BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Elaine K. Alquist, Chair
BILL NO: AB 1759
A
AUTHOR: Blumenfield
B
AMENDED: June 24, 2010
HEARING DATE: June 23, 2010
1
CONSULTANT:
7
Chan-Sawin
5
9
SUBJECT
Health care coverage: premium rates
SUMMARY
Changes the circumstances under which a health care service
plan (health plan) or health insurer may, mid-contract
term, make changes to the premium rates or applicable
copayments, coinsurances, or deductibles for large group
health plan contracts or insurance policies. Exempts a
violation of this prohibition by a health plan from being
subject to the crime provision that applies to the
Knox-Keene Health Care Service Plan Act of 1975 (Knox-Keene
Act).
CHANGES TO EXISTING LAW
Existing law:
Provides for the regulation of health plans and insurers by
the Department of Managed Health Care (DMHC) and the
California Department of Insurance (CDI), respectively.
Prohibits a health plan or insurer from changing premium
rates or applicable copayments, coinsurances, or
deductibles for group health plan contracts or group health
insurance policies after the contract or policy holder has
Continued---
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delivered written acceptance of the contract or policy,
after the start of the open enrollment period, or after
receipt of the premium payment for the first month of
coverage.
Specifies that changes in the premium rates, applicable
copayments, coinsurances, or deductibles of a contract may
be changed when: 1) authorized or required in the contract
or policy; 2) the contract was agreed to under a
preliminary agreement that states that it is subject to
execution of a definitive agreement; or, 3) the plan or
insurer and the contract or policy holder mutually agree in
writing.
Defines "small employers" as 1) any person, firm,
proprietary or nonprofit corporation, partnership, public
agency, or association that is actively engaged in business
or service, that, on at least 50 percent of its working
days, as specified, employed at least 2, but no more than
50, eligible employees, as specified; or, 2) any guaranteed
association, as defined in Section 1357 (n), that purchases
health coverage for members of the association.
This bill:
Deletes the provision that allows changes in the premium
rates, applicable copayments, coinsurances, or deductibles,
when authorized or required in the contract or policy.
Narrows the provision that allows changes in the premium
rates, applicable copayments, coinsurances, or deductibles
of a contract from any types of changes the plan or insurer
and the contract or policyholder mutually agrees to in
writing, to only coverage changes.
Specifies that premium rates, applicable copayments,
coinsurances, or deductibles of a contract may be changed
when a change in applicable copayments, coinsurance, or
deductible is required by law.
Exempts the contracts and policies issued to a small
employer from requirements in existing law limiting health
plans and insurers from changing premium rates or
cost-sharing, except under certain specified circumstances.
Exempts the willful violation of this prohibition by health
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plans from being subject to penalties specified in the
Knox-Keene Act.
Makes other technical changes.
FISCAL IMPACT
This bill is keyed non-fiscal.
BACKGROUND AND DISCUSSION
According to the author, existing law permits health plans
and insurers to change rates mid-year "when authorized or
required in the group contract," and group insurance
contracts and policies typically contain language similar
to the following: "the health plan reserves the right to
re-rate the premium if enrollment varies by more than 10
percent." Such clauses allow insurers to adjust rates
mid-contract. The author states that this bill is
necessary to protect large group purchasers from a
mid-contract rate change, and would provide greater
stability in premium rates for employers and employees.
The author contends that a mid-year rate change is a
significant issue in the current economic environment of
lay-offs and corporate down-sizing, and can be devastating
for an employer who is seeing a reduction in business.
According to labor reports, California lost more than half
a million jobs in 2009. Payrolls shrank by 38,800 jobs in
December 2009, and the unemployment rate remained flat at
12.4 percent. A mid-year rate change for employers buying
coverage for employees could mean financial pressures to
reduce or cancel employer coverage. For workers, the
mid-contract rate increases could have major impact,
including leaving workers without employer-sponsored
coverage or unable to purchase more expensive health
coverage. A mid-year rate change is also a significant
issue for the growing and financially healthy employer. In
either case, employees are the ones most hurt financially
when there is a mid-year rate increase.
2010 health coverage rate increases in the individual
market
In February 2010, Anthem Blue Cross notified CDI of their
intention to raise rates up to 39 percent for policyholders
in the individual market. The decision by Anthem Blue
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Cross to implement these premium increases after similar
increases in 2009 caused great concern, not only in
California, but across the nation, as reports of other
health plans and insurers raising rates similarly were made
public. The California Assembly Committee on Health held
an oversight hearing in late February 2010 on the rate
increases, as did the Congressional House Energy & Commerce
Subcommittee on Oversight and Investigations on February
24, 2010.
Wellpoint, Anthem Blue Cross' parent company, in response
to an inquiry from Kathleen Sebelius, Secretary of the U.S.
Department of Health and Human Services, stated 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 medical loss
ratio 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 copayments do not increase with medical
inflation, and medical costs 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 2010, the independent actuarial review
found numerous errors in the methodology used by Anthem to
project total lifetime loss ratios, which is a projection
of the amount of services that is potentially used.
Specifically, mathematical errors in the double counting of
aging in the calculating medical trend caused Anthem to
overstate the initial medical trends used to project costs
for known risk factors. Once these numerous mathematical
errors were fixed, the average rate increase across Anthem
products was reduced from 25.4 percent to 15.2 percent,
reducing the initial rate increase on average by 10.2
percent.
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While the rate hikes were rescinded by the insurer, Anthem
indicated premiums may be adjusted "more frequently." Some
employers have interpreted these recent rate hikes as a
cautionary warning for future hikes in the group market.
As noted in the February 2010 congressional hearing, while
working families struggled with rising health care costs
and a recession, the 5 largest health insurance companies -
WellPoint, Cigna, UnitedHealth Group, Aetna and Humana -
had combined profits of $12.2 billion, up 56 percent from a
year earlier. Health insurance company profits grew while
the gross domestic product decreased by 1 percent over same
period.
Health plan and health insurance regulation in California
California's regulatory agencies, DMHC and CDI, oversee
roughly 200 health plans and insurers, which collectively
provide coverage for 27 million people. DMHC regulates
health plans, including Health Maintenance Organizations
(HMOs) and some Preferred Provider Organization (PPO)
plans. CDI regulates multiple lines of insurance,
including disability insurers offering health insurance,
which are generally PPO plans and traditional indemnity
coverage. Five HMOs-Kaiser, Blue Cross, HealthNet,
Pacificare, and Blue Shield-currently account for 76.0
percent of health plan enrollment in the state.
Collectively, these plans cover 20 million Californians.
Although DMHC and CDI both regulate health plans and
insurers providing health coverage, each regulator employs
a different approach, based on historical differences. At
the heart of the difference is the "promise-to-pay" versus
the "promise-to-deliver care." DMHC-licensed 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
become blurred over time because of the historical
exceptions made for two large PPO health plans and
insurers, Blue Cross and Blue Shield, who offer PPO
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products under both DMHC and CDI, but fundamental
differences remain in the expectations and regulatory
oversight by each regulator.
DMHC enforces the provisions of the Knox-Keene Act, which
sets rules for mandatory basic services; financial
stability; availability and accessibility of providers;
review of provider contracts; cost sharing; onsite medical
surveys, including review of patient medical records; and
consumer disclosure and grievance requirements. Knox-Keene
licensed plans must submit for review and approval all of
the types of contracts it will offer, as well as its
standard provider contracts and payment methods, audited
financial statements, administrative structure, financial
viability, actuarial analyses, proposed advertising and
marketing materials, and proposed service areas. However,
DMHC does not have authority to regulate rates except in a
few specified circumstances.
CDI requires premium rates to be filed for individual
health insurance, and rating plans to be filed by small
groups, but does not approve the rates per se. For
individual health insurance, CDI reviews rates after they
are filed, and may disapprove policies that provide no
economic benefit to the consumer and require that benefits
be reasonable in relation to use. The Commissioner can
also withdraw an individual health insurance policy upon a
finding that rates are unreasonable in relation to the
benefits.
Medicare supplement policies and contracts sold by both
health plans and insurers are subject to prior approval and
regulation of their medical loss ratios. Some other types
of health insurance are subject to rating restrictions, but
generally are not subject to rate regulation. Health plans
and insurers are subject to rating rules relating to health
coverage sold to small employer groups of 2 to 50 eligible
employees, but these rules do not limit the rate, per se,
that may be charged.
CDI oversees 11 percent of group policies in California,
compared to 39 percent of individual market policies. In
contrast, DMHC oversees 89 percent of the group policies
and 61 percent of individual policies.
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Group insurance
Group coverage is a health policy or contract purchased by
an employer, and offered to eligible employees (and often
to the employees' family members) as a benefit of working
for that company. The majority of Americans have group
health insurance coverage through their employer or the
employer of a family member.
Large group health insurance contracts, unlike small group
contracts and policies, do not have to be offered on a
guaranteed-issue basis, so a health insurance company could
reject an entire large employer group based on its claims
history. However, no individual employee who is eligible
for benefits can be excluded from large group coverage
based on medical history. If a company issues a policy to a
large employer, then all of its eligible employees must be
issued coverage.
Federal law mandates all group insurance contracts,
including large group contracts, be renewed every year at
the employer's discretion, unless there is non-payment of
premium, the employer has committed fraud or intentional
misrepresentation, or the employer has not complied with
the terms of the contract or policy. Large group health
insurance is medically underwritten at the time of purchase
with rates based on employee participation and prior claims
experience, as well as any overall increases in the cost of
providing coverage (an example of such costs would be
changes in laws that may impact operating expenses).
Individual employees are not generally asked to fill out a
medical questionnaire prior to obtaining coverage.
Many employers contract with state regulated health
insurance companies to provide its employees health
benefits. However, larger group health plans (usually
several hundred employees or larger) may choose to either
fully, or partially, self-insure their group benefit plans.
This means that instead of paying health insurance
premiums to a company, the employer sets a pool of funds in
reserve, and assumes its own risk for health benefit
claims. Companies that self-insure generally buy what is
known as a "stop-loss insurance policy" to protect
themselves against losses above a certain threshold. Such
companies contract with either a third-party administrator
or a health plan to administer benefits and handle claims.
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Self-funded plans are regulated federally by the Department
of Labor under the Employee Retirement Income Security Act
of 1974 (ERISA), so they are sometimes known as ERISA
plans.
According to the California Health Benefits Review Program,
in 2010, an estimated 19 million Californians were
privately insured. Of these, roughly 4 million, or 21
percent were in self-funded, ERISA plans, compared to
roughly 9.8 million, or 51.3 percent who were insured in
the large group market and 3.3 million, or 17.5 percent in
the small group market. There were roughly 2 million
individuals, or 10.3 percent, who bought coverage on an
individual basis.
Employer Sponsored Coverage in California
According to the 2009 California Employer Health Benefits
Survey published by the California HealthCare Foundation,
nine percent of California companies provided
employer-sponsored coverage in the large group market in
2009 for seventy-three percent of California workers.
Premiums for individuals, across all firms in California,
averaged $5,133 annually, with an average cost-sharing to
the employee of $564, or roughly 11 percent. Premiums for
family coverage in the state were $13,525 on average, with
the employee contributing $3,398 annually, or roughly 25
percent.
Across the state, 30 percent of employers saw a premium
increase of 10 percent or more from 2008 to 2009. Compared
to smaller firms, larger employers experienced smaller
premium increases and were less likely to see premium
increases over 15 percent. In addition, 15 percent of
California's employers reduced benefits or increased
cost-sharing in response to the economic downturn. Eleven
percent of employers increased employee's premiums.
The survey also found that 44 percent of large employers
and 20 percent of small employers indicated that they were
"very likely" to increase premium cost-sharing to their
employers in 2010. Six percent of employers indicated that
they were "very likely" to drop coverage entirely in the
upcoming year, compared to one percent in 2008.
Grandfather rule in federal health reform
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In March of this year, the President signed the federal
health reform law, the Patient Protection and Affordable
Care Act (PPACA) and its sister Act, the Affordable Care
Act. Once implemented, both acts would make significant
changes to the California health insurance market and its
regulatory environment.
During the health reform debate, President Obama made clear
to Americans "if you like your health plan, you can keep
it." He emphasized that nothing in the health reform law
would force businesses or consumers to change health plans
or change their doctor. This promise was ensured in the
grandfather rule, which enables businesses and families to
keep their plan while adding important new benefits for all
Americans with private insurance. Grandfathered plans are
plans that existed, as of March 23, 2010. Plans can keep
their grandfathered status so long as they only make
routine changes. These routine changes include cost
adjustments to keep pace with medical inflation, adding new
benefits, making modest adjustments to existing benefits,
voluntarily adopting new consumer protections under the new
law, or making changes to comply with state or other
federal laws. Plans will lose their "grandfather" status if
they choose to significantly cut benefits or increase
out-of-pocket spending for consumers - and consumers in
plans that make such changes will gain new consumer
protections.
The grandfather rule is silent about changes in premiums,
and would apply to both state-regulated health plans and
insurers, as well as federally regulated plans. It is
unclear how the grandfather rules in health reform will
change market competition between state regulated health
plans and insurers, and federally regulated ERISA plans.
Arguments in support
The sponsor, Pacific Federal, writes that a mid-year rate
change is a significant issue in this economic environment
of lay-offs and corporate downsizing, and could be
devastating for the employer which is seeing a reduction in
business. Consumer Attorneys of California concurs,
stating that recent rate increases have hit small business
owners hard, and this bill is a common sense measure that
will benefit both consumers and business owners alike, as
they struggle to keep shop doors open and provide adequate
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health coverage for employees. The California Teachers
Association states that this measure would contribute to
affordable, stable health costs for Californians.
Writing in support, the Association of California Water
Agencies state that, as the economy has worsened and
continues to decline, many employers have implemented
layoffs in an attempt to curtail budgetary shortfalls. As
employment ranks have shrunk, often the laid off employees
are younger, newer employees who tend to use less health
benefits. This bill would curtail any rate increases in
insurance premiums mid contract.
Arguments in opposition
Anthem Blue Cross opposes this bill, stating that by
limiting what health plans and insurers use in contracts
will have unintended consequences that will lead to
increased costs to group contracts. Anthem Blue Cross
asserts that these clauses are necessary, and primarily
used only when the risk profile of a particular business is
different than what was initially described and agreed to
prior to signing the contract. This flexibility affords
plans and insurers the ability to change rates when
circumstances require it without having to rate each
customer at a higher rate overall to account for the
potential that the risk of the group may change
significantly.
Blue Shield of California writes that various geographic
locations have large disparities in the cost of medical
services throughout the state (rural vs. urban, for
example), and this bill would prohibit premium changes
based on those factors, even when the changes are favorable
to the employer.
Health Net writes that health plans and insurers
aggressively compete to attract and retain business and,
given the costs associated with attracting new business,
health plans and insurers strive to renew business when the
contract period ends. Health Net argues that a unilateral,
mid-term premium increase without a legitimate
justification is contrary to plans and insurers' goal of
attracting and retaining business. Health Net further
states that, should there be a material, not trivial,
change in the composition of the group, the contracts
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signed by those groups authorize Health Net to review and
adjust the rates.
Kaiser Permanente points out, as part of its opposition,
that this bill establishes rules to tie the hands of health
plans and insurers regulated under California law, but
would impose no such restrictions on the bill's chief
proponent - administrators of self-funded plans for large
employer groups. These self-funded arrangements, which are
exempt from state regulation under federal law, simply pay
claims for health care costs as they are incurred - in
effect, automatically adjusting for changes in the heath
status of the employer group regularly. Kaiser points out
that this is exactly the kind of adjustment the proponents
would prevent their competitors in the marketplace from
being able to make.
Related bills
SB 1163 (Leno) of 2010 would, among other things, require
health plans and insurers to give 180 days written notice
of changes in the premium rate or coverage before such a
change takes effect, as specified. Set for hearing on June
29, 2010 in the Assembly Health Committee.
AB 591 (De La Torre) of 2009 would, among other things,
provide a moratorium on increases in health insurance
premium rates for 90 days after this bill becomes
operative, prohibit a health plan or insurer from
increasing premium rates by more than the average
percentage increase in the medical care component of the
consumer price index for the immediately preceding calendar
year, as specified, and prohibit a health plan or insurer
from increasing the premium rate it charges a subscriber or
policyholder during the 12 months following the last
premium rate increase. Set for hearing on August 4, 2010
in the Senate Health Committee.
AB 2042 (Feuer) among other things, provides predictability
in the individual insurance market by limiting rate and
benefit changes to once per year. Pending hearing in
Senate Appropriations Committee.
AB 2170 (Bonnie Lowenthal) prohibits health plans and
insurers covering prescription drug benefits and using a
formulary from changing the applicable copayments or
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deductibles or coinsurances for prescription drug benefits
for the length of the contract or policy. Failed passed in
Assembly Appropriations Committee.
AB 2578 (Jones and Feuer) requires health plans and
insurers, effective January 1, 2012, to apply for prior
approval of proposed rate increases, under specified
conditions, and imposes on DMHC and CDI specific rate
review criteria, timelines and hearing requirements.
Pending hearing in Senate Appropriations Committee.
Prior legislation
AB 1218 (Jones) of 2009 would have required health plans
and insurers 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. Failed passage in Assembly
Health Committee.
AB 1554 (Jones) of 2008 was substantively similar to AB
1218 (Jones) of 2009. Failed passage in Senate Health
Committee.
SB 425 (Ortiz) of 2006 would have required health plans and
insurers to obtain prior approval for a rate increase,
defined in a similar manner to rates under AB 1218 of 2009.
Failed passage in Senate Health Committee.
AB 2889 (Frommer), Chapter 826, Statutes of 2006, requires
health plans and insurers to permit an individual who has
been covered for at least 18 months under an individual
contract or policy to transfer, without medical
underwriting, to any other individual contract or policy,
as specified.
SB 26 (Figueroa) of 2004 would have required health plans
and health insurers to obtain prior approval of rate
increases from DMHC and CDI, as specified, and would have
potentially required significant refunds of premiums
previously collected. Failed passage in Senate Insurance
Committee.
AB 2052 (Goldberg), Chapter 336, Statutes of 2002,
prohibits a health care service plan or insurer from making
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any change in premium rates or cost sharing after
acceptance of a contract or after the open enrollment
period.
PRIOR ACTIONS
Assembly Health Committee: 44-28
Assembly Floor: 12-6
COMMENTS
1.Current bill continues to limit premium changes due to
changes in enrollment. Previous version of the bill would
have prohibited a health plan or insurer from using a
change in enrollment as the basis for a premium rate change
during the length of the contract. Recent amendments,
which remove the ability of health plans and insurers to
include a clause in the group contract that would allow
them to re-rate the premium if enrollment varies by more
than 10 percent, would have the same effect. The current
version of the bill prevents plans and insurers being able
to make a change in premiums or cost-sharing rates mid-year
that is not based on changes in applicable copayments,
coinsurance, or deductibles, as required by law, or that
are mutually agreed upon by both parties. The effect of
this bill could be anticompetitive for state-regulated
health plans and insurers.
2.The bill would also limit changes due to composition of
workforce. It is unclear if there are other mutually
agreed upon changes, such as a change in network, that may
be cause for premium or other cost-sharing rate changes.
The author and sponsor believe that employers would be
willing to forgo such opportunities for predictability in
health care costs over the term of the contract. However,
if an employer has an increase in younger workers or a
decrease in older workers, this bill would preclude premium
rates from adjusting downward. This situation is likely,
given the increasing rate of retirement of aging baby
boomers. The effect of this bill could be anticompetitive
for state-regulated health plans and insurers.
3.Clarifying amendment to narrow the scope of the bill to
large employers. The author's intent is to limit the
provisions of this bill to large employer contracts without
making changes to small employer contracts. The bill, as
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currently written, removes the prohibition on health plans
and insurers from changing premium rates or cost-sharing
more than once a year, with respect to small employers.
Staff suggests the following clarifying amendments:
(a) On page 2 , line 14, after "contract" insert:
with an employer that does not meet the definition
of "small employer," as defined in Section 1357,
(b) On page 3 , delete lines 3-4 and replace with :
(c) Changes to the premium rates or applicable
copayments or coinsurances or deductibles of a
contract with a small employer, as defined in
Section 1357, shall, subject to the plan meeting
the requirements of this article, be allowed in any
of the following circumstances:
(1) When authorized or required in the group
contract.
(2) When the contract was agreed to under a
preliminary agreement that states that it is
subject to execution of a definitive agreement.
(3) When the plan and contractholder mutually agree
in writing.
(c) On page 3 , line 25, after "policy" insert:
with an employer that does not meet the definition
of "small employer," as defined in Section 10700,
(d) On page 3 , delete lines 3-4 and replace with :
(c) Changes to the premium rates or applicable
copayments or coinsurances or deductibles of a
contract or policy with a small employer, as
defined in Section 10700, shall, subject to the
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insurer meeting the requirements of this chapter,
be allowed in any of the following circumstances:
(1) When authorized or required in the group
contract or policy.
(2) When the contract or policy was agreed to under
a preliminary agreement that states that it is
subject to execution of a definitive agreement.
(3) When the insurer and the policyholder or
contractholder mutually agree in writing.
1.What approach, if any, should California take to regulate
rates and/or benefits? This bill is one of three Assembly
Bills aimed at addressing the substantial rate hikes levied
by health plans and insurers earlier this year. The other
two bills were heard on June 23, 2010 in Senate Health
Committee, and offer two different approaches:
(a) AB 2042 (Feuer), limits rate and benefit
changes in the individual insurance market to once
per year. AB 1759 may be complementary to AB 2042.
(b) AB 2578 (Jones/Feuer) directly regulates
premiums, in both the individual and group market,
by requiring plans and insurers to apply for prior
approval of proposed rate increases with DMHC and
CDI. AB 2578 may have the same deterrent effect in
the group market as AB 1759, but is a more direct
method of rate regulation.
1.Other technical amendment:
(a) On page 3 , delete lines 8-9
POSITIONS
Support: Pacific Federal (sponsor)
American Federation of State, County and Municipal
Employees (AFSCME)
Association of California Water Agencies
California Chapter of the American College of
Emergency Physicians
California Chiropractic Association
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California Communities United Institute
California Medical Association
California Psychological Association
California School Employees Association
California Teachers Association
Consumer Attorneys of California
Neighborhood Legal Services of Los Angeles County
Valley Industry and Commerce Association
Oppose: Anthem Blue Cross
Association of California Life and Health Insurance
Companies
Blue Shield of California
California Association of Health Plans
Health Net
Kaiser Permanente
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