On May 4, the American Health Care Act (AHCA) was passed by the US House of Representatives with only Republican votes. The Board of Supervisors of Shasta County, one of Northern California's more populous jurisdictions, opposed the bill. The Congressional Budget Office estimates that by 2026 the AHCA would reduce the number of Americans with health coverage by 23 million compared with the existing law, the Affordable Care Act (ACA). I reached out to Donnell Ewert, director of the Shasta County Health and Human Services Agency, about how the AHCA would affect rural northern California. Ewert, an epidemiologist by training, joined the agency in 1999 and held management posts before he was elevated to director in 2012. The transcript of our conversation has been lightly edited and condensed.
Q: How would you characterize Shasta County's health care situation?
A: We have three hospitals, four Federally Qualified Health Centers (FQHCs), Indian Health clinics, and reproductive health clinics. One-third of Shasta's population is on Medicaid (Medi-Cal), so the program is extremely important to our residents. Of the 180,000 people who live in Shasta County, more than 60,000 are enrolled in Medi-Cal [California's Medicaid program]. Since the ACA expanded Medi-Cal eligibility rules in 2014, about 16,000 people, mostly single people in low-wage jobs, signed up. Of the 2,000 births in the county each year, Medi-Cal covers about 55% of them.
Q: How have conditions for health care providers changed in Shasta County since the ACA was implemented?
A: We've seen a great expansion of access. The Redding Rancheria opened a huge clinic for non-natives. A new FQHC satellite clinic opened and another one was expanded. Partnership HealthPlan came in as a managed health care plan for Medi-Cal. A lot of work has been done, and everyone acknowledges that the system has gotten better and that safety-net gaps are closing.
Q: Are people satisfied with Covered California, the marketplace for subsidized private plans?
A: First, we have a lot of small employers who don't provide health insurance, so only a minority of our residents have private insurance. About 6,000 people in Shasta County obtain insurance through Covered California. People generally acknowledge that the Covered California market doesn't work that well in our area. We have only Anthem plans available here, and premiums have gone up a lot. While folks around here don't dispute that the individual market needs reforming, I don't think you need to repeal the ACA to fix problems in the individual market.
Q: Does the AHCA have any beneficial qualities?
A: It doesn't seem to be a bill about health care. The real motivation seems to be to get rid of all the taxes associated with the ACA. It's all about Paul Ryan's vision for a society with low taxes for wealthy people and with a reduced amount of money for the federal government to spend on programs for low-income people. Ryan didn't care whether more than 20 million people would lose coverage. He was thrilled about the savings that would accrue.
Q: How would the AHCA affect the county's efforts to cope with the opioid epidemic?
A: The Medi-Cal expansion allowed many childless adults with addiction issues to get care. If the expansion is repealed and those people lose coverage, the substance use disorder treatment benefits that have been expanding would be moot, and more people with addiction would go untreated.
Q: Before the House took action, did Shasta County leaders express their opinions about the bill to Congress?
A: The chairman of the Shasta County Board of Supervisors, David Kehoe, a fiscal conservative, said the bill would shift tens of billions of dollars in costs to counties and reverse the significant progress California has made in providing health coverage. The board sent a letter over the signature of another conservative supervisor, Les Baugh. Kehoe told the Redding Record Searchlight that the overall health status of county residents would suffer over time. They were concerned about the projections from Partnership [HealthPlan of California] that more than 8,500 jobs would be lost in the 14 counties where Partnership provides care, including 900 in Shasta. That's a big blow — both for the economy here and for the quality of patient care.
Q: Shasta is part of the solidly Republican Congressional District 1, which covers most of inland northern California. Last year 64% of Shasta votes in the presidential election went to Donald Trump, and in the congressional race 66% voted for incumbent US Representative Doug LaMalfa, who voted for the bill. What has LaMalfa told Shasta County leaders about their AHCA concerns?
A: I'm super proud to work for our board of supervisors, which took a stand and sent that letter to the congressman. Our supervisors are aware of the extent of the county's health problems because they participate in our health collaborative and are committed to building an effective safety net for our people. The collaborative has interacted with LaMalfa about FQHCs, which he has supported, but they could not get a meeting with him about the AHCA. That was disappointing for our board chairman. The collaborative also asked LaMalfa and his staff to set up a meeting so they could explain their opposition, but that never happened either. The collaborative is still hoping to sit down with the congressman and explain what the bill would do to Shasta County.