By Ana B. Ibarra
APRIL 20, 2018
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 plansthat
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 peoplenationwide
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.”
This story was produced by Kaiser Health News, which publishes California
Healthline, a service of the California Health Care Foundation.
Ana B. Ibarra: aibarra@kff.org, @ab_ibarra
No comments:
Post a Comment