Democrats Debate Access versus Affordability in South Carolina

Health care reform was a hot topic during the presidential candidate’s debate in South Carolina on Tuesday. Senator Hillary Clinton and former Senator John Edwards claimed universal coverage was the most important priority while Senator Barack Obama put affordability at the top of his list. This dichotomy mirrors the debate California experienced with Governor Arnold Schwarzenegger insisting on coverage for all and the legislature’s Democratic leadership questioning the fairness of requiring individuals to buy coverage they couldn’t afford.

I’ve written more about this somewhat strange, but probably not surprising, echo of California’s health care reform debate on the political blog.

Senate Health Committee Analysis of ABX1-1

In preparation for the January 23rd Senate Health Committee’s hearing on Assembly Bill X1-1 the Committee’s staff has issued its analysis of the bill. ABX1-1 is the compromise health care reform worked out between California Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez.

The Senate Health Committee Staff Analysis of ABX1-1 is the most thorough of study of the bill to date. It wil provide plenty of ammunition for both supporters and opponents of the bill, raising serious questions about the complex measure as well as identifying the benefits it could deliver. Along with the analysis due soon from the Legislative Analyst’s Office on the impact ABX1-1 will have on the state’s fiscal condition, the staff study provides Committee members with a rich source of information and questions for the hearing.

For legislation this important and complicated, it has received relatively little scrutiny. The Senate Health Committee’s hearing, will be a long one. Given the substance provided in the analysis, it is likely to be thorough as well. Regardless of the outcome, this can only be a good thing.

ABX1-1 Earns Eclectic Mix of Opponents

People are known by the friends they keep. Public policy is often characterized by its opponents. ”If so-and-so opposes this,” a supporter will say, “it must be good.” Assembly Bill AX1-1, the California health care reform compromise worked out by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, must be one eclectic bit of legislation. It’s opponents are folks you might expect to be loath to remain in the same room together, let alone sit on the same side of a table.

The California Nurses Association opposes ABX1-1 because it permits insurance companies to remain in existence. They prefer a government-run, single-payer system. Blue Cross of California, the state’s largest health plan, opposes ABX1-1 for, among other reasons, it gives government too large a role in the health insurance market.

The California Chamber of Commerce, the National Federation of Independent Business, and the California Manufacturers and Technology Association are among a dozen business groups opposing ABX1-1 because they consider it bad for, well, business. And the United Food and Commercial Workers opposes it because they think it harms workers.

Whether this makes them an eclectic crew or just a motley one says more about you than them, I suppose.

Of course, for every opponent, there’s an opposite and equal proponent. The California Hospital Association, a health plan or two, a business coalition led by Safeway CEO Steve Burd and the Service Employees International Union have already lined up behind ABX1-1 or are likely to soon.

Whether ABX1-1 will ever take effect is uncertain. Passed by the Assembly, it awaits consideration by the State Senate. If it gains legislative approval, it’s implementation is contingent upon passage of a funding initiative supporters are seeking to qualify for the November 2008 ballot.

In the meantime, rumor has it some of these opponents of the health care reform package are already talking about forming an alliance to defeat the funding measure. As one rumor monger, who asked for anonymity noted, “The California Nurses Association and the tobacco industry teaming up. You have to wonder what they’re smoking.”

You also have to wonder about what will happen to the space-time continuum if nurses start asking Californians to vote “No” on the health care reform initiative in commercials paid for by tobacco companies. Where’s Rod Serling when you need him?

Nearly Half of Employers Already Exceed ABX1-1 Payroll Tax

The health care reform legislative/initiative combo being advocated by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez raises a significant amount of it’s $14.4 billion price from employers. California firms would need to spend a specified amount of their payroll on health benefits for their workers or pay a tax to the state. The tax rate ranges from one percent-to-6.5 percent, depending on the size of the payroll. Employees of fee-paying companies would either obtain coverage through a state-run purchasing pool or buy individual coverage. There’s a variety of incentives, however, for most workers to buy through the state’s pool.

Some business groups have charged the payroll tax will cost California jobs and drive businesses from the state. Supporters argue it’s a means of leveling the playing field between employers who provide health care coverage and those who don’t.

The University of California at Berkeley Center for Labor Research and Education is doing a study on the impact of the tax on California payrolls. The folks at Health Access obtained, and were kind enough to post, a preliminary report on the study.

The report contains some interesting statistics, but to get to the bottom line on the tax’s impact on bottom lines: the report’s authors find that “nearly half of all firms (47.3 percent), which account for 54 percent of the workforce, would be required to make no additional payments under the proposed initiative ….”  They predict 82 percent of firms would make payments of less than 1 percent, another 16.6 percent would pay 1.01-to-4.00 percent more of their payroll on health benefits, and only 1.7 percent would pay more than four percent.

There’s a lot of averaging going on in the study. The impact on any particular business could be substantial, but when that pain is spread all enterprises it looks less severe. And, I posted yesterday, there’s a very real possibility the payroll tax rates will be inadequate to fund health care expansion before ABX1-1 is ever implemented.

Both proponents and opponents of the health care reform package will find ammunition in the UC Berkeley Labor Center study. What’s most encouraging is that these issues are finally being addressed – in detail and in public.

Senate Health Committee Hearing on ABX1-1 Agenda

Previously I’ve written about the thorough vetting Assembly Bill X1-1 was likely to receive before the Senate Health Committee. That should be Vetting, with a capital “V.”

ABX1-1, the compromise health care reform package has yet to be subjected to a thorough, formal review. Drafted by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, it passed the full Assembly the same day it was printed in final form. This may be business as usual in the legislature, but it’s no way to review complex, complicated and critical legislation.

So Senate Health Committee Chair Sheila Kuehl is doing Californians a favor by making the time to thoroughly analyze the bill. Her motivation may be fueled, at least in part, by her numerous problems with ABX1-1 (as described in that previous post),  but who cares? What’s important is that lawmakers understand what’s in the bill before they vote on it.

Senator Kuehl’s approach to reviewing the bill, breaking it up into manageable pieces, should make it easier for Senators to dive deeply into different aspects of the legislation. One can question the way it’s broken up. For example, reviewing the mandate on residents to maintain minimum creditable coverage separate from the market reform which requires carriers to issue coverage regardless of an applicant’s health condition, is a bit disjointed. The reason a mandate to buy coverage is necessary is to make the mandate to sell policies work. However, that’s a relatively minor quibble with the approach. Far more important is that details of the bill will have a better chance of coming to light.

The Committee will take up the bill on January 23rd at 9:00 am. Based on the agenda the hearing should last all day. While all witnesses are created equal, some are more interesting than others. The representative of the Legislative Analyst’s Office (LAO) will be the marquee witness. Senate President Pro Tem Don Perata asked the LAO to analyze the impact ABX1-1 was likely to have on the state’s finances back in December when he felt passage of health care reform legislation before Sacramento addresses the state’s budget crisis was “imprudent and impolitic.” He’s since managed to overcome his reluctance, much as Governor Arnold Schwarzenegger seems to have overcome his concerns about changing the state’s term limit laws without redistricting reforms. Coincidence? Nahhhh.

Anyway, back to the hearing, Elizabeth Hill, the Legislative Analyst, is highly regarded by legislators of all parties. Her office’s report will be highly influential if,and it’s a big if, it makes definitive statements instead of couching it’s findings in an ocean of hedges. If the report is full of “ifs,” ”potentiallies” “coulds” and “perhapses” then it’s impact will be muted, unless Committee members can get the LAO’s representative at the hearing to refine the conclusions a bit. We’ll have to wait a few more days to see if that will even be necessary.

For those who want to follow along at home on the 23rd (again, beginning at 9:00 am), the hearing will be broadcast online. To listen in, visit the California Senate’s web site and click on room 4203. The Committee’s expected agenda, subject to change, follows:

Outline for Hearing on ABX1 1 (Nunez)

I. Author’s presentation, including presentation by Secretary Belshe or administration representative

II. LAO presentation of fiscal analysis 

III. Testimony, by topic (order for each topic will be support, support if amended or with amendments, concerns, oppose unless amended, oppose)

  A. Mandate to maintain minimum creditable coverage

  B. Purchasing pool, coverage expansions, and proposed tax credits

  C. Requirements for health coverage outside of purchasing pool

  D. Health insurance market and regulatory reforms

  E. Financing (including provisions of proposed initiative) 
     — Employer assessments
     — Redirection of county funds
     – Tobacco tax
     –Hospital assessments
     –Federal funds
     –Individual contributions
     –Contingencies in event of funding shortfall

  F. Testimony on Massachusetts health plan

  G. Scope of practice changes

  H. Data collection and transparency and pay for performance provisions

  I. Other provisions
     –Hospital and physician rates
     –In-Home Supportive Service (IHSS) worker provisions
     –Electronic prescribing and medical records
     –Healthy actions and incentive rewards
     –Public insurer provisions
     –Diabetes, obesity and smoking provisions
     –Prohibition on hospital balance billing
     –Other

IV. Author’s close

California Health Care Reform Package Already Underfunded?

Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez have already started the process of qualifying an initiative to fund their health care reform compromise legislation. Their hope is that the State Senate will pass the bill, Assembly Bill ABX1-1, soon and voters will approve their ballot measure in November of this year. Both the Governor and Speaker have claimed their health care reform package will be a boon to the state’s hemorrhaging budget.

“Our health care reform plan will bring billions of dollars of badly needed money to our health care system and ensure that future Governors will not have to make the decisions we are being forced to make today,” is the way Governor Schwarzenegger put it in a press release issued by his office last month..

The Legislative Analyst’s Office (LAO) will report soon on its review of the legislation’s impact on California’s finances. This report will carry substantial weight with Senators as they consider the health care reform package. Senator Sheila Kuehl has postponed a hearing on ABX1-1, originally scheduled for January 16th, until no sooner than January 23rd to allow time for the LAO to submit the report and provide lawmakers with some time to digest it.

It’s unknown how precise the LAO report will be in presenting conclusions. Will it highlight some problem areas, but offer nothing definitive? Or will it dive deeply into the financing and evaluate the reliability of each source not only now, but in the future.

For example, consider the funding sources tied to payroll. Approximately $2.7 billion of the $14.4 billion needed to fund ABX1-1’s comes from taxes (some call them fees) businesses would pay on wages. Historically, the cost of health care, and consequently the cost of health care coverage, has increased far more rapidly than wages. Since most of the provisions of ABX1-1 won’t take effect until 2010 — and it could be even later if law suits force a delay — the difference between wage and medical inflation rates could mean ABX1-1 is, in a very real sense, already underfunded.

No one knows with certainty at what rate payrolls and health care costs will increase over the next two years. But we can look back. What would have happened if ABX1-1 was signed into law in 2005 and implemented in 2007?

According to Tom’s Inflation Calculator, $1.00 of payroll in 2005 was worth $1.06 two years later. However, $1.00 of medical care in 2005 cost $1.08 in 2007. Two cents doesn’t sound like a lot, but when multiplied 2.7 billion times it represents a $54 million shortfall.

This calculation accounts for just the two years between now and when ABX1-1 is expected to take effect. Expand the time horizon another three years and the delta increases dramatically. $1.00 in wages in 2002 grew to $1.13 in 2007. But $1.00 in medical costs grew to $1.23 during that time. Multiply the ten cents difference by 2.7 billion and the shortfall is $270 million.

Of course, past performance is no guarantee of future results. And supporters of the health care reform compromise would argue that its provisions will help slow the rate of medical care costs and, to the extent it results in reduced premiums, could free up dollars for higher wages. Maybe. Maybe not. That’s certainly the goal, but there’s no guarantee. And if it’s not, where will the funds come from?

That depends, partly, on whether the payroll tax is considered a tax or a fee. If it’s the latter, a majority of the legislature could increase the percentage of payroll businesses would be obliged to spend on health services or pay to the state. Interestingly, the higher the fee, the more likely companies are to simply provide the coverage themselves. This, in turn, would require a still higher tax rate — I mean fee percentage.

The fact that the reform package’s funding may be inadequate should not, in and of itself, be considered a fatal flaw. It is fatal only if it’s ignored. Recognizing and addressing the risk of underfunding now, before a day of reckoning arrives, is what’s required. 

We’re seeing what happens to state finances when budgeting problems are ignored. Let’s hope the current budget crisis is not repeated when it comes to financing health care reform.

Agents Call for Changes to ABX1-1

Two of California’s largest insurance agent organizations have combined forces to seek urge the State Senate to amend Assembly Bill X1-1, the health care reform package produced by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez. Passed by the Assembly on December 17, 2007, the legislation is scheduled for a hearing before the Senate Health Committee on January 16th.  Governor Schwarzenegger and Speaker Nunez have already started the process of qualifying the ballot measure needed to finance the bill’s provisions. ABX1-1 takes effect only if the funding initiative gains voter approval. It is expected to be on the November 2008 ballot.

The California Association of Health Underwriters (CAHU) and the National Association of Insurance and Financial Advisors-California (NAIFA-California) asked Senators to “take the time to get the legislation right.” Noting the compleixity of revamping the state’s health care system, the agents issued a statement claiming “Comprehensive health care reform is too important, and the stakes for Californians are too high, to push this legislation through without needed changes.”

Agents are asking for changes to how a state-run purchasing pool would operate. Of specific concern is the bill’s driving of residents receiving a tax credit to subsidize their premiums into the pool. Agents want there to be a level playing field. “The state doesn’t require food stamp recipients to shop only at government-run grocery stores. Similarly, Californians receiving tax credits to help pay premiums should not be forced to shop only at a government-run health insurance store.”

The agents are also urging Senators to define the minimum benefits package all residents would need to obtain. Additionally, agnts are asking the Senate to confirm the financing mechanism will actually meet the funding needs of the reform package. Specifically, they express the concern that a substantial portion of funding relies are tied to payroll taxes. Agents noted that wages don’t increase at the same rate as medical costs, meaning, over time, the financing will be inadequate to cover state health care obligations.

Sheila Kuehl on ABX1-1

Assembly Bill X1-1, the California health care reform package worked out by Governor Arnold Schwarzenegger and Assembly Speaker Fabian Nunez, will receive its first Senate hearing on January 16th before the Senate Health Committee. (Update as of January 14, 2008: It appears the Senate Health Committee will take up ABX1-1 on January 23rd, not the 16th). This hearing will focus more on the policy issues underlying the legislation. While the financing scheme underpinning the bill will no doubt be debated, that topic is more in the purview of the Senate Appropriations Committee, which will hear the bill later, assuming the Health Committee moves it forward.

Which it is nearly certain to do. However, that doesn’t mean the Health Committee hearing will likely be an easy time for sponsors of ABX1-1. That’s because Senator Sheila Kuehl chairs the Health Committee.

Senator Kuehl is intelligent and politically savvy, a potent combination. She won’t frustrate Senator President Pro Tem Don Perata’s plans for ABX1-1. If he insists the bill move out of her Committee, it’s will in all likelihood move out of her Committee. But that doesn’t mean Senator Kuehl will give the bill a free ride. Expect tough questions and an insistence on thorough answers.

In anticipation of the January 16th hearing, I thought it would be interesting to explore Senator Kuehl’s views on ABX1-1, the Health Care Security and Cost Containment Act as it is officially known. To get straight to the bottom line: she doesn’t like it.

Senator Kuehl has written extensively over the past year on the Governor’s health care reform efforts. As the most ardent advocate of a government-run, single-payer system, Senator Kuehl was predisposed against the public-private sector approach advocated by the Governor to begin with. And she approves of little of what’s contained in the bill that emerged, or in the way ABX1-1 was fashioned.

Process: Back when it looked like the legislative leaders and the Governor might produce a bill before the regular legislative session ended in mid-September, Senator Kuehl posted a statement on her web site warning “[t]he prospect of legislative staff, sitting behind closed doors, hastily crafting a 100-page health reform ‘compromise’, to be pushed through the legislature with little or no public input over the course of the next 14 days, is deeply irresponsible.  Frankly, given the example of the energy deregulation bill, we ought to know better. “

As it turns out, it took a special session and several more months of negotiations to work out the compromise that became ABX1-1. And while there was extensive consultation with the public and stakeholders, it was only avialable in printed form hours before the Assembly passed the legislation on December 17th.

No one can seriously claim the bill was thoroughly vetted by Assembly Members prior to that vote. Given her previous statements, it’s clear Senator Kuehl will want to make sure it receives the review legislation this complex — and this important — deserves.

Policy: The vetting will no doubt be thorough. There’s not a lot in ABX1-1 Senator Kuehl likes. In an essay posted on her site shortly after the Assembly vote, Senator Kuehl makes it clear she’s underwhelmed with the bill’s scope and unhappy with its approach to addressing health care in California. “The press has described the bill in breathless prose as a ‘giant leap’ for health coverage.  Unfortunately, this is not quite the case, depending on who you are and how and where you work…. [S]ome of the provisions of the bill [are] actually harmful to regular, working-class and middle-class families.  And it provides less help than advertised for poor families, as well.”

She objects to the characterization of the bill as “providing” health care coverage to residents, noting that it’s more accurate to say “Californians would be required to buy insurance with no caps on premiums, no regulation of the cost of insurance or medical expense, no maximum deductibles, and no floor on how little coverage you can buy and satisfy the legal requirement.”

She laments the failure of the bill to define the minimum coverage Californians must have. And how the bill deals with recission of policies by carriers. And how insurers would still be able to maintain provider networks. And how medical assistants working in retail clinics would be subject to less supervision by Nurse Practitioners and Physician’s Assistants.

In short, she finds a lot not to like in the bill.

Senator Kuehl supports creation of a single payer system for California not out of political calculation, but from deeply held beliefs that it’s the right approach for the state and the nation. She knows that if ABX1-1 becomes law it will make it harder to pass her bill, introduced in the past two legislative sessions as Senate Bill 840, to succeed.

As I’ve noted previously, many progressives who support SB 840 seem willing to accept ABX1-1 as a partial victory. Senator Kuehl and a significant number of her strongest supporters are not. Senator Kuehl was one of the few Democrats in the State Senate to vote against AB 8 last September, the health care reform plan sponsored by Speaker Nunez and Senator Perata. Based on her writing, she’s doesn’t think ABX1-1 is much of an improvement.

Meanwhile, her allies, the California Nurses Association are actively campaigning against the bill. They’ve gone so far as to include snippets of a speech by Senator Barack Obama — without his or his campaign’s permission — in radio ads opposing ABX1-1.

None of this means ABX1-1 won’t make it through the Senate Health Committee. It is all but certain to do so. What it does mean is that, at long last, ABX1-1 will have a thorough, rigorous and comprehensive vetting. Whether you support or oppose the bill, that can only be a good thing.

(Note: A January 14th editorial in the San Diego Union provides more insights into Senator Kuehl’s concerns about ABX-1-1. My thanks to agent Bill Robinson for pointing this out).

Proposed Health Care Cuts: California Tragedy or Political Ploy?

The impact of Governor Arnold Schwarzenegger’s proposed budget cuts on health care programs for California’s most vulnerable populations is tragic. No other word describes it.

In January 2007 the Governor and legislative lawmakers were putting forward proposals to expand coverage for low-income residents, increase reimbursements to doctors serving Medi-Cal patients, and reduce the number of uninsured. A year later and they’re debating budget cuts that will move the state in the opposite direction on all those fronts and more.

There are so many draconian cuts in the Governor’s proposal, not just concerning health care, but impacting virtually every service the state provides, that they border on unbelievable. OK, they are unbelievable. Which raises some questions: is this what the Governor really wants? Or is this part of his long campaign to revamp the way California’s budget is made and executed?

Since his election, Governor Schwarzenegger has sought to fix the state’s ineffective budget process. The legislature rejected his first proposal, voters turned down his second. Now he’s back for the third try and some are wondering if the budget he proposed yesterday is designed more to gain support for his reforms than to balance the budget.

Sacramento Bee columnist Dan Walters puts it this way “[The] cuts, coupled with a very hard line on raising taxes, may be laying the groundwork for some kind of grand budget deal next summer in which he would agree, albeit reluctantly, to raise taxes of some kind to ease the impact on schools, prisons, parks, health services and so forth in return for Democrats’ accepting his long-sought constitutional amendment that would grant governors more power to unilaterally balance income and outgo.”

It takes a two-thirds vote of the legislature to pass a tax increase, however, and Republican lawmakers have pledged to oppose one. At the same time, the GOP also wants a constitutional amendment to force California to live within its means. Would enough Republican legislators support a compromise budget package that contains new taxes (or closes existing loopholes) if part of the deal was a strong constitutional amendment on the budget? Mr. Walters think they might and an argument can be made that they should.

Republicans frequently lament the failure of government to act in a more businesslike way. They point to state spending and programs that, once launched, are never reviewed again, state budgets balanced through gimmicks, and a lack of accountability for problems. All are behaviors that would be intolerable in the private sector — or would lead to a going-out-of-business sale.

But it’s inconsistent to call for government to act in a business-like way only when it’s convenient. And when companies face financial crises, their management puts every option on the table. Nothing is off limits. They evaluate every possible cost reduction and every opportunity to increase revenues.

Republicans should take a hard line against tax increases — that’s what they’re there for. But setting a high bar for justifying taxes and ruling out the possibility that any tax increase could be justified are two different things. The first is good business; the latter isn’t.

For a budget deal to come together, Democrats have to break with their traditional response to problemss, too. Not every state program is needed. Not every public service should be expanded. The state can’t tax its way out of this crisis. Governing means setting priorities and making tough decisions. Again, their role is to set a high bar for justifying cuts, especially on programs that comprise the state’s safety net. But they can’t rule out making any reductions anywhere.

Governor Schwarzenegger pegged the state’s deficit at $14.5 billion. In reality it’s even bigger and balancing it will be even harder. Unfunded obligations for retiree health care exceeds $1.2 billion. If the Governor’s health care reform proposal goes through, he says the state will need to raise a minimum of $14 billion to fund it — that figure probably understates the actual cost.

The budget cuts the Governor proposes to make to health care programs are tragic. Avoiding them will require leadership and wisdom from both sides of the aisle. Lawmakers will either rise above easy, ingrained responses and meet this challenge or  the state’s neediest citizens will suffer. That’s the reality.

Is Perata Ready to Push ABX1-1 Through State Senate?

On December 17th, the day the Assembly passed ABX1-1, the health care reform compromised worked out by Governor Arnold Schwarzenegger and Speaker Fabian Nunez, Senate President Pro Tem Don Perata’s told a San Jose television station the bill was “dead on arrival” in the upper house. 

Earlier that day he had asked Legislative Analyst Elizabeth Hill to submit a report to the Senate on ABX1-1’s impact on the state’s finances. The implication of the Senator’s statements. at the time, was that the report would heavily influence the legislation’s fate. If the study determined the legislation’s impact on the state’s $14.5 billion deficit would be positive or merely minimally negative, the Senate would likely pass the bill. If, however, it found ABX1-1 would make the state’s already bad fiscal situation worse, the legislation would likely to go nowhere.

The Legislative Analyst’s report is due soon, but Senator Perata no longer seems to be waiting on it. According to a post by Sacramento Bee columnist Daniel Weintraub on the paper’s CapitolAlert web site, Senator Perata implied today that the Senate will be passing ABX1-1.

Mr. Weintraub reports Senator Perata as saying the Senate may amend ABX1-1, but they won’t change the plan’s financing mechanisms. This is because Governor Schwarzenegger and Speaker Nunez have already started the process of qualifying a ballot initiative to authorize the $14.5 billion needed to finance the health care reform package for the November 2008 ballot. Only if voters approve the measure will the provisions of ABX1-1 take effect (assuming, of course, the likely law suits don’t delay implementation).

Turning over the ultimate fate of ABX1-1 to voters seems to appeal to Senator Perata and could explain his optimism the bill will pass the Senate prior to publication of the Legislative Analyst’s report. He’s in a bit of a political bind and the initiative makes dealing with the situation easier.

Senator Perata has reportedly been under heavy pressure from his political allies to keep health care reform on track in California. And he is a long time supporter of comprehensive health care reform, so he’d sincerely like to see the proposal move forward. However, back in December, the Senator called passage of health care reform legislation before Sacramento addresses the state’s looming budget crisis “imprudent and impolitic.” 

How to make his supporters happy, achieve a long desired legislative goal, and avoid being imprudent and impolitic? If the Legislative Analyst determines ABX1-1 won’t harm the state’s financial situation, he’s off the hook. “She said it’s OK, so it’s OK.”

But even if the report finds enacting ABX1-1 will make California’s budget situation worse, the Senator can say something along the lines of, “I support the goals and policies of this bill. And while the state can’t afford it, if voters decide its the right thing to do then I’ll live by their decision.” In other words, anything the voters do is, by definition, neither imprudent nor impolitic.

Whatever his motivation, Senator Perata’s recent comments make it much more likely voters will determine the outcome of California health care reform effort.