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Can California expand health care insurance programs without the ACA?

Since election day, the words "repeal and replace" have become a familiar refrain. 

But almost as soon as it became clear that Donald Trump was heading to the White House, supporters of Obamacare started on plans to protect and expand California's health insurance options. 

A lot of different approaches have been considered, all tracked by Dr. Robert K. Ross, President and CEO of The California Endowment. He joined Take Two's A Martinez to talk about the future of health care in California. 

The California Endowment — a health care advocacy foundation has, by it's own account, spent upwards of 100 million dollars supporting health care reform in the state. 

Interview Highlights 

4 ACA provisions that are tough to part with

  1. Before Obamacare, insurance companies could discriminate openly against people with chronic health conditions. Obamacare did away with that. So, you're no longer penalized for getting sick. 
  2. Bankruptcy: one of the leading causes of Bankruptcy among families was out-of-pocket health care costs. Obamacare fixed that.
  3. The provision to make sure that young people in the ages of 21-26 could be added to their parents' heath coverage, giving a lot of people comfort around their children as they make the transition to adulthood, and making sure they still had coverage. 
  4. The fact that 22 million Americans now have insurance that didn't have insurance before. 

A public opinion conundrum 

The polling for Obamacare has always been pretty dismal. But when you ask people about specific provisions of Obamacare– the preexisting conditions, the prevention, the capping out-of-pocket cost– the polling for those individual provisions are terrific. So, they love the provisions, they just hate Obamacare. Now, Republicans are figuring out, this thing isn't so bad.   

The whole picture: Covered California vs. Medi-Cal 

The other big issue which is going to be, I think center stage is Medicaid. What is going to happen with Medicaid. 

In the state of California, we have reduced the rate of uninsured Californians from 25% in 2010 (pre Obamacare) down to 9%. Tremendous improvement. That's what we stand to lose in a scorched earth approach that pulls the rug from under Obamacare without an adequate replacement in place. I think even Republican governors across the country are figuring out, they have constituents that benefited from Obamacare no matter how much they hated it.

Right now in California, along with those 5 million recently insured Californians, 2/3 of them on from the benefit of the Medicaid expansion which is what we call Medi-Cal in California. About 1/3 from the health insurance exchange called Covered California which provided subsidies to working families. And then the other 2/3 got insurance from Medicaid expansion. So, there is a way to torpedo the beneficial affect of Obamacare through the congressional budget action. If they take an axe to Medicaid by block granting to the states or some other ways where you put some kind of per capita imposed reduction on Medicaid spending, you really can do damage to the health coverage expansion by cutting the dollars to Medicaid So, Medicaid is center stage in this big debate and is a big problem for Republican governors. 

Challenges on both sides of the aisle  

The Republicans have their problem which is deciding among these replacement plans. You have the Ryan plan, the Price plan, the Cassidy plan. So it'll be entertaining watching them thrash around figuring out which plan to get behind. 

On the progressive side, those of us that have been in support of Obamacare, we have a political problem as well. In the state of California, if you say, now's the time for a different kind of plan, let's say single payer as an example, it doesn't mean politically, you've raised the white flag of surrender on protecting Obamacare. So, do you get too quickly out  in front of the debate that still has to play out in Congress? So that's the tension that we have on our side of the fence. Should we sit and watch and see what happens in Congress? Or, should we move ahead with planning for plan B now?

Without the ACA, can California create it's own health care system?

Theoretically, yes. Pragmatically, where's the money going to come from? That's the problem. Let's go back to Medicaid for example. If we know that California has benefited by virtue of 20 billion dollars from Obamacare. The combination of subsidies and Medicaid expansion. If the Republicans pull the rug out on that, then where does that 20 billion dollars come from? Even if you want to do, let's say, single payer which may have a price tag of 30 billion, now you're down 20 billion from the repeal of Obamacare, and now you've got to find 30 billion dollars in state, general fund revenue or some other revenue source to pay for the implementation of single payer. So in theory, it's wonderful to wax loftily around, now we can do single payer or some other proposal. But now you've got to find another revenue source to pay for it and that becomes probably the next governor's problem. And that'll be a big, big headache. 

Quotes edited for clarity. 

To hear the full interview, click on the blue Media Player above.