California Leaders Defiant, Cautious in Fight for Obamacare

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By Laura Mahoney

California health-care policy leaders plan to turn the potential repeal of the Affordable Care Act into an opportunity to show California’s successful programs make the ACA worth saving.

Sounding alternately defiant and cautious, California Health and Human Services Secretary Diana Dooley, two key state senators and advocates for consumers said they will “educate” Republicans in the California congressional delegation, especially Majority Leader Kevin McCarthy (R) and Rep. Devin Nunes (R), about the impact an Affordable Care Act repeal would have on their constituents. About half of the people in each of their congressional districts are enrolled in Medicaid. Medicaid was significantly expanded under the ACA in 31 states, including California, and the District of Columbia.

“I have a strong sense that we have to dig in and just say no,” Dooley said Dec. 13 at a symposium sponsored by consumer advocacy group Health Access. “I’m not ready to throw in and normalize the behavior that is very abhorrent to me. But there is something to not letting a crisis go wasted.”

Her first goal is to slow or block action so “we can hold onto what we have for a few more years.” To that end, Dooley said, she will also work with Republicans and Democrats in other states that have expanded programs under the ACA to pressure Congress.

California’s Success

Dooley and state Sen. Ed Hernandez (D), chair of the Senate Health Committee, pointed to elements of California’s embrace of the ACA that have made the state’s programs more successful than in other states. They will emphasize these elements as they make the case to save the ACA.

The state has fully expanded Medicaid, created a robust health benefits exchange in which the state is an active negotiator and emphasized managed care in both Medicaid and the state-run exchange. The state’s uninsured rate has dropped from 17.2 percent to 8.6 percent in three years, one of the largest drops in the country, according to the Census Bureau. California, with only a 50 percent match of federal funds for its Medicaid spending, is more efficient than other states with much higher federal matching percentages.

“I see an opportunity to advance progress California has made and be recognized for the way we run our program,” Dooley said.

Dog Chasing a Car

Hernandez faulted congressional Republicans for failing to put forward a replacement for the ACA despite their plans to charge ahead with a repeal in January.

“The opposition to the ACA is like the dog chasing the car,” Hernandez said. “They finally caught the car and don’t know what the hell to do with it now.”

Peter V. Lee, executive director of the health benefits exchange, Covered California, said he will advocate for the exchange without being a combatant.

“Will I be an advocate? Damn right I will. But I don’t know if saying I’m a combatant works,” Lee said, adding that he will focus on the data Covered California has gathered to make his case to Congress and President-elect Donald Trump’s Cabinet members. “At Covered California we have a wealth of data. I will be in the thick of it as an evidence-based advocate for California.”

Health for All

State Sen. Ricardo Lara (D) told attendees he will also continue his push for health-care coverage for undocumented immigrants. California has applied for a waiver from the Centers for Medicare & Medicaid Services to allow undocumented immigrants to buy unsubsidized insurance through Covered California, based on legislation he authored. He also authored a measure in 2015 to expand full-scope Medicaid coverage to all low-income children regardless of immigration status.

Lara said he has no plan to withdraw the waiver application from the CMS because of Trump’s election, and he will introduce a bill in 2017 to expand Medicaid to undocumented adults.

“I’m not backing down to any bully anywhere, anytime,” Lara said.

Embracing Immigrants

The state health-care leaders, as well as other advocates who spoke at the symposium, said California is a few years ahead of the rest of the country in embracing immigrants and diversity. In the 1990s and early 2000s, California voters approved measures to ban bilingual education in public schools, ban undocumented immigrants from receiving public benefits and end affirmative action programs.

All of those measures have since been repealed or overturned, and the Republican Party is a diminished presence in state politics partly as a result of its support for them, they said.

“Where California is now is where the nation is going in several years,” Sarah de Guia, executive director of the Pan-Ethnic Health Network, said.

Role for Labor

The labor movement is part of the fight to save the ACA as well, Sara Flocks, policy coordinator for the California Labor Federation, said. Although union members typically have health insurance, they want to maintain affordable health care for everyone. Unions and private employers also will see the costs of care for the uninsured shift to the large-group market if the ACA is repealed, she said.

The potential ACA repeal, together with potential changes to Medicare that congressional Republicans are considering, would leave California without at least $40 billion to $50 billion a year in federal funding, the advocates said. California would be hard pressed to fill that gap itself.

Dooley said Gov. Jerry Brown (D) isn’t likely to include contingency plans in his state budget to be released Jan. 10, before Trump is inaugurated.

“Our approach is to only deal with what we know,” she said. “There are far more questions than there are answers at this point.”

To contact the reporter on this story: Laura Mahoney in Sacramento, Calif., at

To contact the editor responsible for this story: Brian Broderick at

Copyright © 2016 The Bureau of National Affairs, Inc. All Rights Reserved.

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