CHIRA – Part I

For the sake of simplicity, I’m going to submit two email excerpts relating to the subject of SB 840, the California Health Insurance Reliability Act (CHIRA).  The first one (CHIRA – Part I) is below. The second one (CHIRA – Part II) references my response to a letter from State Senator Jeff Denham, which indicates that State legislative leaders (or their staff) are not necessarily aware of pertinent information, and certainly the general population could be even less well informed if they do not take the effort to investigate the issue fully.
My original letter to the editor was at the request and approval of George Lundberg, M.D., Editor-in-Chief of MedGenMed (Medscape LLC) and Adjunct Professor of Health Policy, Harvard School of Public Health, Boston, MA.
Dr. Lundberg:
Regarding the judging of proposals for true health system reform based on your 11 evaluation characteristics, (“American Health “System” Reform – Part 6” )[1] , a model proposed for California should be put to the test of those elements. 
Senator Sheila Kuehl, Dem-Santa Monica, has authored SB 840, the California Health Insurance Reliability Act (CHIRA)[2].  This measure deserves to be reviewed and discussed beyond the State’s borders as its success in the world’s sixth largest economy would signal a shift in healthcare delivery systems toward fiscally sound, comprehensive, affordable and consistent health insurance coverage. 
So, based on my attempt at applying your evaluation elements, let’s see how this program might measure up compared to your grade of the 2005 American system of 52 and my grade of the current American system.
1. Access for all to basic care:  CHIRA eligibility is based on residency, not on employment, income or insurability.  All residents will have coverage of all care prescribed by a patient’s health care provider that meets accepted standards of care and practice.           
CHIRA Score:            9                      Current system score:            5
2. Produce real cost control: The plan not only involves no new spending on health care, this measure will make the health care system more reliable and secure by stabilizing the growth in health spending; linking spending increases to the state GDP, population growth, employment rates and other relevant demographic indicators.           Administrative costs will be capped by statute.
CHIRA Score:            9                      Current system score:            5
3. Promote continuing quality: “Quality” is an elusive characteristic.  Current systems attempt to fill the quality measure gap, but I believe that the best measure of quality is when consumers vote with their feet, given the opportunity to do so.  In CHIRA, providers will be free to apply their medical training and skills and patients can choose their providers based on their perception of those providers’ quality of care.  Also, the plan will invest in statewide medical databases to assist in improving health care quality and in creating programs to encourage personal responsibility for good health.  However, even a program like CHIRA can’t effect this change completely on its own. Consumers still must choose healthy lifestyles, including educating themselves and adopting appropriate nutrition and exercise programs.
CHIRA Score:            6                      Current system score:            4
4. Reduce administrative hassle and cost: Providers and consumers will not have to deal with the maze of confusing health care delivery system bureaucracies. The estimate of the current system is that half of every dollar spent on health care is squandered on clinical and administrative waste, insurance company profits and overpriced pharmaceuticals. The CHIRA model is based on independent studies showing estimated savings of about $20 billion through reduced administrative costs in the first year alone.  Analyses also show estimates through system wide bulk purchasing of $5.2 billion in the first year.    

CHIRA Score:            9                      Current system score:            4
5. Enhance disease prevention: The plan will combine needed cost controls with medical standards that use the best available medical science and place an emphasis on preventative and primary care to improve California’s overall health in a way that also saves billions of dollars. CHIRA gets an A for Effort, but; again, an educated, motivated and involved consumer is essential to disease prevention.
CHIRA Score:            7                      Current system score:            4
6. Encourage primary care: With some limited exceptions, consumers will be required to select a personal primary care physician.    Access to primary care providers could save $3.5 – $6 billion in unnecessary emergency room visits and preventable hospitalizations.
CHIRA Score:            9                      Current system score:            4
7. Consider long term care: Considerable expert analysis on Long Term Care is included in the development of the plan.  Beyond the 100 days of skilled nursing facility care post hospitalization, it is not a part in the initial benefits; but it is planned for subsequent inclusion with further review and incorporation of appropriate guidelines.        
CHIRA Score:            2                      Current system score:            1
8. Retain patient autonomy: All licensed providers and accredited facilities may participate.  Every Californian will have the right to choose his or her own personal primary care physician.  Some limited continuing service arrangements will be allowed for patients under specialist care initially, but generally a referral for specialist visits will be required from a consumer’s primary care physician or emergency physician.
CHIRA Score:            7                      Current system score:            5
9. Retain physician autonomy: Physician freedom from the profit-driven motives of most managed care plans is a major feature of the plan.  It will put medical decision-making back in the hands of medical professionals and their patients. Overall governance will be from an elected Commissioner and the State Health Agency which, while having physician and other health care provider representation, will have boards that include others, such as members of the public, consumer advocates, policy experts, and labor leadership.
CHIRA Score:            8                      Current system score:            6
10. Limit professional liability: The information system enhancements, inherent controls and quality improvement measures of the plan will present a foundation for malpractice premium stabilization and reduction.  Any specific malpractice reform would be a separate issue.
CHIRA Score:            6                      Current system score:            4
11. Possess staying power: A plan such as CHIRA has the balance of incentives and controls necessary to maintain the stability and assurance of consistent health insurance delivery over long periods of time with fluctuating personal, societal and economic conditions.  It has the mechanisms to account for the inevitable changes that will arise in health care delivery operations and technology.
CHIRA Score:            9                      Current system score:            6
CHIRA Points:             81                     Current system points:            48
Well, as you say, no reformed health care system can be perfect nor satisfy all the constituencies.  But CHIRA could be on the right track as a model plan for assuring and stabilizing health insurance coverage for a large and diverse population base.
Thank you,

Joe Polaschek


1.   Lundberg GD. The American Healthcare “System” in 2005 – Part 6; How to Grade the Current System and Proposed Reforms. Medscape General Medicine. Posted 3/11/2005.  Available at:
2.  (Link to the full text of SB 840, the California Health Insurance Reliability Act)  

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