Health care in California is a mosaic of federal, state, and local government services, in addition to those funded by employers and, rarely, by individuals.
It is also by far the single largest component of California’s $ 3.4 trillion economy with more than 2 million workers and at least $ 450 billion in spending from all sources, an average of more than $ 11,000 for California.
Virtually every facet of the system is subject to some form of government oversight, not surprisingly, as the federal government pays half the costs, and state and local governments enter another 30%.
Given the large amounts of money involved in health care and its impact on the lives of nearly 40 million Californians, it’s also not surprising that it draws the huge attention of California’s 120 lawmakers.
It should come as a surprise, however, that these legislators, only a handful of whom have direct professional medical training and experience, exercise close control over who can perform what medical procedures in any part of the human anatomy.
They do so more directly by defining the “scope of practice” of each professional graduate, and the Capitol has seen bitter fights over these definitions, often pitting a medical specialty against a rival faction. A good example was the years-long conflict between podiatrists and orthopedic surgeons over who had the legal right to have an ankle surgery, a battle that was eventually won by podiatrists.
One might think that the scope of the practice should depend on training and other professional factors, rather than on contributions to campaigns, the influence of the lobby and other features of gross policy, but it is not like this.
The scope of the practice, however, is only a limited issue that draws legislative attention. Another is to decree which diseases should be covered by health insurers, with advocates for victims of specific diseases who together with insurers for their inclusion or exclusion.
One aspect of the problem of insurance coverage is the perennial conflict between insurers and health care providers, especially physicians, over “prior authorization”. It is the requirement imposed by health care plans on doctors to obtain permission before ordering certain diagnostic or treatment procedures, and this year is the subject of an intense political duel.
Health insurers claim that prior authorization saves money by limiting procedures to only those needed for a positive outcome and avoiding duplication. Doctors argue that the fact that non-medical insurance employees make these decisions undermines their professional judgment about what is best for patients.
Senator Richard Pan, a Sacramento Democrat who is also a doctor, is introducing a bill that would loosen pre-authorization rules for doctors who have low levels of denial of treatment requests. The California Medical Association is the main sponsor of the measure, along with other physician organizations. The California Association of Health Plans leads the opposition, which also includes some group practices of physicians.
Pan and his supporters argue that loosening prior authorization requirements would give doctors the freedom to maximize positive outcomes for their patients, while insurers, in a recent circular, mark Senate Bill 250 “a single law that will decrease health care “. transparency, increase premiums and potentially worsen patients’ health outcomes. “
Probably both sides are right, but it is impossible for anyone without a deep knowledge of medical procedures and insurance underwriting to say what the best argument is, and this includes legislators who, despite their ignorance, will end up approving or defeating the bill.
So far, Pan and the California Medical Association are winning the political conflict. His bill has passed the Senate and is now pending in the Assembly.
CalMatters is a public interest journalism company committed to explaining how the California State Capitol works and why it’s important. For more Dan Walters stories, go to Comments.