These days, when the federal government turns in one direction, California veers in the other — and in the case of health care, it’s a sharp swerve.
In the nation’s most populous state, lawmakers and other policymakers seemingly are not content simply to resist Republican efforts to dismantle the Affordable Care Act. They are fighting to expand health coverage with a series of steps they hope will culminate in universal coverage for all Californians — regardless of immigration status and despite potentially monumental price tags.
The Golden State embraced the health care law early and eagerly, and has more to lose than any other state if the ACA is dismantled: About 1.5 million Californians purchase coverage through the state’s Obamacare exchange, Covered California, and 3.8 million have signed up for Medicaid as a result of the program’s expansion under the law.
While other states are making efforts to preserve the ACA and expand coverage, California stands out by virtue of its ambition and size, economic clout, massive immigrant population and liberal bent.
Its health care resistance movement is broad and includes Attorney General Xavier Becerra, who has made a sport of suing the Trump administration. He is currently leading a coalition of 15 states, plus the District of Columbia, against a Texas-based lawsuit that seeks to strike down the ACA.
Even Covered California, the ACA marketplace, has jabbed at the feds. During the most recent enrollment period, which ended in January, it preserved its three-month sign-up window while the federal government cut the enrollment period in half for states that rely on the healthcare.gov exchange. Covered California also deployed a monster advertising budget of $45 million to encourage enrollment, while the federal government slashed its ad dollars to $10 million.
California’s activism could be contagious, said Linda Blumberg, a fellow at the nonprofit research institution the Urban Institute.
“California has been in the forefront” on a lot of health policy issues, she said. To the extent that it is successful, she said, “that helps not only the state of California itself but other states as well.”
Since last year, the federal government has allowed some states to impose work requirements on Medicaid recipients; promoted temporary health plans that have fewer consumer protections than Obamacare insurance; and, most recently, adopted a rule allowing states to lower the percentage of premium dollars that insurers are required to spend on medical care.
In response, California lawmakers are debating bills that would prohibit work requirements in Medi-Cal, the state’s version of Medicaid; ban the sale of short-term plans in the state; and increase the percentage of insurance premiums that must go toward consumers’ care.
“Look at what we’ve done in women’s issues, climate change, protecting immigrants. … That’s just the kind of thing we do. Health is no different,” said state Sen. Ed Hernandez (D-West Covina), the head of the Senate Health Committee and author of several proposals.
Four pending bills in California would provide some consumers with state-funded financial help to supplement federal subsidies created by Obamacare. One such proposal could cost the state about $500 million initially.
“We continue to move forward and push the envelope, now more than ever,” state Sen. Ricardo Lara (D-Bell Gardens) told a room full of physicians recently in Sacramento. Lara, a candidate for state insurance commissioner, is carrying a bill that would offer full Medicaid benefits to a group that’s never been covered before: adults who are in the country illegally.
“We not only play defense, but we want to make sure we’re more proactive,” he said.
California’s efforts to cover unauthorized immigrants under Medi-Cal predate the Trump administration. Achieving it now would represent not only a significant expansion of coverage within the state, but also a direct challenge to the federal government, which has made a point of cracking down on immigrants.
Critics point out that this spirit of defiance does not represent all Californians.
“We have some crazy things happening here,” said Sally Pipes, president of the conservative Pacific Research Institute. “Nobody talks about how to pay for these. Well, you pay for it in increased taxes.”
Sara Rosenbaum, a professor at the Milken Institute School of Public Health at George Washington University, said it’s no secret that President Donald Trump doesn’t like California — and that the feeling is mutual.
While she believes his administration might try to punish the state for its defiance, California will nonetheless persist in its campaign to defend the ACA and expand coverage.
“I’m sure [federal officials] can try to do a million things to make the state’s life miserable,” she said. “They can jerk it around on the federal Medicaid payments. … But I just think this, too, shall pass.”
It’s not clear whether the pending legislative proposals will succeed. Assuming any of the bills make it through the legislature, their fate lies with Gov. Jerry Brown, a Democrat known for fiscal conservatism.
“If the past is any indication, it seems unlikely that bills with sizable and uncertain ongoing costs will move forward,” said Shannon McConville, a researcher at the Public Policy Institute of California.
California is not alone in resisting health care policies put forth by the Trump administration. Other states, including Maryland and New Jersey, may establish state-based penalties for not having insurance — a response to Congress’ decision to kill the federal Obamacare penalty starting in 2019.
But California’s approach, characteristically, is different.
“Rather than use the stick, use the carrot,” said Hernandez. His bill would target $500 million from the state’s general fund to help some income-eligible Californians pay their premiums or out-of-pocket medical costs. This assistance would supplement the federal financial aid for those on the Covered California exchange.
The Senate Health Committee approved the bill last week.
The Congressional Budget Office estimates that about 4 million people nationwide will become uninsured when the tax penalty for not having insurance goes away. In California, the number would be about 378,000, according to a recent Harvard University study.
Three other bills would offer state-based financial aid to different groups of consumers, including those who make too much money to qualify for federal tax credits but still struggle to pay their premiums.
The biggest potential budget-buster of them all is a proposal to establish a single-payer health system, which was pulled from consideration last year, largely because of its eye-popping price tag: $400 billion annually.
Advocates for universal health care aren’t giving up, though some have shifted their strategy to moving piecemeal toward universal health care in lieu of a massive single-payer bill.
“There are individual steps that we can still take to expand coverage to various populations that are falling through the cracks,” said Gerald Kominski, director of the UCLA Center for Health Policy Research.
One of those populations, and a large one, is immigrants living without authorization in the country.
Lara is not the only legislator with a proposal to extend full Medi-Cal coverage to income-eligible adult immigrants without legal status. State Assemblyman Joaquin Arambula (D-Fresno) has introduced a separate bill that would do the same. Arambula’s measure made it through the Assembly Health Committee on Tuesday, and Lara’s bill passed the Senate Health Committee earlier this month.
Of the nearly 3 million Californians without insurance, about 58 percent are currently ineligible for full Medi-Cal benefits or Covered California insurance because they’re not in the country legally.
California must “lead the nation in bold and inclusive polices” that support the health of all communities, said Arambula, who is an emergency room doctor.
In 2016, the state extended full Medi-Cal benefits to all children, and now more than 200,000 undocumented kids are enrolled. It’s not clear how much it would cost to cover undocumented adults, but last year, the state budgeted $279.5 million for the children. Adults are generally more expensive to cover.
All of these measures, successful or not, add up to a campaign of defiance.
“It’s a signal that California is willing to fight very hard, on multiple fronts … to protect certain values and policies,” McConville said. “This shows we’re not willing to go backwards on that.”
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