BILL ANALYSIS Ó
AB 52
Page 1
Date of Hearing: April 26, 2011
ASSEMBLY COMMITTEE ON HEALTH
William W. Monning, Chair
AB 52 (Feuer and Huffman) - As Amended: March 25, 2011
SUBJECT : Health care coverage: rate approval.
SUMMARY : Requires health care service plans (health plans)
licensed by the Department of Managed Health Care (DMHC) and
health insurers (collectively carriers) certificated by the
California Department of Insurance (CDI) (collectively
regulators), effective January 1, 2012, to apply for prior
approval of proposed rate increases, under specified conditions,
and imposes on regulators specific rate review criteria,
timelines, and hearing requirements. Specifically, this bill :
1)Prohibits any rate from being approved or remaining in effect
that is found to be excessive, inadequate, unfairly
discriminatory, or otherwise in violation of the standards
established by this bill. Defines "rate" as the charges
assessed for a contract or policy or anything that affects the
charges associated with such a contract or policy, including,
but not limited to, premiums, base rates, underwriting
relativities, discounts, copayments, coinsurance, deductibles,
and any other out-of-pocket costs.
2)Prohibits carriers from implementing a rate for a new product
or change the rate it charges, unless it submits an
application and the application is approved by regulators.
3)Permits regulators to approve, deny, or modify any proposed
rate for a new product or any rate change for an existing
product, as specified.
4)Makes this bill's provisions apply to contracts and policies
offered in the individual or group market in California, but
exempts specified plans and policies, including specialized
health plan contracts, Medicare supplement contracts, and
contracts offered in the Medi-Cal Program: the Healthy
Families Program; the Access for Infants and Mothers Program;
the California Major Risk Medical Insurance Program; or, the
Federal Temporary High Risk Pool.
5)Requires regulators to review rate applications pursuant to
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regulations it promulgates to determine excessive, inadequate,
or unfairly discriminatory rates, as specified. Requires
regulators, in promulgating such regulations, to consider
whether the rate is reasonable in comparison to coverage
benefits.
6)Requires carriers to file a complete rate application, 60 days
prior to the effective date, for any proposed rate change or
rate for a new product that would become effective on or after
January 1, 2012. Prohibits carriers from submitting a rate
application within one year of the date of implementation of
the most recently approved rate change for each product in the
individual or small group market.
7)Requires carriers, for individual or small group rate
applications, to disclose 18 specified data elements and for
large group rate applications 44 specified data elements, and
in addition to submit any other information required pursuant
to any regulation adopted and related regulations.
8)Requires the rate application to be signed by the chief
executive officer and chief financial officer of the carrier
and requires those officers to certify that the
representations, data, and information provided to support the
application are true. Requires the carrier to have the burden
to provide evidence and documents establishing, by
preponderance of the evidence, the application's compliance
with the requirements of this bill.
9)Permits regulators to request from a carrier, and requires
carriers to provide, any information required under this
article or the federal Patient Protection and Affordable Care
Act.
10)Requires the regulators to review for compliance, with the
requirements in this bill, all rate increases which become
effective January 1, 2011 to December 31, 2011. Requires
regulators to order the refund of payments made pursuant to
any such rate, to the extent DMHC or CDI find the rate to be
excessive, inadequate, or unfairly discriminatory.
11)Requires that all information submitted in a rate application
and all information submitted in support of the application be
subject to the California Public Records Act, except for
financial data, where the disclosure of which would be
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competitively injurious to the carrier, as determined by the
regulator.
12)Requires carriers to submit all information electronically
and to be made public and posted to the carrier's Website site
for not less than 60 days after the date of public notice.
Requires the entirety of the rate application to be made
available upon request to regulators, except as specified.
13)Requires regulators to accept and post to their Website any
public comment on a proposed rate submitted during the 60-day
period.
14)Requires regulators to notify the public of rate applications
submitted by carriers through a posting on regulator Websites
and distribution to the major statewide media and to any
member of the public who requests placement on a mailing list
or electronic mail list to receive the notice. Requires
regulators to issue a decision within 60 days after the date
of the public notice, unless the regulator and the applicant
agree to waive the 60-day period or the regulator notices a
public hearing on the application. Requires the regulator, if
it holds a hearing on the application, to issue a decision and
findings within a reasonable time after the hearing. Requires
regulators to hold a hearing on any of the following grounds:
a) A consumer, or his or her representative, requests a
hearing within 45 days of the date of the public notice,
and the regulator grants the request for a hearing.
Requires regulators, if a hearing request is denied, to
issue written findings in support of that decision;
b) The regulator determines for any reason to hold a
hearing on the application; or,
c) The proposed change would exceed 10% of the amount of
the current rate, or would exceed 15% for any individual
subject to the rate increase, in which case a hearing upon
a timely request for a hearing is required to be held.
15)Requires all hearings required by this bill to be conducted
in accordance with laws governing state administrative
hearings, including that the hearing be conducted by an
administrative law judge (ALJ) in the Department of General
Services Office of Administrative Hearings, that the
regulators be subject to required notices and discovery and
that the decision of the ALJ is subject to review by the
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regulators. Requires the right to discovery to be liberally
construed and requires discovery disputes to be determined by
the ALJ.
16)Authorizes any person to initiate or intervene in any of the
proceedings, establishes parameters for judicial review, and
ensures the right of consumers to challenge final decisions by
the regulator in court, as specified, and requires the
regulator or the court to award reasonable costs, including
witness fees, for persons meeting specified requirements, and
requires the applicant to pay those fees.
17)Subjects health plans and insurers to penalties for violation
of the provisions in this bill, and authorizes the regulators
to charge fees to cover costs of applications filed, and
establishes two new state special funds to receive those
revenues for the sole purpose of implementing this bill.
18)Permits regulators, on or before July 1, 2012, to issue
guidance regarding compliance with this bill, as specified.
Requires regulators to have all necessary and proper powers to
implement this this bill and requires the adoption of
regulations no later than January 1, 2013.
19)Requires regulators to report to the Legislature at least
semiannually on all rate applications approved, modified, or
denied, as specified.
20)Requires regulators to post the following on their Websites:
a) Any changes submitted by a plan to a rate application,
including any documentation submitted by the plan
supporting those changes;
b) Whether it approved, denied, or modified a proposed rate
change; and,
c) A proposed rate that is excessive, inadequate, or
unfairly discriminatory, or that a rate application
contains inaccurate information.
EXISTING LAW :
1)Provides for the regulation of health plans by DMHC and
regulation of disability insurers who sell health insurance by
CDI.
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2)Limits administrative costs for health plans regulated by DMHC
to 15% and establishes minimum medical loss ratios for health
insurers regulated by CDI for specified individual indemnity
dental and vision policies (50%), and minimum loss ratios for
individual health insurance, excluding indemnity payout
policies (70%).
3)Authorizes DMHC and CDI to charge fees associated with
regulatory filings and, in addition, requires that the
regulatory enforcement programs be entirely paid for by health
plan and insurer fees and assessments.
4)Requires health plans and health insurers to file, with
regulators, specified rate information for individual and
small group coverage at least 60 days prior to implementing
any rate change, as specified. Requires the filings in the
case of large group contracts only for unreasonable rate
increases, as defined by the federal Patient Protection and
Affordable Care Act (PPACA), prior to implementing any such
rate change. Increases, from 30 days to 60 days, the amount
of time that a health plan or insurer provides written notice
to an enrollee or insured before a change in premium rates or
coverage becomes effective. Requires carriers that decline to
offer coverage to or deny enrollment for a large group
applying for coverage or that offer small group coverage at a
rate that is higher than the standard employee risk rate to,
at the time of the denial or offer of coverage, provide the
applicant with reason for the decision, as specified.
5)Establishes the Consumer Participation Program within DMHC,
which allows for the awarding of reasonable advocacy and
witness fees to any person who meets specified criteria and
who has made a substantial contribution on behalf of consumers
to the adoption of a regulation, order, or decision made by
the Director.
FISCAL EFFECT : This bill has not yet been analyzed by a fiscal
committee.
COMMENTS :
1)PURPOSE OF THIS BILL . According to the author, excessive
health insurance rate increases place health insurance out of
the reach of millions of families. California should have the
authority to minimize families' loss of health insurance
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coverage as a result of steeply rising premium costs. The
author further states that skyrocketing increases force
business owners and employees to absorb major costs or search
for less expensive - and less comprehensive - coverage
options. Small business owners need the stability that this
measure provides through ensuring that rates cannot be raised
more than once per year. The author states that insurance
rates continue to escalate at a remarkable pace: from 1999 to
2009, health insurance premiums for families rose 131%, while
the general rate of inflation increased just 28% during the
same period, according to a report by the Kaiser Family
Foundation. The same report concluded that states with robust
and transparent rate review and approval processes have
greater power to protect consumers from large rate increases.
The author states that this bill would bring California in
line with 35 other states that require some form of prior
health insurance rate approval by state regulators.
2)HEALTH INSURANCE REGULATION IN CALIFORNIA . Regulation and
oversight of health insurance in California is split between
two state departments, the DMHC and CDI. DMHC regulates
health plans, including HMOs and some Preferred Provider
Organization (PPO) plans. CDI regulates multiple lines of
insurance, including disability insurers offering health
insurance, generally PPO plans and traditional indemnity
coverage.
Although DMHC and CDI both regulate carriers providing health
coverage, each department approaches that regulation very
differently. At the heart of the difference between health
plans and health insurers is the "promise to pay" versus the
"promise to deliver care." DMHC-licensed plans, often
referred to as Knox-Keene Health Care Service Plan Act of 1975
(Knox-Keene) health plans, arrange for and organize the
delivery of health care and services through contracted or
owned providers and facilities and are required to cover all
medically necessary services. Disability insurers protect
against (indemnify) the expense or charges (losses) associated
with illness or injury and typically provide coverage for
defined benefits that may be specifically limited in the
policy, such as number of visits or annual dollar limits. The
distinction between the two regulatory frameworks has blurred
over time because of the historical exceptions made for two
large PPO carriers, Blue Cross and Blue Shield, who offer PPO
products under both DMHC and CDI, but fundamental differences
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remain in the expectations and regulatory oversight by each
regulator. In general, DMHC has greater authority and
responsibility to review and approve health plan products and
benefit designs than CDI has to review health insurance
products under its purview.
In California, health insurance is generally not subject to rate
regulation, with few exceptions. Medicare supplement policies
and contracts sold by both health plans and insurers are
subject to prior approval and regulation of their medical loss
ratios (MLRs), the ratio of benefits to premium. Health plans
and insurers are subject to specific marketing, underwriting,
and rating rules relating to health coverage sold to small
employer groups of 2-50. Both regulators ensure compliance
with the small group rating rules primarily in response to
complaints. CDI-regulated insurers are subject to filing and
review of rates, referred to as "file and use" and must meet
minimum MLR standards, but only for individual products. The
MLR requirements do not apply to Knox-Keene plans. Knox-Keene
plans are limited to no more than 15% administrative costs,
but DMHC does not include profit as an administrative cost.
3)PPACA . On March 23, 2010, President Obama signed the PPACA.
Among other provisions, the new law makes statutory changes
affecting the regulation of and payment for certain types of
private health insurance. The law also significantly expands
health care coverage to currently uninsured individuals
through public program expansions, a mandate to purchase
coverage, a temporary high-risk pool program, and by requiring
guaranteed issue of coverage. Millions of currently uninsured
people in California will obtain coverage under the provisions
of PPACA. In August 2010, DMHC and CDI received federal funds
available under PPACA for rate review activities (DMHC
received $607,998 and CDI received $392,002) to:
a) Enhance the DMHC's and CDI's IT infrastructure to
support data collection and public disclosure of premium
rates through the NAIC's System for Electronic Rate and
Form Filing (SERFF); and,
b) Hire actuaries or obtain contractual actuarial services
to develop premium rate review process and review rate
filings.
According to DMHC, the grant funds will allow both departments
to improve the collection of premium rate information; to
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enhance the depth and breadth of current rate reviews; and, to
build the infrastructure necessary to enable each department
to perform the expanded range and significantly greater volume
of rate reviews required by PPACA.
4)HEALTH CARE COSTS . For many years, health spending growth has
outpaced inflation. The United States spends a larger share of
its gross domestic product (GDP) on health care than any other
major industrialized country. Expenditures for health care
represent 17% of the nation's GDP. In 1960, health care
expenditures accounted for about 5% of the GDP. By 2019, the
federal Centers for Medicare and Medicaid Services project
health care expenditures will account for 19% of GDP. As
costs have risen, health care coverage has become more
unaffordable. The 2010 California Employer Health Benefits
Survey (CEHBS) found health insurance premiums increased 8.1%
in California in 2010. Other key findings from CEHBS were:
Since 2002, premiums have increased 134.4%, more than
five times the 25.4% rise in California's overall inflation
rate.
Single-coverage premiums in California averaged $5,463
annually, significantly more than the national average of
$5,049. Premiums for family coverage were $14,396.
California workers contributed $725 annually for single
coverage in 2010, and $3,632 for family coverage. The
contribution for single coverage in California is less than
for workers nationally ($899), but increased from 12% of
the premium in 2009 to 15% in 2010.
Enrollment in plans with a deductible of $1,000 or more
for single coverage has increased significantly for workers
in small firms (at 27%, up from 7% in 2006).
Twenty-eight percent of California firms either reduced
benefits or increased cost sharing for employees as a
result of the economic downturn in 2010, up considerably
from the 15% who did so in 2009. Cost sharing may continue
to increase for California workers. Just under half of
large firms (200 or more workers) are "very" or "somewhat"
likely to increase the amount workers' pay for coinsurance
or copayments in the next year. Sixty-eight percent are
"very" or "somewhat" likely to raise the amount workers'
pay toward premiums.
Four percent of California firms indicated they are
"very likely" to drop coverage entirely in the next year.
In 2008, only 1% of firms said this.
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1)RECENT HIGH-PROFILE PROPOSED RATE INCREASES . In November
2009, the state's largest health insurer in the individual
market, Anthem Blue Cross, notified CDI of their intention to
raise rates for policyholders by up to 39% in the individual
market. The Assembly Committee on Health held an oversight
hearing on February 23, 2010 on the rate increases, as did the
House Energy & Commerce Subcommittee on Oversight and
Investigations on February 24, 2010. Kathleen Sebelius,
Secretary of the U.S. Department of Health and Human Services,
wrote to the president of Anthem Blue Cross asking for a
detailed justification for the increases to the public.
Secretary Sebelius also requested that Anthem Blue Cross make
public information on the percent of the company's individual
market premiums that is used for medical care versus the
percent that is used for administrative costs.
WellPoint (Anthem Blue Cross' parent company) sent a response to
Secretary Sebelius on February 11, 2010, stating that an
independent actuarial firm concluded that their rates are
actuarially sound and necessary, reflecting the expected
medical costs associated with the membership in their plans,
and that they satisfy or exceed the MLR required by California
law. The letter went on to state that rate increases reflect
the increasing underlying medical costs in the delivery system
which are unsustainable. Specifically, WellPoint explained
that rates in the individual market were rising faster than
medical inflation due to a number of factors, including: a) a
less healthy risk pool; b) individuals moving to lower-cost
options; c) individuals aging into a higher age category; and,
d) "deductible leveraging," when enrollee deductibles and
co-payments do not increase with medical inflation, and
medical cost increases disproportionately fall on the
premiums.
At the request of Insurance Commissioner Steve Poizner, Anthem
Blue Cross agreed to delay the increases until May 1, 2010 to
allow an independent actuary to review their rates. In April,
the independent actuarial review found numerous errors in the
methodology used by the company to project total lifetime loss
ratios, which is a projection of the amount of services that
is potentially used. Once these numerous mathematical errors
were fixed, the average rate increase across products was
reduced from 25.4% to 15.2%.
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In October 2010, Blue Shield of California filed rates with
CDI for members in the individual market that included average
increases of 30% for a two-year period. The rates were
proposed to go into effect in March 2011. In a January 2011
statement, the company stated that the average annual increase
of 15% was appropriate given underlying health care cost
trends, which were driven by increased utilization of health
care services, increased unit cost of medical services, and
increased proportion of health care costs paid by insurance
when deductibles stay the same but the cost of medical
services increase. Responding to concerns raised about rising
individual health insurance rates, Blue Shield announced it
would delay the filing for 60 days and subject its rates to an
independent actuarial review (by the same actuary who
discovered the Anthem errors). Blue Shield indicated that it
would pay refunds to policyholders if the actuary found the
rates to be unsound. In March 2011, the actuary concluded
that the rates were not excessive and met the MLR requirements
of federal and state law. However, there remained significant
negative public response to the increases, and Blue Shield
withdrew the rate increase.
2)PROPOSITION 103 . This bill proposes to confer direct rate
regulation authority for health coverage on both regulators,
using language similar to that enacted when the voters passed
Proposition 103 (Prop 103) in 1988. Prop 103 currently
applies to auto, homeowners, and other forms of
property/casualty insurance and, generally, requires extensive
examination of any rates proposed by insurers. CDI will find
that proposed rates meet the one test that they are not
excessive, inadequate, or unfairly discriminatory if the rates
produce a return on surplus (generally analogous to Tangible
Net Equity for health plans and insurers) of between -7% and
+15%. Importantly, the regulations implementing Prop 103 were
just finalized in 2006, nearly 20 years after passage of Prop
103. During that time, CDI regulated rates under draft
regulations that were the subject of persistent legal
challenges and litigation by insurers. Consumer advocates
point out that during the decade after Prop 103 was adopted,
auto insurance rates in California went down by 4% while auto
insurance products remain broadly available and competitive,
and the uninsured motorist population declined by 38%.
Nationally, auto insurance rates rose over 25% during this
period. In 2001, the Consumer Federation of America selected
Prop 103 as resulting in the best practices in the nation with
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regard to auto insurance regulation.
3)RAND study on premium regulation . In 2004, the California
HealthCare Foundation commissioned a RAND study to analyze the
likely effect of premium regulation on the California health
insurance market. RAND researchers found no compelling need
to regulate health insurance premiums in California and noted
that such regulation could have unintended, adverse
consequences on consumers, such as reduction in the quality or
quantity of care, stricter utilization management, and
discouraging expensive technologies from coming to market
while motivating the introduction of cost-saving technologies.
The study recommended a number of steps to mitigate the
potential adverse consequences of rate regulation by:
Monitoring coverage and the quality of health care that
enrollees and insureds receive;
Using objective indicators, such as insurers' profits,
over a two- or three-year period to judge whether premium
increases are appropriate;
Monitoring market participation among insurers; and,
Monitoring technology adoption in California and in
states without premium regulation.
1)PREVIOUS LEGISLATION . AB 2578 (Jones and Feuer) of 2010, AB
1218 (Jones) of 2009, and AB 1554 (Jones) of 2008 would have
required health plans licensed by DMHC and health insurers
certificated by CDI, to annually submit for prior approval to
the respective regulator any increase in the rate charged to a
subscriber or insured, as specified, and would have imposed on
DMHC and CDI specific rate review criteria, timelines, and
hearing requirements. AB 2578 failed passage on the Senate
Floor, AB 1218 failed passage in the Assembly Health
Committee, and AB 1554 failed in the Senate Health Committee.
SB 1163 (Leno), Chapter 661, Statutes of 2010, requires
carriers to file, with regulators, specified rate information
for individual and small group coverage at least 60 days prior
to implementing any rate change, as specified. Requires the
filings in the case of large group contracts only in the case
of unreasonable rate increases, as defined by the PPACA, prior
to implementing any such rate change. Increases, from 30 days
to 60 days, the amount of time that a health plan or insurer
provides written notice to an enrollee or insured before a
change in premium rates or coverage becomes effective.
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Requires health plans and insurers that decline to offer
coverage to or deny enrollment for a large group applying for
coverage or that offer small group coverage at a rate that is
higher than the standard employee risk rate to, at the time
of the denial or offer of coverage, provide the applicant with
reason for the decision, as specified.
SB 425 (Ortiz) of 2006 would have required carriers to obtain
prior approval for a rate increase, defined in a similar
manner to rates under AB 1218 of 2009. SB 425 did not have a
hearing, at the author's request, and died in the Senate
Health Committee.
SB 26 (Figueroa) of 2004 would have required carriers to
obtain prior approval of rate increases from DMHC and CDI, as
specified, and would have potentially required significant
refunds of premiums previously collected. SB 26 died in the
Senate Insurance Committee.
2)SUPPORT . This bill is supported by a number of consumer,
labor, and business groups. Supporters write that health
insurers are continuously increasing rates on individual and
group policyholders, and the uninsured often come from the
most vulnerable communities of the state. Currently seven
million Californians still struggle to maintain their health
without insurance, and this demonstrates an urgent need to
pass state-level legislation that ensures strict regulation of
health insurance rates in the state. Supporters contend that
in order to keep costs down it is imperative that regulators
have the power to deny unreasonable rate increases.
Supporters further state that the increases in health
insurance premiums for individuals and small businesses
revealed in recent months have capped years of steady
increases in overall premiums. Supporters state that recent
rate filing under existing California law suggest that HMOs
and insurers are not accustomed to public scrutiny of rates;
they have failed to produce substantial evidence to justify
the proposed rate increases or even to provide complete
information about the reason for the rate increases.
Supporters state that at the same time rates have been
increased, the five largest health insurers saw their profits
increased by 56%. Supporters contend that 35 states already
require prior health insurance rate approval by state
regulators that this bill would protect Californians from
unreasonable and unnecessary health insurance rate increases
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and greater oversight to the health insurance industry.
Children's groups state that in the midst of a very difficult
economy, consumers and businesses struggle to pay for health
insurance and that they should have the assurance that rates
are fair and subject to approval by in impartial regulator;
and this is especially important for 6 million California
children with private coverage. Consumer Watchdog writes that
like the auto insurers prior to Proposition 103, the health
insurance industry is stashing billions of dollars in excess
surplus, unaffected by the economic downturn. Consumer
Watchdog determined that Blue Shield of California alone held
$2.9 billion in excess surplus, the amount needed to assure
financial stability under state law. Consumer Watchdog
asserts that regulators in California should be able consider
this financial bloat when determining reasonable rates. U.S.
Senator Dianne Feinstein states that it is critical to protect
California consumers and businesses and this bill will give
regulators the authority to reject excessive, inadequate, or
unfairly discriminatory rate increases. Senator Feinstein
further states that insurance companies are driven by the need
to return profits to shareholders, and without properly
oversight, will continue to raise rates and drop people from
coverage to maximize profits. Senator Feinstein contends that
it is clear that California's state regulators need authority
to reject excessive rate hikes.
3)OPPOSITION . Anthem Blue Cross writes that because insurance
rates are a function of insurance costs, adding an additional
layer of regulation will only increase the cost of delivering
health care to Californians. Blue Cross states that numerous
studies conclude that the primary drivers of premium cost
increases are due to increasing consumer utilization of
services and increasing provider prices. The Civil Justice
Association state that the most troubling part of this bill
allows any person to intervene in any proceeding to "enforce
any action of the department under this article, and enforce
any provision of this article on behalf of himself or herself
or members of the public." Because that provision would allow
lawsuits to be filed by uninjured parties who had suffered no
harm. Health Net writes that they administer hundreds of
product designs and each change varies the rate charged to the
purchaser, in some cases a product and its accompanying rate
is unique to one employer. Health Net states that under rate
regulation, after negotiating with the single employer, the
plan would have to request approval of a rate that is already
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agreeable to the purchaser. Health Net further asserts that
given the responsibility of staff to review proposed rates, it
is likely that significant time will pass before a plan and
the employer know whether the contract can take effect, and
that as a result carriers are likely to restrict variations in
the contracts to limit the number of reviews it must undergo.
Kaiser Permanente Medical Program (KPMP) writes that
supporters of this bill assert that Proposition 103 has
lowered auto insurance rates - by an astonishing $23 billion
in 10 years - as a reason to impose rate regulation on health
insurance. KPMP believes the evidence for this claim is
dubious because proponents give no consideration to the much
more likely causal factors of dramatically reduced accident
rates and decreased liability costs after the California
Supreme Court prohibited third-party bad faith lawsuits.
REGISTERED SUPPORT / OPPOSITION :
Support
U.S. Senator Dianne Feinstein
California Insurance Commissioner Dave Jones
AARP
Alameda County Superintendent of Schools
American Diabetes Association
American Indian Healing Center
AnewAmerica Community Corporation
Asian Business Association
Bay Area Black United Fund, Inc.
Bel Air Beverly Crest Neighborhood Council
Black Business Association
Black Economic Council
Brain Injury Association of California
Brightline Defense Project
California Alliance for Retired Americans
California Black Chamber of Commerce
California Chiropractic Association
California Commission on Aging
California Communities United Institute
California Health Advocates
California Labor Federation
California Mortgage Association
California NOW
California Nurses Association
California Pan-Ethnic Health Network
California Physical Therapy Association
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California Professional Firefighters
California Rural Legal Assistance Foundation
California School Boards Association
California School Employees Association
California Teachers Association
CALPIRG
Children NOW
Children's Defense Fund-California
City of Beverly Hills
City of Los Angeles
Community Union, Inc.
Congress of California Seniors
Consumer Attorneys of California
Consumer Federation of California
Consumer Watchdog
Consumers Union
Council of Asian American Business Associations
Domar Group, Inc.
Greater Los Angeles African American Chamber of Commerce
Greenlining Institute
Having Our Say
HCI Project Amiga
Health Access California
Inland Empire Latino Coalition
Korean Center, Inc.
Korean Churches for Community Development
Korean Health Education Information & Research Center
La Maestra Family Clinic, Inc.
Laborers' Locals 777 & 792
Latino Business Chamber of Greater Los Angeles
National Federation of Filipino American Associations
National Physicians Alliance-California
Northern California District Council - ILWU
Older Women's League of California
Our Weekly Newspaper, Los Angeles
PICO California
Planned Parenthood Action Fund of Santa Barbara, Ventura and San
Luis Obispo Counties, Inc.
Planned Parenthood Advocacy Project of Los Angeles County
Planned Parenthood Affiliates of California, Inc.
Planned Parenthood Mar Monte
Six Rivers Planned Parenthood
TELACU
The Children's Partnership
Unitarian Universalist Legislative Ministry Action Network
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United Policyholders
Vietnamese-American Chamber of Commerce of Orange County
Ward Economic Development Corporation
Opposition
America's Health Insurance Plans
Anthem Blue Cross
Association of California Life & Health Insurance Companies
Blue Shield of California
California Association of Health Plans
California Association of Physician Groups
California Chamber of Commerce
California Hospital Association
California Medical Association
Chico Chamber of Commerce
Civil Justice Association of California
Fullerton Chamber of Commerce
Garden Grove Chamber of Commerce
Hayward Chamber of Commerce
Health Net
Irvine Chamber of Commerce
Irwindale Chamber of Commerce
Kaiser Permanente Medical Program
Orange Chamber of Commerce
Oxnard Chamber of Commerce
Palm Desert Chamber of Commerce
San Diego East County Chamber of Commerce
San Jose Chamber of Commerce
Simi Valley Chamber of Commerce
The Greater San Fernando Valley Chamber
United Chambers of Commerce
UnitedHealth Group
Analysis Prepared by : Melanie Moreno / HEALTH / (916)
319-2097