BILL ANALYSIS Ó
SENATE COMMITTEE ON HEALTH
Senator Ed Hernandez, O.D., Chair
BILL NO: SB 1446
AUTHOR: DeSaulnier
AMENDED: April 28, 2014
HEARING DATE: May 7, 2014
CONSULTANT: Boughton
SUBJECT : Health care coverage: small employer market.
SUMMARY : Authorizes a small employer health plan or health
benefit plan (another name for health insurance policy) in
effect on October 1, 2013, and renewed by December 31, 2013,
that does not qualify as a grandfathered health plan or health
benefit plan, to avoid compliance with specified provisions of
the Affordable Care Act (ACA) and related state law, and, be
renewed until October 2016, at which time compliance with the
ACA and state law is required. Contains an urgency clause that
will make this bill effective upon enactment.
Existing law:
1.Regulates health plans through the Department of Managed
Health Care (DMHC) and health insurance policies through the
California Department of Insurance (CDI). Health plans
include Health Maintenance Organizations (HMOs) and some
Preferred Provider Organizations (PPOs). Health insurance
policies include PPOs, but not HMOs.
2.Requires on or after October 1, 2013 a non-grandfathered plan
or insurer to fairly and affirmatively offer, market, and sell
all of the plan's small employer health plan contracts and
insurance policies for plan years on or after January 1, 2014
to all small employers in each service area in which the plan
provides or arranges for health care services. This is
referred to as "guarantee issue."
3.Prohibits a plan or insurer from rejecting an application from
a small employer for a small employer health plan contract or
insurance policy if certain conditions are met.
4.Requires health plans and health insurers to consider as a
single risk pool for rating purposes the claims experience of
all insureds and enrollees in all non-grandfathered health
benefit plans in this state, whether offered as a health plan
contract or health insurance policy, including those insureds
Continued---
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and enrollees who enroll in individual coverage through
Covered California and enrollees and insureds outside of
Covered California. This requirement applies separately for
individual market products and small group products.
5.Requires the premium rate for a small employer health plan or
insurance policy issued, amended, or renewed after January 1,
2014 to vary only by age, not more than three to one for like
individuals of different ages, as specified, geographic
region, as specified, and whether the contract or policy
covers an individual or family, as specified.
6.Requires individual and small group health plans and insurance
policies issued, amended, or renewed, on or after January 1,
2014, to cover at a minimum, essential health benefits (EHBs)
as specified in state and federal law.
7.Requires, on or after January 1, 2015, for non-grandfathered
health plan contracts or health insurance policies in the
individual and small group markets to provide for a limit on
annual out-of-pocket (OOP) expenses for all covered benefits
that meet the definition of EHBs, including out-of-network
emergency care, as specified.
8.Requires the maximum OOP limit to apply to any copayment,
coinsurance, deductible and any other form of cost sharing for
all covered benefits that meet the definition of EHBs.
9.Requires the limit, described in 8) above, to result in a
total maximum OOP limit for all EHBs equal to the dollar
amounts in effect under the Internal Revenue Service, as
specified, as adjusted by the ACA, as specified.
10.Prohibits small employer health plan contracts and insurance
policies offered, sold, or renewed on or after January 1, 2014
from containing deductibles that exceed $2,000 for a single
individual and $4,000 for any other plan contract or policy.
11.Defines levels of coverage for the non-grandfathered small
group market as Bronze, Silver, Gold, Platinum, as specified.
12.Establishes premium rate rules for small employer health plan
and insurance contracts including, that effective July 1,
1996, the employee risk adjustment factor may not be more than
110 percent or less than 90 percent, and requires plans and
insurers to apply standard employee risk rates consistently
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with respect to all small employers.
This bill:
1.Authorizes a small employer health plan or health benefit plan
in effect on October 1, 2013, including those renewed by
December 31, 2013, and still in effect as of the effective
date of this bill, that does not qualify as a grandfathered
health plan or health benefit plan, to be renewed until
October 2016, and continue to be in force until after
September 30, 2017, subject to applicable federal law, and any
other requirements imposed by this bill.
2.Authorizes a small employer health plan contract or health
benefit plan described in 1) above, to continue to be in force
after September 30, 2017, if the contract or plan is amended
to comply with all of the provisions, listed in 4) below, by
October 1, 2017, and if the contract or plan complies with all
other applicable provisions of law.
3.Requires, prior to renewing a small employer health plan
contract or health benefit plan pursuant to 1) above, the
health plan or health benefit plan to provide notice to the
group contract holder regarding the option to renew coverage
using a specified notice issued by the United States
Department of Health and Human Services, Centers for Medicare
and Medicaid Services (CMS) on March 5, 2014.
4.Exempts a small employer health plan contract or health
benefit plan, described in 1) above, from the following
provisions in existing California law:
a. Requirements to guarantee issue;
b. Prohibitions against rejecting applications;
c. Requirements for a single risk pool;
d. Rating limitations associated with age, family
size, and geographic regions;
e. Requirements to provide EHBs;
f. Maximum limitations on OOP expenses and
deductibles; and,
g. Definitions on levels of coverage and
actuarial value.
5.Requires a small employer health plan contractor health
benefit plan, pursuant to 1) above, to be subject to risk
adjustment factors of not more than 110 percent and not less
SB 1446 | Page 4
than 90 percent and consistent employee risk rates with
respect to all small employers. Requires the small employer
health plan contract or health benefit plan to continue to be
subject to all other requirements on non-grandfathered small
employer plans and the Knox-Keene Act or laws applying to life
and disability insurance.
6.Requires, no later than October 1, 2017, a small employer
health plan contract or health benefit plan to be amended to
comply with the provisions, described in 4) above.
7.Defines a small employer health plan contract as a group
health care service plan contract other than a specialized
health plan, issued to a small employer, as defined.
8.Defines a health benefit plan as a policy of health insurance,
as defined, for the covered eligible employees of a small
employer and their dependents. The term does not include
coverage of Medicare services pursuant to contracts with the
United States government or coverage that provides excepted
benefits, as specified.
9.Contains an urgency clause that will make this bill effective
upon enactment.
FISCAL EFFECT : This bill is keyed non-fiscal.
COMMENTS :
1.Author's statement. According to the author, state law is not
consistent with the ACA transition policy announced by
President Obama, which can lead to consumer confusion and
policyholders asking why they aren't allowed to keep their
existing health insurance coverage that their employees are
happy with when the President announced that they may do so.
A significant percentage of small business owners will choose
to move to ACA compliant products by the end of 2014, but this
bill allows those who wish to avail themselves of President
Obama's transition policy to do so.
2.ACA, Risk Pools and California Implementation. The ACA, enacted
on March 23, 2010 and amended on March 30, 2010 represents a major
expansion of U.S. health care coverage through an expansion and
simplification of the Medicaid program and the adoption of major
reforms of the health insurance market. Most transformational are
changes to the small group and individual insurance markets, such
as mandating guaranteed issuance of coverage, eliminating pre-
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existing condition exclusions, limiting factors upon which premium
rates can be developed, and authorizing the creation of health
benefit exchanges either at the state or federal level.
Beginning in 2014, individuals are required to maintain health
insurance or pay a penalty, with exceptions for financial
hardship (if health insurance premiums exceed eight percent of
household adjusted gross income), religion, incarceration, and
immigration status. Large businesses (those with 50 or more
full-time workers) that do not provide adequate health
insurance are required to pay an assessment if their employees
receive premium tax credits in Exchanges to buy their own
insurance.
Small businesses with generally fewer than 100 employees can
shop in an exchange for qualified health benefit plans (QHPs).
Exchanges offer a choice of plans that meet certain benefits
and cost standards.
For the self-employed, the cost of the health insurance may be
deductible from federal taxes. Tax credits are available for
individual health insurance purchased through an exchange.
These tax credits are available to individuals with income
between 100 percent and 400 percent of the federal poverty
level and who are not eligible for other affordable coverage.
To stabilize health insurance rates during this market
transition and to spread health risk across health plans and
insurers, the ACA established programs of risk adjustment,
reinsurance and risk corridors. Before the ACA, health plans
and insurers often maintained several separate risk pools
within their individual and small group market business, often
as a way to segment risk and further underwrite premiums.
Beginning in 2014, health plans and insurers are no longer
able to deny coverage based on applicants' health status and
are limited in the types of rating factors they can apply in
setting premiums in the individual and small group markets.
Without a single risk pool rule, these prohibitions against
traditional underwriting could incentivize health plans and
insurers to find ways to segment the market into separate risk
pools and charge differential premiums based on segmented
risk, a de facto mechanism for underwriting. As a result, the
ACA requires a health plan or insurer to consider all of its
enrollees in all plans and policies (other than grandfathered
plans or policies) offered by the health plan or issuer to be
members of a single risk pool in the individual market or
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small group market, respectively, which prevents plans and
insurers from creating separate pools in order to segment high
risk and low risk enrollees. While risk adjustment will
address some risk segmentation, the single risk pool
requirement provides another layer of protection against
adverse selection among plans and protects consumers by
requiring health plans and insurers to consider the risk of
all enrollees when developing and pricing unique plans.
Pursuant to the ACA, California has established Covered
California as a state-based exchange that is operating as an
independent government entity with a five-member Board of
Directors. California has also enacted legislation to
incorporate most of the federal insurance market reforms into
state law, including a requirement that in both the individual
and small group markets, coverage issued, amended, or renewed
on or after January 1, 2014, must be compliant with ACA
reforms, such as guaranteed issue, premium limits, and use of
a single risk pool for determining rates.
Prior to the ACA, California adopted AB 1672 (Margolin and
Hansen), Chapter 1128, Statutes of 1992, which enacted
guaranteed issue and renewability as well as rating and
pre-existing condition limitations affecting small group
health insurance.
3.Plan Cancellations Individual Market. On May 7, 2013, Covered
California adopted model contract requirements that require
participating plans, also known as QHPs, to terminate all of
their non--ACA compliant policies effective December 31, 2013.
In compliance with this requirement, QHPs began sending out
cancellation letters to their enrollees and insureds in late
September. However, the Commissioner of CDI did not approve
the termination of policies of two companies under CDI's
jurisdiction, indicating that the cancellations were not in
compliance with notice requirements of existing law. For
people insured by these companies, cancellation periods were
extended to allow for adequate notice. As such, these policy
cancellations were permitted in February and March of 2014.
In addition, two carriers chose to withdraw from the market.
These QHP contract requirements are specific to individual
market health plan contracts and insurance policies, not small
group market contracts and policies.
On November 14, 2013, President Obama announced and CMS issued
a policy giving insurers the option to offer renewals to
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people in non--ACA compliant plans who were enrolled on
October 1, 2013. However, implementation was deferred to
states and is subject to state law. See below for more
information about the federal transitional policy.
In response to the November 2013 federal policy option to
allow for renewals of insurance coverage, Covered California's
governing board chose to maintain its policy to require the
cancellations for individual market QHPs (with the exception
of the two CDI regulated carriers) for a number of reasons,
including that for the vast majority of Californians, ACA
coverage is better coverage. A special consumer assistance
unit was established to help consumers through this
transition.
4.Federal Transitional Policy. On November 14, 2013, CMS issued
a letter to the State Insurance Commissioners outlining a
transitional policy for non-grandfathered coverage in the
small group and individual health insurance markets. CMS
announced in its November 14, 2013 letter that, if permitted
by applicable state authorities, health insurance issuers may
choose to continue certain coverage that would otherwise be
cancelled, and affected individuals and small businesses may
choose to re-enroll in such coverage. CMS further states that,
under the transitional policy, non-grandfathered health
insurance coverage in the individual or small group market
that is renewed for a policy year starting between January 1,
2014 and October 1, 2014 will not be considered out of
compliance with certain ACA reforms if certain specific
conditions are met. The ACA reforms are:
a. Section 2701 (relating to fair health insurance
premiums);
b. Section 2702 (relating to guaranteed availability of
coverage);
c. Section 2703 (relating to guaranteed renewability of
coverage);
d. Section 2704 (relating to the prohibition of
pre-existing condition exclusions or other discrimination
based on health status), with respect to adults, except
with respect to group coverage;
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e. Section 2705 (relating to the prohibition of
discrimination against individual participants and
beneficiaries based on health status), except with
respect to group coverage;
f. Section 2706 (relating to non-discrimination in
health care);
g. Section 2707 (relating to comprehensive health
insurance coverage);
h. Section 2709 (relating to coverage for individuals
participating in approved clinical trials); and,
i. Additionally, policies subject to the transitional
relief are not considered to be out of compliance with
section 1312(c) of the ACA (relating to the single risk
pool requirement).
On March 5, 2014, CMS issued another letter extending the
transitional policy for two years - to policy years beginning
on or before October 1, 2016, in the small group and
individual market. CMS indicates that it will consider the
impact of the two-year extension of the transitional policy in
assessing whether an additional one-year extension is
appropriate. CMS indicates this policy also applies to large
businesses that currently purchase insurance in the large
group market but that, as of January 1, 2016, will be
redefined by the ACA as small businesses purchasing insurance
in the small group market.
States that did not adopt the November 14, 2013 transitional
policy, and that regulate issuers whose 2013 policies renew
anytime between March 5, 2014 and December 31, 2014, including
any policies that were renewed early in late 2013, may choose
to implement the transitional policy for any remaining portion
of the 2014 policy year (i.e., this policy could apply to
"early renewals" from late 2013). Moreover, states can elect
to extend the transitional policy for a shorter period than
through October 1, 2016 (but may not extend it to policy years
beginning after October 1, 2016). Furthermore, states may
choose to adopt both the November 14, 2013 transitional
policy, as well as the extended transitional policy through
October 1, 2016, or adopt one but not the other, in the
following manner:
a. For both the individual and the small group markets;
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b. For the individual market only; or
c. For the small group market only.
1.Key Issues. According to Covered California, there are
250,000 employers who now offer health coverage in today's
small group market. These numbers include employers with
grandfathered plans that were in place when the ACA was
enacted. These employer-sponsored plans cover about 2.2
million individuals. Based on information provided by Covered
California based on aggregated information from multiple
carriers, an estimate of how the provisions of the ACA affect
the small group market rates, in general, is below. Twenty
percent of the employers in the total small group market
(employing 15% of the employees in the total small group
market) will see a reduction in rates on average of 10% upon
transitioning to ACA compliant coverage. Conversely, 20% of
the small group businesses (employing 30% of the employees in
the small group market) will see an average rate increase of
35-40%.
Rate Impact: Employers & Employees in Existing Small Group
Market
--------------------------------------------------------------
|Statewide |Statewide |Range of Rate |Average |
|Percentage |Percentage of |Increases/Decre|Increase/Decrea|
|of Small |Affected Small |ases (includes |se |
|Group |Group Employees |4-5 percent | |
|Employers | |medical trend | |
| | |not due to | |
| | |ACA) | |
|-------------+----------------+---------------+---------------|
|20 percent |30 percent |30-100 percent |35-40 percent |
|-------------+----------------+---------------+---------------|
|60 percent |55 percent |0-30 percent |14 percent |
|-------------+----------------+---------------+---------------|
|20 percent |15 percent |-40-0 percent |-10 percent |
--------------------------------------------------------------
According to Covered California, approximately one-third of
the overall California small group market renews in the first
half of the year, and approximately 40 to 50 percent of the
market renews in November and December. Employers receive
renewal rate information approximately 75 days prior to their
effective date. Therefore notices for November renewals would
start going out in August.
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It is important to keep in mind that some percentage of small
employers will already have converted to ACA compliant
coverage prior to enactment should this bill be enacted.
According to Covered California one-third of the market will
have renewed by the end of June. Additionally, those in
grandfathered plans are already permitted to renew their non-
ACA compliant coverage. As such it is difficult to estimate
how many employers and employees would be affected by this
bill. The individual insurance carriers are in the best
position to know those numbers.
2.Small Business Health Options. The Small Business Health
Options Program (SHOP) facilitates the purchase of health
insurance for small-business owners. SHOP is a second
marketplace run by Covered California, separate from the one
for individuals. In 2015, Covered California will expand this
program to begin offering health plans to employers with one
to 100 employees, for coverage beginning January 1, 2016.
Plans participating in the SHOP are: Blue Shield of
California, Chinese Community Health Plan, Health Net, Kaiser
Permanente, Sharp Health Plan and Western Health Advantage.
These plans are sold through licensed insurance agents trained
and certified by Covered California. SHOP is administered for
Covered California by Irvine-based Pinnacle Claims Management,
Inc., which was awarded the contract in April 2013. The only
way for small-business owners to access tax credits available
through the ACA is to purchase insurance through Covered
California's SHOP. The first phase of tax credits under the
law goes through tax year 2013 and provides businesses with
fewer than 25 full-time-equivalent employees with a tax
credit, provided the employees make less than $50,000 a year.
During this first phase, qualifying employers can receive a
tax credit of up to 35 percent of their contribution toward
their employees' premium (25 percent for non-profits). The
maximum tax credit increases to 50 percent (35 percent for
non-profits) in 2014 and is available for a total of two
consecutive years. Generally, businesses with 10 or fewer
full-time-equivalent employees and wages averaging $25,000 or
less a year will qualify for the maximum credits. To qualify
for tax credits, employers must also pay at least 50 percent
of employee-only premium costs. Through March 31, 2014, 1,156
small businesses (representing about 4,900 employees and their
dependents) have enrolled for coverage. Enrollment in SHOP is
available year round.
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3.Related legislation. AB 1507 (Logue) would authorize health
plans and insurers to renew individual and small group health
benefit plans in effect October 1, 2013, as specified, and
requires such coverage to be treated as "grandfathered"
coverage, exempt from California implementing provisions of
the ACA explicitly identified in this bill. AB 1507 was never
heard in Assembly Health Committee.
SB 959 (Hernandez) would prohibit a change in premium rate or
coverage for an individual plan contract or policy unless the
plan or insurer delivers a written notice of the change at
least 15 days prior to the start of the annual enrollment
period applicable to the contract or 60 days prior to the
effective date of renewal, whichever occurs earlier in the
calendar year. Makes several corrections and clarifications
to provisions of law governing individual and small group
health insurance, including clarifying that health plans and
insurers have a single risk pool for enrollees and insureds.
SB 959 was placed on the Senate Appropriations suspense file.
4.Prior legislation. SB 639 (Hernandez), Chapter 316, Statutes
of 2013, codifies provisions of the ACA relating to
out-of-pocket maximums on cost-sharing, health plan and
insurer actuarial value coverage levels and catastrophic
coverage requirements, and requirements on health insurers for
coverage of out-of-network emergency services. Applies
out-of-pocket limits to specialized products that offer
essential health benefits and permits carriers in the small
group market to establish an index rate no more frequently
than each calendar quarter.
AB 1180 (Pan), Chapter 441, Statutes of 2013, makes
inoperative several provisions in existing law that implement
the health insurance laws of the federal Health Insurance
Portability and Accountability Act of 1996 and additional
provisions that provide former employees rights to convert
their group health insurance coverage to individual market
coverage without medical underwriting. Established
notification requirements informing individuals affected by AB
1180 of health insurance available in 2014.
SB X1 2 (Hernandez), Chapter 2, Statutes of 2013-14 First
Extraordinary Session, and AB X1 2 (Pan), Chapter 1, Statutes
of 2013-14 First Extraordinary Session, conform California law
to the ACA as it relates to the ability to sell and purchase
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individual health insurance by prohibiting pre-existing
condition exclusions, establishing modified community rating,
requiring the guaranteed issue and renewal of health
insurance, and ending the practice of carriers conditioning
health insurance on health status, medical condition, claims
experience, genetic information, or other factors. The bills
also update the small group market laws for health plans to be
consistent with final federal regulations.
AB 1083 (Monning), Chapter 852, Statutes of 2012, amended
California's small group health insurance laws to enact the
relevant ACA provisions, such as eliminating pre-existing
condition requirements and establishing premium rating factors
based only on age, family size, and geographic regions. AB
1083 permits a waiting period of no longer than 60 days;
requires an affiliation period under a health plan contract to
run concurrently with any waiting period under that contract,
not to exceed 60 days; and, allows a waiting period for plan
years on or after January 1, 2014 to be applied as a condition
of employment if applied equally to all full-time employees,
consistent with ACA and any rules, regulations, or guidance
issued consistent with that law.
SB 951 (Hernandez), Chapter 866, Statutes of 2012 and AB 1453
(Monning), Chapter 854, Statutes of 2012 establishes
California's EHBs benchmark requirements.
5.Support. CDI sponsors this bill to allow pre-2014
nongrandfathered small group policies that were sold or
renewed in 2013 to be renewed through October 1, 2016. CDI
writes that plans subject to this transitional policy would
continue to be subject to existing small group law regarding
premiums, risk adjustment factors, and standard employee risk
rates; other provisions of existing law, including the
prohibition against the use of preexisting condition or
waivered condition provisions, the prohibition against
establishing rules for eligibility based on health
status-related factors, waiting periods and disclosure
requirements for solicitation, and sales materials. According
to CDI, the impact of the extension of policies is different
in the small group market than the individual market for a
number of reasons: 1) Pre-existing condition exclusions were
not permitted in the small group market prior to the ACA, and
so the small group market is not exposed to an influx of
previously uncovered lives; 2) Implementing the transitional
policy preserves coverage options because the ACA does not
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require small employers to purchase coverage for their
employees; 3) The transitional policy would have little impact
on the SHOP because it is a small part of the small group
insurance market; and, 4) The rate filings for the 2014 ACA
compliant small group products indicate that the rate changes
associated with adding health benefits to comply with the EHB
benchmark are between 0 and 2.7 percent because small group
coverage already includes comprehensive benefits, in large
part due to the state mandates that were already in place.
A number of employer and insurance organizations, such as the
California Chamber of Commerce and the California Association
of Health Underwriters write that this extended transitional
period will give small employers more time to prepare to bear
the costs associated with fully ACA compliant plans,
minimizing the potentially negative impacts this new burden
could have on the continuing economic recovery.
6.Support if Amended. The Bay Area Council writes that a one
year extension of non-ACA compliant plans is sufficient time
to assist small employers in their transition to new federal
regulations, but will minimize the potential negative impact
on ACA implementation. Moreover, the definition of small
employer will grow to 100 full time equivalent employees or
less in January 2016, potentially putting these new entrants
at a significant disadvantage. A lengthy extension of these
exemptions could also threaten the financial viability of the
SHOP exchange through Covered California by allowing a certain
portion of the small group market to operate under a different
regulatory environment.
7.Concerns. A number of employer groups, including the Silicon
Valley Leadership Group, Small Business California and the Los
Angeles Area Chamber of Commerce write that this bill could
considerably disrupt the small employer health insurance
market by fracturing the small group market with some plans
complying with the ACA and others operating under a different
set of rules. These employer groups write that this
undermines the goals of the ACA and could create instability,
leading to higher premiums for business. This bill would also
hurt the SHOP by leading to premium increases and anemic
enrollment until at least 2018. SHOP is required to be
self-sustaining, starting in 2015, which will be difficult,
perhaps impossible, without strong enrollment growth
beforehand.
SB 1446 | Page 14
8.Opposition. The Small Business Majority opposes this bill
because it would roll back existing state law by removing
protections for the 2.5 million small business owners and
employees who purchase health coverage in the small group
market. The Small Business Majority writes that as of January
1, 2014 state law provides additional protections to our
state's small entrepreneurs by guaranteeing the health
insurance products they purchase meet minimum standards,
contain limits on out-of-pocket costs and fit into
standardized "metal tiers" that provide more transparency when
shopping for insurance. This bill proposes to undo these
improvements already in effect for small businesses and their
covered employees and delay these provisions until 2017. This
would also hurt the SHOP administered by Covered California
because plans outside of Covered California would operate
under a different set of rules. Health Access California
writes that this bill would undo numerous consumer protections
that assure that covered employees of small businesses will
have EHBs, limits on out-of-pocket costs, protection against
rescission, the ability to shop for standardized plans based
on apples to apples comparisons and limits on deductibles.
Consumers Union fears this bill will create a climate for
adverse selection against Covered California.
9.Amendments.
a. Specialized health plans and insurance policies are
not subject to the authority provided under this bill.
Specialized health plans are explicitly excluded in the
Health and Safety Code provisions of this bill. Because
specialized health insurance policies are "excepted
benefits," they are also excluded from the Insurance Code
provisions. However, to be parallel and explicit, the
sponsor requests an amendment to make this clear.
b. The author proposes additional amendments to limit
the renewal of policies to one year only and to establish
specified notices to be issued by the small group health
plans and health care benefit plans.
SUPPORT AND OPPOSITION :
Support: California Department of Insurance (sponsor)
Associated Builders and Contractors of California
California Asian Pacific Chamber of Commerce
California Association of Health Underwriters
California Chamber of Commerce
California Manufacturer and Technology Association
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California Restaurant Association
California Small Business Association
Health Net
Independent Agents and Brokers of California
National Association of Insurance and Financial
Advisors - California
National Federation of Independent Businesses
Oppose: American Federation of State, County and Municipal
Employees, AFL-CIO
Consumers Union
Health Access
Small Business Majority
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