Last week, the House bill to repeal and replace the Affordable Care Act (ACA) emerged from the shadows into the glare of public scrutiny, and it wasn’t a pretty sight. The American Health Care Act (AHCA) is a deeply disturbing plan that would shift hundreds of billions of dollars to the rich and the healthy at the expense of the poor, the sick, and the elderly.
Four years after the ACA enabled millions of Californians to gain health coverage from California’s Medicaid program (Medi-Cal) and the Covered California marketplace, House Speaker Paul Ryan, with support from President Donald Trump, wants to revoke coverage and care for our most vulnerable people. In the process, he wants to dismantle the carefully constructed broad base of revenues that finance that care. The Congressional Budget Office (CBO) estimates that the Ryan bill would reduce the number of Americans with health insurance by 14 million next year, rising to 24 million in 2026.
In unflinching empirical language, the CBO report contradicts the president’s repeated promises that there would be “insurance for everybody” and that he would not hurt those whose care is provided through Medicaid. The report also debunks the claim that the ACA’s private insurance marketplace is in an actuarial “death spiral.” The truth is that the Ryan bill would reverse the gains in coverage made under the ACA. It would harm millions of Americans struggling to get by — the very people who need affordable health care to have a shot at realizing their full potential. It is a penny-wise, pound-foolish policy that will drive millions of uninsured people to forgo necessary care, which will increase sickness and premature deaths.
Increasing the Burden on States and Localities
The repeal bill would cut a breathtaking $880 billion from Medicaid over 10 years. It would radically change the federal financing structure of the program and undermine the protections we give to one in three Californians — including seniors, half of our children, and people with mental and physical disabilities. The federal government would walk away and leave it to governors, state lawmakers, mayors, and county supervisors to develop what would likely be a patchwork of solutions.
In the private insurance market, the Ryan repeal bill would eliminate $673 billion worth of income-adjusted premium tax credits and cost-sharing subsidies and replace them with tax credits adjusted only for age. For some elderly, lower-income Americans who buy insurance on the private market, the bill would cause premiums to leap by as much as 750%. And it would shrink access to treatment of substance use disorders even though Congress and the president have acknowledged we are in the middle of an opioid epidemic that claimed 52,000 American lives in 2015. As Vox editor Ezra Klein wrote, “Under the GOP’s bill, the more help you need, the less you get.”
The people who would be harmed are members of your family and mine, like my cousin who has long been unable to work because of schizophrenia and who recently suffered a stroke. They are people like Lisa Leonard, a Santa Barbara woman who depends on her Medi-Cal plan for physical therapy to treat painful cervical stenosis in her neck. The coverage Ms. Leonard got through the ACA is providing emotional relief and keeping her on the road to recovery — and on the way back to work.
Vigilance in an Uncertain Time
For two decades, the California Health Care Foundation has devoted itself to making health care work for all Californians, especially the people with the lowest incomes and the greatest health vulnerabilities. As the debate about the future of health care unfolds, CHCF will continue sharing sound data, research, ideas, and insights that can light the path forward for California. We will remain vigilant, providing detailed analyses of proposals and their potential impact on consumers and the health care system. We will continue to partner with organizations and people across the state to uphold the value of inclusivity and preserve the important gains realized by the ACA.
This debate is about something much larger than one misguided bill. It’s about the social contract that the American people solemnly embraced more than a half-century ago when Medicaid was enacted. Medicaid animates the values that make America exceptional, and it enriches our understanding of what it means to be an American. Medicaid demonstrates our commitment to a caring and just society. This social contract must be upheld.
This is a historic moment. Much is at stake. I urge the millions of Californians who have been helped by the ACA — along with family and friends who hold them dear — to raise their voices now and be heard.
Dr. Sandra R. Hernández is president and CEO of the California Health Care Foundation. Prior to joining CHCF, Sandra was CEO of The San Francisco Foundation, which she led for 16 years. She previously served as director of public health for the City and County of San Francisco. She also co-chaired San Francisco’s Universal Healthcare Council, which designed Healthy San Francisco, an innovative health access program for the uninsured.
Sandra is an assistant clinical professor at the University of California, San Francisco, School of Medicine. She practiced at San Francisco General Hospital in the AIDS clinic from 1984 to 2016. She was appointed by Governor Jerry Brown to the Covered California board of directors in February 2018. She currently serves on the Betty Irene Moore School of Nursing Advisory Council at UC Davis and the UC Regents Committee on Health Services. Sandra served on the External Advisory Committee at the Stanford Center for Population Health Sciences in 2016. Sandra is a graduate of Yale University, the Tufts School of Medicine, and the certificate program for senior executives in state and local government at Harvard University’s John F. Kennedy School of Government.