How California can survive Trumpcare
By Gerald F. Kominski
Los Angeles Times, November 18, 2016
No one knows exactly what Donald Trump’s pledge to “repeal and replace” the Affordable Care Act means. The hints, however, are troubling. No state has embraced the ACA — Obamacare — more enthusiastically and successfully than California. And no state has more to lose with Trumpcare.
The question is, what comes next? The Trump campaign was short on details. Suggestions included promoting health savings accounts linked to high-deductible health plans; allowing insurance to be sold across state lines in an effort to increase competition and thus affordability; and allowing everyone to deduct health insurance premiums from their taxes.
In one “replace” scenario — contained in Ryan’s 2016 “A Better Way” proposal — those tax credits would continue but would no longer be scaled to income as they are under Obamacare.
As for Medi-Cal, Trumpcare would fundamentally transform the program. Under Trumpcare, each state will instead receive a block grant program that fixes its allocation at a to-be-determined point in time. Because healthcare spending has always grown faster than inflation, the real value of Trumpcare block grants is guaranteed to shrink over time.
For Medi-Cal, the options are some combination of cutting eligibility, cutting benefits and raising taxes. Paying providers less won’t be viable because California already has some of the lowest rates in the country for its Medicaid program.
For Covered California, higher taxes will be required if the state wants to keep the program going with health plans and policies that meet Obamacare standards. Californians would have to agree to make up whatever the shortfall is between Trumpcare’s tax credits and Obamacare credits. The only other option is reduced benefits.
A brand new state “single payer” plan is another possibility, but it would face its own challenges, particularly under a Republican administration in Washington hostile to innovations that aren’t based on the mythical “free” market for health. The economics and administration of single payer work best if all government health insurance programs — including Medicare, the Veterans Administration system and the military’s Tricare program, as well as the state’s CalPERS program for public employees — are folded into one plan. The Trump administration is not going to easily grant permission for California to exit the federal programs taking its share of the taxes that support them.
California’s experience with Obamacare has been extremely positive, and there are already indications that state politicians will try to keep it alive regardless of what Washington does. As the details of Trumpcare come into focus, so will the state’s best strategies to close the expected funding gaps. All options need to be considered, and no option should be ruled out quickly because it appears too difficult or politically impossible. Californians dream big, and that’s what will be required to keep healthcare accessible in the Golden State.
Gerald F. Kominski is director of the UCLA Center for Health Policy Research.
By Don McCanne, M.D.
Quoting Professor Gerald Kominski:
“No option should be ruled out quickly because it appears too difficult or politically impossible.”
“The economics and administration of single payer work best if all government health insurance programs — including Medicare, the Veterans Administration system and the military’s Tricare program, as well as the state’s CalPERS program for public employees — are folded into one plan.”
We need to consider the possibility of “a ‘brand new’ state single payer plan.”
Obviously a national single payer program is what we really need, but that would require a total turnabout by Sen. McConnell and Speaker Ryan – a political shift that would be about as likely as electing Donald Trump president. But think about that for a minute. Think about what that means when someone says that it’s not politically feasible.
At any rate, California politicians have an excellent track record of supporting optimal policies. Just because they have been very successful in implementing the Affordable Care Act doesn’t mean that they should rest on their laurels and simply accept the intolerable deficiencies that remain.
It’s time for California to initiate another effort to move forward with enactment of whatever single payer policies are possible within federal restrictions that Congress refuses to waive – as an interim measure until we have an enlightened Congress and administration that will bring us a single payer national health program – an improved Medicare for all.