granted states huge numbers of waivers to the federal requirements.  Now the Obama administration is shielding states that are cutting their Medicaid programs by saying Medicaid patients and doctors cannot sue states for reducing doctor payments, even if such cuts cause a reduction in the number of doctors serving Medicaid patients to the point where patients cannot access care.
  • California has among the lowest Medicaid payments to doctors and pharmacies in the nation, and among lowest Medicaid doctor-to-patient ratios in the country.  Doctors, pharmacies, and patient advocates, including San Francisco and Sacramento Gray Panthers, sued California in response to Schwarzenegger’s 10% cuts to Medi-Cal.  Brown’s budget includes and additional 10% cut.  The suit has worked its way up to the Supreme Court, and it is this context that the Obama administration has submitted a brief saying states cannot be sued for cutting their Medicaid programs.
  • Democrats and Republicans are unified in their determination to cut our programs.  Medicare and Medicaid were won in the in the streets in the 1960s, and that is where they must be defended now.

By Robert Pear

WASHINGTON — Medicaid recipients and health care providers cannot sue state officials to challenge cuts in Medicaid payments, even if such cuts compromise access to health care for poor people, the Obama administration has told the Supreme Court.

States around the country, faced with severe budget problems, have been reducing Medicaid rates for doctors, dentists, hospitals, pharmacies, nursing homes and other providers.

Federal law says Medicaid rates must be “sufficient to enlist enough providers” so that Medicaid recipients have access to care to the same extent as the general population in an area.

In a friend-of-the court brief filed Thursday in the Supreme Court, the Justice Department said that no federal law allowed private individuals to sue states to enforce this standard.

Such lawsuits “would not be compatible” with the means of enforcement envisioned by Congress, which relies on the secretary of health and human services to make sure states comply, the administration said in the brief, by the acting solicitor general, Neal K. Katyal.

In many parts of the country, payment rates are so low that Medicaid recipients have difficulty finding doctors to take them.

But, the Justice Department said, the Medicaid law’s promise of equal access to care is “broad and nonspecific,” and federal health officials are better equipped than judges to balance that goal with other policy objectives, like holding down costs.

The administration expressed its views in a set of cases consolidated under the name Douglas v. Independent Living Center of Southern California, No. 09-958.

In 2008 and 2009, the California Legislature passed several laws reducing Medicaid payment rates. Recipients and providers challenged the cuts in court, arguing that the California plan violated — and was pre-empted by — the federal Medicaid statute.

The law does not explicitly allow such lawsuits. But the United States Court of Appeals for the Ninth Circuit, in San Francisco, said beneficiaries and providers could sue under the supremacy clause of the Constitution, which makes federal law “the supreme law of the land.” In reducing payment rates, the appeals court said, California violated the requirements of federal Medicaid law and threatened access to “much-needed medical care.”

California appealed to the Supreme Court, which is likely to hear oral arguments in the fall, with a decision by next spring.

Consumer advocates were dismayed by the administration’s position, which they said undermined Medicaid recipients’ rights and access to the courts.

“I find it appalling that the solicitor general in a Democratic administration would assert in a Supreme Court brief that businesses can challenge state regulation under the supremacy clause, but that poor recipients of Medicaid cannot challenge state violations of federal law,” said Prof. Timothy S. Jost, an expert on health law at Washington and Lee University, who is usually sympathetic to the administration.

Representative Henry A. Waxman of California, the senior Democrat on the Energy and Commerce Committee and an architect of Medicaid, said the administration’s brief was “wrong on the law and bad policy.”

“I am bitterly disappointed that President Obama would accept the position of the acting solicitor general to file a brief that is contrary to the decades-long practice of giving Medicaid beneficiaries and providers the ability to turn to the courts to enforce their rights under federal law,” Mr. Waxman said. He said that he and other Democratic lawmakers planned to file a brief opposing the administration’s view.

By contrast, many state officials agree with California and the Obama administration.

The National Governors Association and the National Conference of State Legislatures filed a friend-of-the-court brief endorsing California’s position that Medicaid recipients and providers could not sue.

In a separate friend-of-the-court brief, Michigan and 30 other states went further. “Allowing ‘supremacy clause lawsuits’ to enforce federal Medicaid laws will be a financial catastrophe for states,” they said.

Medicaid is financed jointly by the federal government and the states. The number of recipients and the costs increased sharply in the recent recession and will increase further with the expected addition of 16 million people to the rolls under the new federal health care law.

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Shortages of key drugs endanger patients. Free market to blame.

“Doctors, hospitals and federal regulators are struggling to cope with an unprecedented surge in drug shortages in the United States that is endangering cancer patients, heart attack victims, accident survivors and a host of other ill people.”  … The causes vary from drug to drug, but experts cite a confluence of factors: Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.”

This is a perfect illustration of why the research, development, ownership and production of medicines must not be left in the hands of private businesses.  Drugs must be researched and produced according to our needs, not profit opportunities. Private companies must not be allowed to own patents on drugs. Despite spectacular advances in research techniques, companies’ profit-driven research has produced few significant advances.  It is virtually impossible to oversee private manufacture of medicines, and companies regard fines in response to tragic “accidents” as a cost of doing business.

Washington Post, Sunday, May 1, 2011

Shortages of key drugs endanger patients

By Rob Stein

Doctors, hospitals and federal regulators are struggling to cope with an unprecedented surge in drug shortages in the United States that is endangering cancer patients, heart attack victims, accident survivors and a host of other ill people.

A record 211 medications became scarce in 2010 — triple the number in 2006 — and at least 89 new shortages have been recorded through the end of March, putting the nation on track for far more scarcities.

The paucities are forcing some medical centers to ration drugs — including one urgently needed by leukemia patients — postpone surgeries and other care, and scramble for substitutes, often resorting to alternatives that may be less effective, have more side effects and boost the risk for overdoses and other sometimes-fatal errors.

“It’s a crisis,” said Erin R. Fox, manager of the drug information service at the University of Utah, who monitors drug shortages for the American Society of Health-System Pharmacists. “Patients are at risk.”

The causes vary from drug to drug, but experts cite a confluence of factors: Consolidation in the pharmaceutical industry has left only a few manufacturers for many older, less profitable products, meaning that when raw material runs short, equipment breaks down or government regulators crack down, the snags can quickly spiral into shortages.

“It seems like there were a lot of things happening with consolidations and quality issues and more things coming from overseas,” said Allen J. Vaida, executive director of the Institute for Safe Medicine Practices, a nonprofit group that helped organize a conference last fall to examine the issue. “It just reached a point where the number of shortages was slowly going up and up, and now we have a national crisis with this huge shortage of critical medications.”

While the dearth that has garnered the most public attention is — ironically — for a barbiturate that is hindering prisons trying to execute inmates, the scarcities are having a much broader impact on keeping people alive, especially in emergency rooms, oncology wards and intensive care units.

No one is systematically tracking the toll of the shortages, but reports are emerging of delayed treatments, anxious searches for desperately needed drugs, devastating injuries from mistakes and less-adequate drugs, and even possible deaths.

Federal regulators have been rushing to alleviate the shortages, sometimes helping firms resume production more quickly or approving emergency imports of supplies from overseas.

The Food and Drug Administration eased a shortage of the anesthetic propofol last year by allowing foreign importation, for example, and this year approved bringing in several other medications, including two cancer drugs.

“The types of products we’re seeing shortages of are really concerning,” said Valerie Jensen, who heads the FDA’s Drug Shortages Program. “This is affecting oncology drugs, critical-care drugs, emergency medicine drugs. We’re doing everything we can under our current authority to try to deal with this situation.”

In Congress, legislation has been introduced to address the problem. For example, a bill would require companies to notify the FDA in advance about anything that might cause a shortage and give the agency new powers to try to assuage them.

“We can’t put patients’ lives at risk simply because there’s some snafus in a process or a manufacturer decides it’s less profitable to make a certain drug,” said Sen. Amy Klobuchar (D-Minn.). “Patients deserve better than that.”

‘Very global supply chain’

Many of the shortages involve older, cheaper generic medications that are less profitable, causing many firms to stop producing them and leaving fewer sources. Most involve “sterile injectable” medications that are more complicated to produce and therefore are more prone to manufacturing problems.

In addition, drug companies increasingly rely on raw materials from other countries.

“We’ve certainly reached a very global supply chain for drug products, with the active ingredients typically made outside of the United States,” said Gordon Johnston, vice president for regulatory sciences at the Generic Pharmaceutical Association. “It could be Europe, India — some cases China. If there’s a problem at a facility in Italy or India, it leads to disruption of the drug supply in the United States.”

Some industry representatives blame part of the problem on increased oversight by the FDA, which has made drug safety a higher priority after coming under intense criticism for being too lax.

“As you know right now, FDA has taken a heightened approach towards drug safety,” said Maya Bermingham, senior assistant general counsel at the Pharmaceutical Research and Manufacturers of America. “FDA has stepped up inspections. The more you look, the more you may discover problems.”

While acknowledging that the industry needs to do a better job of coordination, some company officials said the agency should coordinate enforcement actions and drug shortage issues more closely to avoid administrative requirements that cause interruptions.

“We’re not sure how much of that is going on recently because we’ve seen more and more shortages in the industry. We think that maybe some of those coordination issues can be worked on,” said Joshua Gordon, vice president and general manager of specialty pharmaceuticals at Hospira, the largest producer of specialty generic sterile injectables.

Shortages of pre-loaded epinephrine syringes and propofol, for example, occurred when suppliers dropped out just as the FDA was demanding additional documentation, he said.

“They are very focused on taking quick and and aggressive action,” Gordon said. “We applaud the agency’s role in assuring quality, but it can slow things down significantly.”

FDA officials dispute that greater government oversight is a major factor, saying manufacturing problems were the cause of most shortages.

“There has not been a significant increase in domestic enforcement actions (seizure or injunction) for this class of products in recent years,” Jensen wrote in an e-mail.

‘Too many . . . will die’

Whatever the causes, many of the affected drugs are mainstays of medical care, such as the potent painkiller morphine, norepinephrine, which is commonly used in emergency rooms, and electrolytes, which are often given to patients in intensive care.

But shortages have been reported in many categories of drugs, including antibiotics, and drugs central to the treatment of many cancers, forcing oncologists to delay or alter carefully timed chemotherapy regimens.

“We have heard some horror stories where patients are really begging to get the drugs from other sources and where practices or institutions are forced to kind of triage patients and save the drugs for those — quote — most curable, where they have the best prognosis and using substitutes where there isn’t a cure possibility,” Michael Link, president-elect of the American Society of Clinical Oncology.

The drug cytarabine has caused the most concern and gotten the most attention because it is highly effective for treating several forms of leukemia and lymphoma but must be administered as quickly as possible, especially to patients with acute myeloid leukemia.

“With this drug they can be cured and without this drug too many of them will certainly die. That’s the simplest way to put it,” said Deborah Banker, vice president for research communication at the Leukemia & Lymphoma Society. “The disease progresses so rapidly that untreated patients can sadly die within days. There is no time for delay and no certainty of a good outcome if you can’t get a full dose.”

Many hospitals are running low, and some have run out completely. That has required many facilities to ration the drug, giving priority to those who need it most urgently.

“It’s so unbelievable,” said Mary Collins, 57, of La Crosse, Wis., whose husband, Michael, 66, had problems obtaining cytarabine to fight lymphoma. “A cancer diagnosis is a long, very, very stressful circumstance. And then to learn that a particular drug is no longer available to you and that there seems to be no formalized mechanism in place to correct it just makes it worse.”

Cytarabine’s scarcity was caused by hitches that two out of the three manufacturers hit in obtaining raw materials, as well as the discovery of crystals in some shipments.

The third manufacturer was unable to make up for the shortfall. Some of the problems have been resolved, however, and the FDA is working on importing the drug.

The shortages are forcing hospital pharmacists to juggle supplies and hunt for new sources. Many hospitals, including several contacted in the Washington area, say they are usually able to patch together solutions.

But some resort to paying inflated prices or buying from unfamiliar suppliers, increasing the risk they may be getting counterfeits.

“When it becomes clear that some drug may be in short supply or going into a shortage, what happens is sometimes there are unsavory folks — small distributors — who buy up whatever is left and sell it back at exorbitant prices,” said Roslyne Shulman, director of policy development for the American Hospital Association.

‘Panic in the pharmacy’

When shortages occur, physicians turn to less optimal alternatives or find out too late that the drug they need is unavailable. Mark Warner, president of the American Society of Anesthesiologists, described two calamities that occurred in the past year because of shortages. In one, a 16-year-old boy suffered brain damage because doctors did not have one muscle relaxer needed to treat a complication from jaw surgery.

In another, a middle-aged woman was left in a permanent vegetative state because doctors did not have the drug epinephrine after she experienced complications from heart surgery.

“These are tragic cases,” Warner said. “It’s one of those things most anesthesiologists in the country think about when they are driving to work every day. We don’t know where the shortages are and they come on very quickly. ”

Nurses and doctors responding to emergencies, meanwhile, are losing precious minutes when they must work with unfamiliar substitutes or recalculate dosages, increasing the chances of overdosing or under-dosing patients. One of the biggest problems is a shortage of syringes pre-filled with precisely measured doses.

“Grabbing the right medication out of a crash cart that’s already in a syringe is a big advantage over having to get out the syringe, get out the needle, get the medication and get the measurement right,” said Angela Gardner, an emergency medicine physician at the University of Texas Southwestern Medical Center in Dallas and immediate past president of the American College of Emergency Physicians. “Those minutes are lives.”

Many hospitals are recalibrating electronic medication delivery systems or preparing the correct doses ahead of time, especially for the emergency room, to minimize mistakes.

“We’ve been extremely fortunate using strategies in cooperation with our medical staff,” said Jay Barbaccia, head pharmacist at the Washington Hospital Center. “We’ve had a lot of panic and inconvenience but minimal, if any, impact on our ability to provide care. It makes my life miserable — the panic is in the pharmacy when we’re scrambling around to find alternatives.”

Nevertheless, a long list of errors and near-misses have been reported, including incidents in which patients required emergency care to save them.

At least two patients reportedly died from overdoses of hydromorphone they received because of a morphine shortage.

At least 19 patients were sickened and nine died in Alabama this year after being infused with a solution through their feeding tubes that was apparently contaminated with bacteria by a pharmacy using an unfamiliar ingredient because of a shortage.

The shortage occurred because the manufacturer had trouble getting the product’s packaging.

“It’s horrible. It’s something that shouldn’t have happened,” said Donald J. Mottern of Alabaster, Ala., whose 71-year-old mother was one of the victims. “We lost the matriarch of our family. The loss to our family has left each of us very hollow.”

© 2011 The Washington Post Company

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Damage Already Done by California’s 2009 Healthcuts

As California’s Governor Schwarzenegger proposes a 2010-2011 budget with more disastrous health and human service cuts , Health Access looks at the effects of the 2009-2010 cuts.

Health Acess, January 7, 2010

The Damage Already Done

Executive Summary

Six months after major health care cuts were made to the 2009-2010 budget, and despite major efforts to prevent or delay the impacts, the ramifications are rippling through California’s families, economy, and the health system on which we all rely.

Since the Governor signed the budget in July 2009 slashing $2 billion from the health care system, some cuts have been partially averted through various actions. The delay and uncertainty, however, has created serious problems, and combined with the cases where the cuts were actually made, there have been very real human hardships and economic impacts for Californians. Some of these impacts include:

  • Almost three million low-income adults have lost ten important benefits, such as dental care, vision care, speech therapy, and psychological services – in the last six months, over 450,000 Californians in poverty have either had to forego or pay for dental care and another 240,000 have lost coverage for prescriptions eyeglasses; (See demonstration against these cuts)
  • About 93,000 children waited uninsured for Healthy Families coverage until the cut was averted by non-government donations and higher cost sharing for 269,000 children on the program;
  • At least five community clinics in the state have already been forced to shut down and hundreds of workers have been laid off, plus another 10 clinics are on the brink of closure;
  • Thousands of HIV/AIDS patients have been denied access to needed services and affordable medications they rely on;
  • About 300,000 low-income women no longer have access to life-saving breast cancer screenings;
  • Over 300,000 school children have missed an educational opportunity to learn proper dental care and positive life-long oral habits;
  • Programs focusing on prevention and prenatal care have been forced to significantly scale back or are closing altogether; and
  • Six domestic violence shelters were temporarily closed while the Legislature passed a bill to find ways to keep shelters open, and even afterwards, most have been forced to reduce services;

With only six months into the budget year, it is too soon to present statewide comprehensive data about the full scope of the damage of the cuts. However, based on a review of available records and interviews with providers, program directors, health care advocates, and patients throughout the state, this report is a first step in quantifying the damage of the decisions made to cut the health care budget in the 2009-10 fiscal year.

These budget cuts were choices that could have been averted if California policymakers decided to prioritize differently and, for example, raise revenues and/or taxes as an alternative to making such drastic cuts. As California policymakers begin to debate additional cuts in 2010, this report shows the damage already done by making certain choices about the budget.

Read the entire report (PDF)

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Schwarzenegger threatens to eliminate IHSS if he’s not given complete freedom to slash programs

“The Governor in his letter specifically cited recent federal court decisions that has blocked the State from implementing budget reductions impacting the State’s contribution (participation) toward IHSS worker wages; blocked a 10% reduction in reimbursements to foster family agency providers, blocked a 10% and 5% reduction for most Medi-Cal providers; stopped a reduction in the number of days Adult Health Care Centers could provide services; stopped major reduction in elgibility and services  based on a little known assessment tool (called the functional index scores and rankings) that would have eliminated or reduced services to over 130,000 children and adults in the IHSS program. The federal courts have said those reductions that the State wanted to make in order to close a budget gap of over $60 billion, violated federal law.

San Francisco and Sacramento Gray Panthers were among the plaintiffs in the successful suits against reductions to Medi-Cal providers.  Schwarzenegger has refused to consider single-payer healthcare, which could eliminate billions of state healthcare expenses.  He has also refused any serious attempts to raise revenue from corporations or rich Californians who could afford to pay the revenue the state needs to provide needed services in health, welfare, education, housing,  and many other vital services.

CDCAN Report, #326-2009, December 22, 2009

State Budget Crisis:



SACRAMENTO, CALIF (CDCAN) [Updated 12/22/09 07:50 PM  (Pacific Time)]  – Citing an increasing heavy burden of costs imposed on the states at a time when most are experiencing enormous budget shortfalls, Governor Arnold Schwarzenegger early this evening released a letter addressed to House Speaker Nancy Pelosi (Democrat – San Francisco) urging that Congress not impose increased Medicaid program costs on states through new unfunded federal requirements (mandates) and allow states the flexibility to reduce reimbursement rates and benefits to recipients, in the pending health care reform bills.  The Governor said in his letter that the latest health care reform bills would increase California’s unfunded mandate costs through new Medicaid and other health requirements by over $3 billion, adding to the state’s budget woes.

But the Governor also mentioned in his letter what will likely be an politically explosive proposals of the possible elimination of the entire In-Home Supportive Services (IHSS) program that provides in-home supports and services to over 462,000 children and adults with disabilities (including developmental), mental health needs, the blind, persons with traumatic brain and other injuries, low income seniors.

The Governor, in his letter that also went to all members of California’s congressional delegation, said that the combination of recent court decisions blocking many of the state budget cuts to Medicaid funded services including and lack of “flexibility” in current federal Medicaid rules to allow the states to reduce services or provider reimbursement rates when necessary, will mean that “California is now faced with a decision to eliminate the entire IHSS program”

The Governor did not firmly say that the proposed elimination of the entire IHSS program would be in his proposed 2010-2011 State Budget, expected to be releasd January 8, 2010 – but today’s letter was the strongest indication that it would be.

Any such proposal however would require approval by both the Assembly and State Senate – and advocates and advocacy organizations, representing disability, mental health, the blind, low income seniors, IHSS workers are certain to  raise major protests to have such a proposal rejected immediately.

Both houses of the Legislature are in recess and are not scheduled to return to the State Capitol to begin the 2010 legislative session until Monday, January 4.

Governor Says Health Reform Bill Must Give States “Flexibility”

The Governor, in his letter to Pelosi, wrote that  “…For health care reform to succeed, Congress must first and foremost give states the flexibility to meet our current obligations within the revenues available to states…Congress must either let states reduce their costs to live within limited resources or treat states equally by fully funding all Medicaid populations above a certain eligibility level…”

The Governor said in his letter that “Congress has a chance to make history with this legislation,” but that  “the current structure and the proposed expansion of Medicaid under health care reform are unsustainable for California. Governors in every part of the country have raised similar concerns. “

He said that “California stands ready to help achieve successful health care reform, and I look forward to continuing to work with you as the final comprehensive bill is negotiated in Congress”.

Congress is expected to take final action on a reform package sometime early next year – but the Governor stressed in his letter to Speaker Pelosi that the reform effort “…will only succeed if Congress gives states, like California, the flexibility to meet current obligations within the revenues available to states.”

Governor Says Court Decisions and Federal Rules Hampering Efforts To Control Costs

The Governor in his letter specifically cited recent federal court decisions that has blocked the State from implementing budget reductions impacting the State’s contribution (participation) toward IHSS worker wages; blocked a 10% reduction in reimbursements to foster family agency providers, blocked a 10% and 5% reduction for most Medi-Cal providers; stopped a reduction in the number of days Adult Health Care Centers could provide services; stopped major reduction in elgibility and services  based on a little known assessment tool (called the functional index scores and rankings) that would have eliminated or reduced services to over 130,000 children and adults in the IHSS program.

The federal courts have said those reductions that the State wanted to make in order to close a budget gap of over $60 billion, violated federal law.

The Governor said those lawsuits, and also what he termed lack of “flexibility” in federal Medicaid laws that make it difficult for the states to make changes or reductions in services and eligibility and provider reimbursements will have serious consequences on the state’s Medi-Cal program and related services in the coming year.

The Governor in his letter wrote that “Ironically, while federal courts have ruled that California cannot reduce provider rates for optional benefits such as dental services or IHSS, they have ruled that completely eliminating those same optional benefits is perfectly legal. Adult dental was eliminated as part of our effort to close a $62 billion budget gap earlier this year.”

The Governor noted that “If states had more flexibility to reduce rates and benefits under Medicaid rules, we might have been able to save a portion of that program. Similarly, we reduced services to specified populations in our In-Home Supportive Services program, but federal court decisions have prevented those reductions from occurring.” and warned that “ California is now faced with a decision to eliminate the entire IHSS program.”


December 22, 2009

The Honorable Nancy Pelosi

Speaker of the House

U.S. House of Representatives

Washington, DC 20515

Dear Madam Speaker,

As one of the few governors in the nation who attempted to pass comprehensive health care reform at the state level, I have great appreciation for the historic effort you are leading in Congress.  In fact, I am one of the only Republican elected officials in the country to publicly support the President’s health care reform efforts.

When asked for my support, I was assured that federal legislation would not increase costs to California or include new unfunded mandates. Unfortunately, under nearly every scenario we can predict, the federal health care reform legislation being debated would cost California’s General Fund an additional $3 billion to $4 billion annually. This crushing new burden will be added to a safety net that is already shredding under billions of dollars in unfunded federal mandates that we are struggling to meet. Medicaid is a partnership program between the federal government and the states. As the partner responsible for implementing this program, I am telling you that our Medicaid program is already at the breaking point, and if federal health care reform is passed without addressing the underlying faults in the system, health care reform will fail.

Let me be clear: I continue to support federal health care reform and believe that the current reform efforts could provide a historic achievement that will benefit all Americans. However, if Congress fails to address the existing unfunded mandates and adds yet another layer, federal health care reform could collapse the very safety net system it seeks to expand.

For health care reform to succeed, Congress must first and foremost give states the flexibility to meet our current obligations within the revenues available to states.

Giving California Flexibility to Manage Its Current Medicaid Budget

Under federal rules, California is locked into eligibility standards and benefit levels that are far more expansive and costly than other states’. For instance, Texas’s Medicaid program covers parents with incomes up to 27 percent of the Federal Poverty Level (FPL); Pennsylvania covers those earning up to 34 percent of FPL and Florida up to 53 percent. California has expanded coverage over the years and now covers parents with incomes up to 106 percent of FPL. Federal rules for accepting American Reinvestment and Renewal Act funding prevent California from rolling back eligibility to 70 percent of the FPL to adjust our budget for lower revenues during the recession. Reducing eligibility to 70 percent of FPL in California would save more than $500 million General Fund dollars and would still cover more people than many other states.

Federal rules actually punish California twice for expanding our safety net. First, maintenance of effort rules prevent us from targeting limited resources toward the neediest populations as described above. Second, under health care reform, the federal government will shoulder almost the entire cost for states like Texas to expand their coverage from 27 percent of FPL up to whatever the federal mandated coverage level is, while California must continue to pay half the cost for populations below 106 percent. Thus, states that made little or no effort to expand coverage to low-income families are rewarded with either 82 percent or 91 percent federal funding, and states that did expand coverage, like California, are punished with costs that other states never incurred. Congress must either let states reduce their costs to live within limited resources or treat states equally by fully funding all Medicaid populations above a certain eligibility level.

Federal Medicaid rules also restrict California’s ability to modify its program to reduce costs by reducing provider rates, establishing utilization controls on benefits and requiring greater financial participation by Medicaid recipients. Once again, California has over the years expanded services beyond those offered by other states including In-Home Supportive Services (IHSS), adult day health care, adult dental, pharmacy, hospice, family planning, medical supplies and so on.  Over the past two years, California has reduced spending in virtually every program area, and, in more than a dozen lawsuits filed in federal court, judges have enjoined nearly every effort to reduce rates, modify optional benefits or limit eligibility. In these lawsuits, federal judges cite Medicaid rules requiring studies on the impact of those reductions on the communities served. The cumulative impact of these federal lawsuits contributes more than $1.4 billion toward our current year deficit alone.  Should the state fail to ultimately win these legal challenges, the impact on future budgets will be in the billions. Congress must authorize states to reduce costs by lowering provider rates, limiting benefits and increasing co-pays as needed to live within limited resources.

Treat States Equally in Medicaid Reimbursement Rates

The Federal Medical Assistance Percentage (FMAP), the formula that determines federal reimbursement rates for states in the Medicaid program, is flawed and forces California to subsidize the Medicaid costs of other states. The current formula relies on per capita income over other indices, particularly poverty rates. California’s relatively small number of high wage earners distorts our per capita income, masking the large number of low-income individuals we cover in Medicaid.  This flawed formula results in California receiving the lowest possible Medicaid reimbursement rate in the country.  In a 2003 U.S. Government Accountability Office report titled “Differences in Funding Ability among States Often are Widened,” California was specifically called out as one of three states in the nation with one of the largest populations in poverty, while ranking 49th in per-capita costs (the second leanest Medicaid program in the U.S.). Other large states have much higher reimbursement rates: Florida receives 56.83 percent; Michigan 58.10 percent; Ohio 60.79 percent; Pennsylvania 54.08 percent; Texas 60.53 percent. The bottom line is that this flawed FMAP formula is forcing California to subsidize Medicaid costs in other states. If California received an FMAP rate equal to the average of the 10 largest states, it would be 57 percent – a difference of $2.2 billion.

Fixing the flawed FMAP rate is even more urgent in the context of national health reform. If this flawed methodology is locked into the federal health reform bill, it will be impossible for California to meet the mandatory Medicaid expansion anticipated in either the House or Senate legislation.

Enhanced Federal Matching Rates for Providers Must Extend Beyond Primary Care

Both federal health reform proposals require states to expand Medicaid to new populations. For California, that means adding almost two million people to the program.  California will need to increase provider rates significantly in order to attract and retain providers willing to serve Medi-Cal patients.

This is not a theoretical problem. In 1990, a federal district court held that California’s Medi-Cal reimbursement rates for certain services were so low that they violated the equal access provision of the Medicaid Act, which requires states to set reimbursement rates at a level sufficient to enlist enough providers so that services are available equally to recipients and to the insured general population.  California lost its appeals in that case, and the judge ordered the state’s Department of Health Services to raise the rate to 80 percent of average billing. This decision dramatically affected dental rates and increased California’s dental expenditures from $167 million in 1990 to more than $800 million in 1995 – more than a four-fold increase. In large part due to California’s lower-than-average FMAP rate, our state has been forced to reduce other provider rates even further to balance our budget.

Ironically, while federal courts have ruled that California cannot reduce provider rates for optional benefits such as dental services or IHSS, they have ruled that completely eliminating those same optional benefits is perfectly legal. Adult dental was eliminated as part of our effort to close a $62 billion budget gap earlier this year. If states had more flexibility to reduce rates and benefits under Medicaid rules, we might have been able to save a portion of that program. Similarly, we reduced services to specified populations in our In-Home Supportive Services program, but federal court decisions have prevented those reductions from occurring. California is now faced with a decision to eliminate the entire IHSS program.

While some argue that California’s low provider rates are self-inflicted, the fact is that if California was not subsidizing other states through a notoriously flawed FMAP rate at a loss of more than $2.2 billion, we would have the resources to increase our Medi-Cal rates to more reasonable levels.

The House version of federal health reform does provide enhanced federal funding match for Medicaid provider rate, but it must be expanded to all provider groups providing outpatient services, not just primary care.  Without addressing the flawed FMAP rate or adequately funding an increase in provider rates, the mandated expansion of Medicaid coverage becomes an empty promise to millions of individuals as well as an unfunded mandate for California of more than $3 billion.

Paying California Funds it is Owed

Before adding new responsibilities on states to expand Medicaid coverage, the federal government should reimburse the amount that it owes states for past errors with other safety net programs. For example, California has paid for individuals in Medi-Cal while they awaited their Medicare disability determination. This error by the Social Security Administration was acknowledged in 2001. States have never been paid back. The amount owed to California on this issue alone is nearly $700 million.

Comprehensive health care reform is essential and long overdue.  As I wrote in October, I believe that the elements of successful reform have been proposed in one form or another by Congress, but additional work is required to ensure the reform package contains the necessary balance to ensure success.  Congress has a chance to make history with this legislation.  The current structure and the proposed expansion of Medicaid under health care reform are unsustainable for California. Governors in every part of the country have raised similar concerns.  California stands ready to help achieve successful health care reform, and I look forward to continuing to work with you as the final comprehensive bill is negotiated in Congress.


Arnold Schwarzenegger

/cc:   Members of the California Congressional Delegation

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Appeals Court accuses California State lawyers of deception to ram through Medi-Cal cuts.

San Francisco and Sacramento Gray Panthers are plaintiffs in this suit against the State of California for cutting its payments to Medi-Cal doctors, dentists, pharmacists, clinics, and adult day health centers, even though California’s payments to these providers and the ratio of providers to patients are among the lowest in the country.  It is already difficult for Medi-Cal patients to find doctors, yet the California was willing to go to the US Supreme Court to cut its payments by 10% and make the situation even worse.  Now the State has been caught in deceptive practices in the courtroom.  Read more about this case from CDCAN, the California Disability Community Action Network, and here.

San Francisco Chronicle, December 22, 2009

Court accuses state lawyers of lying

Bob Egelko, Chronicle Staff Writer

(12-21) 17:58 PST SAN FRANCISCO — A federal appeals court bluntly accused the Schwarzenegger administration and state Attorney General Jerry Brown’s office on Monday of lying about its defense of cuts in Medi-Cal fees.

Lawyers in Brown’s office committed a “clear violation” of State Bar rules that prohibit attorneys from misleading judges, raising doubts about the credibility of any future statements they make on behalf of state health officials, said the Ninth U.S. Circuit Court of Appeals in San Francisco.

The court said health officials, through their lawyers, had lied about why the state waited more than a year to make its current arguments in the case.

Brown’s office said the court’s comments were “based on a misunderstanding” that the state’s lawyers will try to clear up in the next few days.

In July, the court ruled that the state had violated federal law with 2008 legislation that cut by 10 percent the rates it paid to doctors, dentists, pharmacists, clinics and adult day health care centers serving 7.1 million poor people in the Medi-Cal program.

The ruling required the state to reimburse health care providers hundreds of millions of dollars that the state cut from their fees from July 2008 to March 2009, when a new law took effect setting rates at 1 to 5 percent below July 2008 levels.

The court said state health officials and legislators were simply trying to save money and did not study how the cuts would affect Medi-Cal patients, as federal law requires.

On Monday, the same three-judge panel rejected the state’s claim that the court lacked authority to prohibit the 10 percent rate cuts in July because the law requiring those cuts had expired March 1. The court said it still could order reimbursement, which the state has yet to pay.

The allegations of lying involved the state’s failure to cite the change in reimbursement rates in arguments before the appeals court issued its July ruling. The court noted that the modified reductions were approved in September 2008 and took effect in March, but the state did not mention that fact, or argue that it was important, until its recent appeal that sought to set the July decision aside.

State officials explained that their lawyers became aware of the legal issue only recently while preparing a potential U.S. Supreme Court appeal, the court said Monday.

In fact, the panel said, the state had already filed Supreme Court papers June 1, in an earlier Medi-Cal case, that discussed the latest change in rates and how it affected the appeals court’s jurisdiction over the issue.

Health officials “feigned ignorance” of the facts they had already presented to the Supreme Court, the appeals court said. Citing State Bar rules that forbid attorneys to mislead judges by making false statements, the court said state lawyers’ “clear violation … gives us pause about accepting the veracity of future pleadings filed by the attorney general on behalf of the (state health) director, if not more generally.”

In response, Brown’s office said it had not tried to hide the March rate change, which was well known to all sides in the case. Instead, the attorney general said, the state focused only recently on an argument that the change deprived the court of jurisdiction over the case.

The argument was made “entirely in good faith,” the attorney general’s office said in a statement. The office promised a filing in the next few days that would clear up the confusion.

But a lawyer for plaintiffs in the case said the court was on the mark.

Brown’s Los Angeles office, which handled the appeal, “has consistently lied and misrepresented statements of fact and law throughout the litigation,” said Lynn Carman, attorney for a group of pharmacists. “It is gratifying that the Ninth Circuit has now called a spade a spade.”

E-mail Bob Egelko at

This article appeared on page C – 1 of the San Francisco Chronicle

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Commissions and Feinstein: The Next Threats to Medicare and Social Security

Upcoming issue of CARA (California Alliance for Retired Americans) Alert

Commissions and Feinstein: The Next Threats to Medicare and Social Security

By Michael Lyon

Four years after Bush tried to privatize Social Security and cut its benefits, there is new clamor to restructure Medicare and Social Security and to cut their future costs. This time it is led by Democrats, and California Senator Dianne Feinstein is in the thick of it.  These lawmakers want to slash the healthcare and income of seniors and people with disabilities to pay for the war in Afghanistan and for the insurance and drug company bailouts that pass for health reform. Forcing through these cuts involves huge concentration of government power, and overturns decades of budget principles to guarantee benefits for retired and poor people.

Feinstein and Texas Republican Cornyn are promoting their bill, S.276, calling for a “National Commission on Entitlement Solvency.” Almost half of Feinstein’s Commission would be Presidential appointees and the rest are leaders of House and Senate Committees on revenue and spending. Each grouping has equal numbers of Democrats and Republicans, so neither party has to accept blame for the cuts. For a year, the Commission would hold town hall meetings on fiscal responsibility across the nation, and would then propose sweeping laws cutting Medicare and Social Security, which would be fast-tracked through Congress. The Commission would be permanent, and would submit new fast-tracked legislative packages to Congress every five years.

Congress has several more bills to reduce Medicare, Social Security, and Medicaid.  A House bill, HR 1557, with nearly 70 co-sponsors, proposes a “Securing America’s Future Economy Commission,” to restructure Medicare and Social Security as well as the tax system. There is a Senate equivalent, S. 1056. (PDF, p. 5, part of a lengthy discussion of Commissions) In the Senate, Budget Committee leaders Kent Conrad and Judd Gregg are demanding a “Bipartisan Task Force for Responsible Fiscal Action” with powers to “improve the long-term fiscal balance of the Federal Government, including the fiscal balance of Social Security and Medicare.” Over a dozen Democrats, including Feinstein, threatened to bring government to a halt by refusing to raise the national debt limit unless their Task Force was formed.    Like Feinstein’s Commission, these groups would be bipartisan, would include House and Senate finance committee leaders, and would have their recommendations fast-tracked through Congress, in some cases with no amendments allowed.

These Commissions are set up to be powerful and independent for a reason.  For decades, Medicare, Social Security, and Medicaid benefits have been guaranteed by having their funding increase automatically as the number of recipients increases. Both Democratic and Republican lawmakers have wanted to eliminate this protection for years, but they are pressing harder as millions of baby-boomers prepare to retire and deficits mount from oil wars, tax cuts, bank bailouts, and giveaways to health insurance and drug companies.

CARA fought against Feinstein’s earlier Commission bill, S 355, in early 2007, and it is now deadA new national coalition, including the Alliance for Retired Americans has formed to protect Medicare and Social Security, and we will have an important role in California.   We have worked all our lives. We deserve and demand healthcare and a living income!

Also see the video “William Greider on the Looting of Social Security” and Greider’s more extensive article in The NationLooting Social Security.”    (Thanks to Dandelion Salad.)

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