Editor's Corner: California Dreamin' in a post-Trump healthcare world

California flag and American flag
Ron Shinkman
Ron Shinkman

I’ve been writing about the business of healthcare for 23 years. Despite it being a buttoned-up sector, I’ve encountered my share of reactions from those within the trade: Anger, defiance, arrogance, hope.

A stunned stupor was a new one to me. Yet it's a common mood in recent days.  

“Most of my phone calls weren’t being returned last week. I can’t figure out why that is,” deadpanned a long-time friend of mine in healthcare PR who has a wry sense of humor.

With Donald J. Trump’s improbable rise to become the 45th President, there is a gathering momentum to dismantle the Affordable Care Act. This is singularly without precedent. At what time in the past 227 years has there been an emboldened movement to eradicate a safety net program in the United States?

And the healthcare sector was taken completely by surprise. “I was in Washington on election day, and I was at a National Association of Medicaid Directors Conference. Everyone was talking about the continued expansion of the ACA,” Bill Barcellona, director of government affairs for the California Association of Physician Groups, told me. “No one was thinking about what might happen now.”

Trump suggests he likes parts of the ACA, such as the barring of underwriting and lifetime caps on coverage. But there has never been a person like him to enter the Oval Office. So little he said during the election campaign was moored to facts, truth and human empathy. So little attention was paid to policies and their attendant details. And so many radicals—such as Senior Advisor Steve Bannon, standard bearer of the alt-right—have his ear.

Thus, it’s entirely possible that Congress will simply eradicate the ACA in a single piece of legislation, and Trump will just sign it into law, consequences be damned. I’d like to say that’s unlikely, but our nation’s ability to heed consequences is somewhat from operational peak. 

That brings me back to stunned stupor. I will say it’s been fairly good for my work ethic. Anxious not to sit around and contemplate the future, I began working the phones in my native California, a state that has embraced the ACA like no other.

The state set up the Covered California exchange that insures nearly 1.5 million people, of whom 90 percent receive some sort of premium subsidy. It obtained a waiver to expand its Medicaid program on an accelerated timetable, and now about one out of three Californians has coverage through Medi-Cal, the state Medicaid program.

The consensus among policymakers and observers: Not good.

“At risk is insurance coverage for literally millions of Americans,” said Anthony Wright, executive director of the advocacy group Health Access California.

Jim Lott, who teaches healthcare policy at USC and Cal State Long Beach and was the longtime executive vice president of the Hospital Association of Southern California, noted that even if parts of the law are preserved the way Trump suggests, it would still be imperiled.

“If you don’t have an employer mandate and an individual mandate, the market would self-destruct,” Lott said. “It will create havoc.”

Barcellona, an attorney by training, concurred with Lott. “The law matters and these federal programs are conditioned on the act being implemented in a certain way,” he said.

Barcellona also brought up a consequence that would be utterly disastrous for millions of middle-class Americans: If the ACA is eliminated in the middle of a calendar year, it could put them on the hook for repaying billions of dollars in premium tax credits.

Maybe it’s better to focus on the California microcosm. 

About 6 million Californians obtained insurance coverage as the result of the ACA—that’s about 15 percent of the state’s population. And as well as California has performed economically in the years since the Great Recession, it relies so heavily on federal funding to insure so many people—about $15 billion a year for the Medicaid expansion alone—that replicating it would be an immense task.

“California will of course look at going it alone,” Wright said. “But it’s going to be very tough.” He added that some people might lose coverage or benefits as a result.

Yet who knows what the future might portend? California is the sixth-largest economy in the world. If its citizens agree, the state certainly has the means to preserve the ACA, perhaps even forge a single-payer system. Lott suggested that is a possible consequence of an imploded ACA.

The state certainly possesses the generosity of spirit. That was borne out by the huge percentage of voters in my beloved Los Angeles, who just agreed on a tax increase that will fund a stunning $125 billion initiative to expand the public transportation system and improve the existing infrastructure. They also voted to spend another $1.2 billion to house the homeless. Despite the bitterness and shock of the Presidential election, November 8 was among my proudest days ever as an Angeleno and a Californian. 

And, if that’s the case—and if the national hysteria against making sure everyone has access to healthcare is ever allowed to die down—perhaps the desire of the rest of the country wishing to share in the California dream may yet survive. If not thrive. - Ron (@FierceHealth)