HEALTHCARE POLICY-In March, a coalition of unions, health-care advocacy groups, and immigrant-rights organizations, promoting a campaign dubbed Care4All California, unveiled a package of roughly 20 pieces of legislation that they believe are achievable in the next year or two; are affordable; and that, if passed, would move the state toward a level of coverage of between 97 and 99 percent of the population – a level roughly comparable to that of Canada, France and most other countries with “universal” systems.
This effort comes on the heels of last year’s unsuccessful attempt, pushed hard by the California Nurses Association, to legislate single-payer health care, which would have replaced the patchwork of private insurance plans, subsidies and state-funded health coverage for the low-income and elderly, with a single, state-funded system in California. (Disclosure: The union is a financial supporter of Capital & Main.) Care4All’s advocates claim their solution — which they are pushing not as a long-term alternative to single payer, but as an interim fix while the state works toward securing the needed federal waivers (unlikely in the Trump era, given the administration’s hostility to all-things-Californian) and funding streams for single payer — will come with a price tag in the low billions, rather than the much higher price tag that a single-payer plan would currently require.
“We’re excited that not only can we defend [against] Trump’s sabotage of our health system, but California can take bold steps forward,” says Anthony Wright, executive director of the Sacramento-based non-profit Health Access California, and a driving force behind Care4All.
Assembly member Jim Wood (D-Healdsburg), who co-chairs the Select Committee on Health Care Delivery Systems and Universal Coverage, is also somewhat optimistic. “We’re exploring a variety of different ways to get coverage to people,” he says. “The more people in the pool is better for the overall health of the system.” Wood, who believes that “the road to single payer is a very long road,” claims that in the short-term, gaps can be plugged by expanding Medi-Cal, the state’s version of Medicare; access provided for undocumented adults; quality and price control systems set in place; insurance subsidies expanded to include people who have incomes that currently exclude them from subsidies; and ways found to bring down disparate health-care outcomes across income, race and geographic boundaries.
“Our primary priorities are protecting Medi-Cal, and ensuring we finish what we started with the ACA [Affordable Care Act] expansion of Medi-Cal,” says Jen Flory, health policy advocate at the Western Center on Law and Poverty, one of the organizations involved in this health-care push.
For 24-year-old Karen, who didn’t want her last name used in this story, the changes couldn’t occur soon enough.
In 2001, when she was 8, Karen’s parents brought her and her older sister across the border from Mexico to San Diego. Shortly before, Karen’s 50-year-old grandmother, who had looked after her while her parents worked low-wage jobs in the Mexican city of Cuernavaca – her father as a bartender, her mother as a Kmart cashier – died of diabetes. With no one to help them raise Karen and her older sister, and with income desperately tight, the couple relocated the family to the United States.
In California there were more opportunities for earning enough money to survive, but there were also tremendous hardships. Lacking legal paperwork, Karen’s family faced numerous obstacles, including no access to comprehensive health care. “I just knew that we were poor, that we didn’t have the means or resources other people had,” recalls Karen, a recent university graduate and a DACA recipient (the Obama-era program that permits undocumented immigrants who came to America as children to remain here. “But I didn’t fully understand what ‘undocumented’ meant until my mom said, ‘We don’t qualify for health care.’” Growing up, Karen almost never visited a doctor.
The 2010 Affordable Care Act specifically excluded the undocumented from coverage — either under the expanded Medicaid system, or via the insurance subsidies offered on state insurance exchanges. While DACA doesn’t provide for the expansion of federal Medicaid provisions to cover recipients, several states, including California, have chosen to use their own state dollars to cover their DACA populations. But while that benefits someone like Karen, it still leaves other family members just as vulnerable as before.
Thus, while Karen will continue to have insurance for as long as DACA exists (and since President Trump has pledged to end the program it could, if the court rulings keeping it in place are overturned, all come crashing down sooner rather than later), the other adult members of her family continue to go without.
When Karen’s father, who had found low-wage employment installing flooring, also got diabetes, he began visiting a Chinatown doctor who was known to treat immigrants without insurance or Medi-Cal for relatively small cash payments. But even those payments of several hundred dollars were frequently out of the father’s price range. He takes his medicine only “when he can afford them.” He foregoes regular check-ups, doesn’t often get his blood-sugar levels monitored, tries to ignore his hypertension, his aching back and chronic joint pain.
Karen’s mother, who, she says, suffers from gastrointestinal issues and anxiety, almost never visits doctors, instead going to local curanderas (healers) when she gets sick. She does receive annual check-ups and mammograms at free clinics that cater to undocumented immigrants – but, in the Trump era, she is scared of going to such places; immigrants believe they are now being targeted by ICE agents and that using them puts the clients at risk of deportation.
In 2011, Karen’s sister, two years her senior, needed emergency surgery for appendicitis. Even after she negotiated the $60,000 bill down, she still owed $26,000 — which it took her nearly six years to pay off, with the loan payments taking huge chunks of her two minimum-wage jobs. Now pre-diabetic, Karen’s sister lacks access to the preventative care that could help her navigate her symptoms better and stop the onset of the deadly disease.
Over the past several years, California has made huge leaps in expanding health-care coverage to those who previously were uninsured. Before the ACA’s passage, nearly 20 percent of the state’s residents lacked regular, stable, coverage, either via private insurance or government-funded programs. Today, because of expanded access to Medi-Cal and a thriving state insurance exchange, Covered California, that number is down to about seven percent, according to Anthony Wright, who adds that $25 billion now flows into California’s health-care system annually via ACA provisions. No other state has used the provisions of the ACA anywhere near so effectively.
While the California Nurses Association, the driving force behind the state’s single-payer movement, supports expanding Medi-Cal to include the undocumented, the union is deeply suspicious about the rest of Care4All California’s package, regarding it as little more than an excuse for industry-friendly Assembly Democrats, who killed off single payer last year, to pretend to be fixing the problem while ignoring its fundamental causes.
Says CNA spokesperson Chuck Idelson, “There’s nothing in there to control profits, nothing about drug costs that I’m aware of, nothing that talks about the broader problems with insurance companies.” Idelson continues, noting, “You’re either fish or fowl. You can’t be protecting the profit-gouging of an industry and say it’s a step toward achieving the systemic reform you need.”
As it has been with immigration and environmental issues, California is at the forefront of resisting Congressional Republicans and the Trump administration in their campaign to undo the ACA and to undermine the insurance exchanges. It has also fought back against attempts to let junk-insurance plans be sold to residents; and it is looking to create state safeguards against a federal repeal of the individual mandate, the core provision within the ACA that, in bringing healthy people into the insurance pool, allows insurers to sell affordable insurance to sicker individuals.
Despite California’s efforts, roughly three million adults remain uninsured, or dramatically under-insured, in the state.
Seeking a backdoor way to roll back Medicaid expansion, the Trump administration has encouraged states to seek waivers from current Medicaid regulations that provide access to the program to anyone of a certain age who meets specific poverty thresholds. These waivers, which are being pursued by several states, would impose work requirements on recipients and fundamentally alter the nature of the program. California’s current political leadership is working on legislation that would prevent future state political leaders and health-system administrators from seeking such federal waivers limiting eligibility to Medicaid. “Trump is setting booby-traps all through our health-care system,” says Wright, “and we’re systematically going through to undo them.”
California’s politicians are realizing that the state must also play offense in order to preserve and expand its health-care gains, and to protect vulnerable groups – particularly the state’s huge immigrant population. Paradoxically, the more the feds push to reduce access to health care for poor populations, the more the logic of the moment pushes California to expand that access.
Over the past couple of years California has enacted legislation that uses state dollars to bring undocumented children, whose families earn up to 266 percent of the poverty line, (nearly $67,000 for a family of four) under the Medi-Cal umbrella. On the West Coast, Oregon and Washington have enacted similar legislation, as have Illinois, New York, Massachusetts and Washington, DC. California, to all intents and purposes, now has universal health care insurance available to its under-19-year-olds. It has also pumped money into the insurance exchange and, in contrast to federal efforts to reduce the advertising dollars used to publicize such exchanges, California has increased outreach efforts to inform poor individuals and communities about ways to purchase affordable, subsidized insurance. And it is ramping up efforts to monitor, and to improve, the quality of care delivered to them.
Despite California’s efforts, roughly three million remain uninsured. And the problem of under-insurance also plagues many others. Wright’s coalition estimates that between 50 and 60 percent of the uninsured are undocumented, most of them poor enough to qualify for Medi-Cal — had they legal status. “We cannot reach universal health coverage until we remove this unjust exclusion based on immigration status,” argues Betsy Estudillo, of the California Immigrant Policy Center. Senate Bill 974, authored by state Senator Ricardo Lara (D-Bell Gardens), and the linchpin of the new legislative effort, aims to tackle this gap. Using state tax dollars would expand the program that covers undocumented children to include undocumented adults within the Medi-Cal program.
Since almost one million of these men and women already are covered by emergency, “restricted scope” Medi-Cal, which is covered by the same cost-sharing federal-state formulae that cover the broader Medicaid program, expanding the program to allow them more comprehensive Medi-Cal access wouldn’t be prohibitively expensive to the state. Also, many others already receive primary care coverage from their counties, according to the Berkeley Labor Center at the University of California.
The remainder are divided between people who are currently deemed just too affluent to qualify for Covered California subsidies. The cutoff is 400 percent of the federal poverty line – which, for a single individual, is currently $12,140; for a family of four it’s $25,100 — which can leave residents in high-cost-of-living counties, where people spend a disproportionate amount of income on housing, unable to afford insurance; and elderly Californians, with income between 123 percent and 138 percent of the poverty level ($14,932 to $16,553), who are caught in an obscure poverty trap that allows them access to Medicare, but not to Medi-Cal (despite the fact that, for younger Californians, the cutoff is 138 percent of the poverty line), meaning that they still have to foot unaffordably high bills for medicines and other out-of-pocket expenses.
Take, for example, a 47-year-old woman from Richmond, who wished to remain anonymous for this story. She suffers both from a benign brain tumor that needs regular monitoring, and from a damaged aortic valve that will eventually require surgery. Earning $50,000 a year, she is slightly too affluent to qualify for insurance subsidies – but the $600 a month that she has to put down for a plan that will cover her extensive medical needs eats up all of her spare income. While she can, currently, just about afford coverage, she is consumed by fears of what will happen if she ends up being priced out of the market. “Losing health care for me would be like being closer to death,” she explains, her voice a knot of anxiety. “I don’t know where to cut back now. Maybe I can eat rice and beans.”
Then there’s Julie Marty, a retired San Joaquin County clerk, widow and breast-cancer survivor who is too young to qualify for Medicare yet too affluent to qualify for subsidies. She, nevertheless, can’t afford to buy insurance and also pay her mortgage. She hasn’t seen a doctor once in the last five years, she tells me. “It would be much more reassuring to have health insurance,” she says. “But that’s the way it goes. I’m looking forward to Medicare!”
And there’s the 53-year-old Fresno survivor of multiple heart attacks and triple-bypass surgery, who spent months trying to prove to Medi-Cal that his income placed him just below 138 percent of the poverty line and thus making him eligible for coverage. “I was at the point I wasn’t going to be able to go to the doctor no more,” he said. “I couldn’t afford it.”
Anthony Wright believes that Care4All’s legislative package has the potential, at a cost that taxpayers will be willing to bear, to bring medical coverage to all of these men and women. In addition to Lara’s bill, there’s Assembly Bill 2565, authored by Assemblymember David Chiu (D-San Francisco), which increases subsidies to those who can’t afford health care despite existing subsidies; Assemblymember Joaquin Arambula’s (D-Fresno) AB 2430 aims to end the poverty trap for elderly Californians who are just on the wrong side of being 123 percent of the poverty line, and who currently don’t qualify for Medi-Cal. And AB 2275, another Arambula bill, builds in stricter quality controls into the Medi-Cal system. A raft of other measures, including Ash Kalra’s AB 3087, the Health Care Price Relief Act, are designed to rein in drug prices, as well as the fees charged by doctors and hospitals for medical services, both for the state and for individual patients, thus providing cost savings that can be fed back into paying for increased coverage.
While the Care4All package would still leave uninsured the small fraction of Californians who can afford to buy insurance but simply choose not to, it would provide a realistic pathway to coverage for a majority of those currently excluded from health-care access. “The ACA gave California $25 billion per year to get here,” he says. “It would take a fraction of that to go from [seven percent uninsured] to one, two, three percent – the level most European countries are at.”
There is, of course, opposition. Republicans will oppose measures to provide any form of benefits to undocumented adults. The insurance and pharmaceutical industries, as well as many doctors and hospitals, all of which have many allies amongst legislators in both parties, are already vocal in their opposition to the price-control measures; as a result, Wright acknowledges that a bill such as Kalra’s price relief act will have a hard time just getting out of committee. And some Democrats may balk at adding another big-ticket item, Medi-Cal expansion, to the state’s financial obligations. There’s also no guarantee that Governor Brown, who prides himself on his cautious fiscal policies, will sign such an open-ended measure in his final months in office. “The governor is famously frugal,” Wright says. “But when the legislature has prioritized it [health-care expansion], he has gone along with investments in the past. I don’t think he’s a lost cause.”
Whether or not Brown sides with Care4All, the momentum is building for these reforms to be enacted over the coming years. More and more unions are on board, as are the leading gubernatorial candidates. After the Care4All launch event, Gavin Newsom indicated his support for its key measures as an interim step on the road to universal coverage. Stories such as Karen’s are proving potent as Wright’s effort moves forward, and the likelihood of at least parts of this package being enacted over the next couple of years is high.
Sitting in a café near the capitol building, after speaking at a launch event for Care4All’s legislative campaign, Karen thinks through what it would mean to her family to be able to access health care. “My dad would feel more comfortable visiting the clinic and receiving follow-up care. My mom and sister could have access to preventative care. It would definitely change our lives.”
(Sasha Abramsky is a journalist and author whose work has appeared in "The Nation," "The American Prospect," "The New Yorker" online, and many other publications. His most recent book, "The American Way of Poverty: How the Other Half Still Lives," was listed by "The New York Times" as among the one hundred notable books of 2013. He is a Senior Fellow at Demos think tank, and teaches writing at University of California, Davis.) Prepped for CityWatch by Linda Abrams.