The Work of the New Year: Protecting and Continuing California’s Progress

As the California Legislature restarted for the new year this week, I wanted to share a portion of my remarks at our 30th Anniversary event for Health Access California last month, where we acknowledged the progress we had made with California’s successful efforts to implement and improve upon the Affordable Care Act, focused on how we can take additional steps in our coalition’s goals to expand coverage, protect consumers, lower costs, improve quality and equity, and work for a healthier California–and adjusted our work to a new context:

 

The grim post-election context should not diminish the pride in the progress we’ve made—in fact, it is now more essential than ever to highlight these hard-won victories for California consumers–if only to signify what is at stake in the fights ahead.

Our progress on Consumer Protection includes passing the HMO Patients’ Bill of Rights fifteen years ago, and several additional laws on timely access, language access, and other key patient protections since. In 2016, in fighting unfair out-of-pocket costs, we passed landmark legislation against surprise medical bills for unfair out-of-network bills—a longstanding problem unresolved for decades. We increased information to consumers about their rights-from the right to complain to their right to know if their premiums rate hike was deemed unreasonable—thus giving them the ability to shop around. We worked to implement recent patient protections against extreme prescription drug cost-sharing, and new oversight over health plans to ensure timely access, network adequacy, and accurate and updated provider directories.

  • Yet now we face a proposal to allow out-of-state insurers to sell across state lines without state licensure or oversight, undermining our patient protections, not just the HMO Patients’ Bill of Rights like the right to independent medical review but Knox Keene Act which Governor Brown signed in his first term forty years ago—including basic standards on medically necessary care. We can’t go back.

Our progress on Coverage has been substantial: With our aggressive implementation of the ACA, California cut the uninsured rate by more than half, a larger percentage than any state in the nation, according to new Census data. In 2016, we went beyond the ACA, launching in May expansion of coverage to all California children regardless of immigration status—so now we can say that every child in every classroom and every playground in California has access to affordable health care and coverage; we also worked closely with local advocates to get various counties to adopt more inclusive and smarter safety-nets (in fact, we went 18 months ago, only 9 counties provided any health care to the uninsured and undocumented—today that number is 47.

  • Yet now, proposals for ACA rollbacks and repeals could mean that an Urban Institute proposal that over 5 million Californian may lose coverage, including the 3.7 million who have gotten coverage through the Medi-Cal expansion, the 1.2 million who get financial help through Covered California. And pending proposals would undermine the progress not just under the last five years under the ACA, but the last fifty under Medicaid and Medicare. We can’t go back.

Our progress on working for a fair Budget that invests in public health, including successful getting through the Great Recession, preventing the worst of the cuts, partially restoring some of those cuts like to dental coverage, and for budget reforms and revenues to sustain these program. This year, we worked for new resources for Medi-Cal through an MCO tax, a new Medicaid waiver, and voter approval of ballot initiatives extending upper-income tax brackets and approving a tobacco tax. California voters agreed—three times—to support investing in Medi-Cal, even if it meant taxes.

  • Yet just the Medi-Cal expansion being rolled back would means a loss to the state budget of $16 billion, the proposal to cap and cut Medicaid through a block grant could be tens of billions more. These cuts are massive, and of a scale beyond what California could make up on its own. In comparison, the tobacco tax that many in this room worked so hard for and finally won after three times and $200 million against those efforts: that $2/pack increase raised $1 billion for Medi-Cal. These proposals tens of billions, including the Medicare privatization, could blow a huge hole in the $125 billion state budget, impacting not just health but other vital services. It could be the scale of the cuts of the Great Recession—but forced by intentional votes. We can’t go back.

There are some victories that will stand the test of time, for example, our work on tobacco tax this year was also part of our burgeoning work on public health, where we were proud to work alongside other groups to help pass the strongest tobacco control policies in a generation including raising the smoking age and regulating e-cigarettes. We won’t go back.

We won’t go back on the other issues as well—because of the people in this room, fighting back.

The first fight will be the repeal of “Obamacare:” The GOP House of Representatives plans to vote in early January to repeal large parts of the Affordable Care Act. The Senate would vote on it in mid-January, using a process called budget reconciliation so they only need 51 votes in the Senate. The idea is to have this done so that the new President could sign such a repeal on inauguration day, or at least in his first week, by the end of January.

Congress has no replacement ready—their current plan is to have the individual and employer requirements end immediately, and the Medicaid expansion and the financial assistance in the exchanges in California to expire in two-three years while they figure out a replacement. Losing the subsidies alone would mean people dropping coverage, leaving the rest of us in a smaller and sicker risk pool, leading to skyrocketing rates, insurers pulling out, and a collapsed individual market. Even if all the repeals were delayed, this lack of direction would put the health care sector—one-sixth of our economy, in chaos.

Let’s be clear: it’s not just about Obamacare but Medicaid and Medicare and many other issues as well. If the Congress can rip away health care for 30 million Americans without a push back, then they’ll keep going. What’s more, if they repeal the ACA with no replacement in place, they are in effect repealing not just the financial help to low-income families, but giving away, through a massive tax break to the wealthiest, the funding for any replacement proposal. Beyond the havoc such a vote would cause the health system, it would also mean that any replacement would be a fraction of what is needed, and funded largely through even larger cuts to Medicaid and Medicare.

So our first job is to be very clear, that it’s wildly irresponsible to repeal—especially without a replacement in place. Three Republican Senators, or a handful of House members, need to recognize the chaos this would cause, the backlash that would result, and to back off from the cliff that they now promise to hurdle over.

If that common sense and instinct for political preservation prevails, or even if it doesn’t—then we still have a long list of federal fights—from a campaign point of view, we need to both run a sprint through January, and be prepared for the marathon ahead.

As we debate any replacement, we should be fortified by the fact that a majority of Americans—by nearly 3 million voters—did not vote for repeal, even as we recognize there will be some changes, given the sentiments of the voters who supported the leadership in Congress. The name “Obamacare” will not last, but the question is whether its key elements—the Medicaid expansion, the financial help to afford coverage, and the consumer protections—can be saved. This also isn’t just about Obamacare, but interwoven with threats to Medicare and Medicaid as well—through proposals to block grant Medicaid and privatize Medicare. We can’t go back.

This #Fight4OurHealth is to protect our progress and continue California’s leadership on coverage, on costs, on care, and on consumer protections. We here in California have three crucial roles in this fight.

  • California has a big Congressional delegation of 55 members, and they need to be fully aware of the catastrophic consequences to their California constituents of these pending proposals. This means we need to engage our two Senators (including one of the most veteran and another who is a rising star.) We need educate our five new Congressmembers about these issues, and for all of them be very clear about the impacts with our own elected leaders. We need to focus on those who opposed “Obamacare” in the past—but while those past votes were like shooting blanks, these new proposals will have live ammunition—aimed squared at their constituents, with real world consequences to the health system they themselves depend on. There is nowhere more true than in the Central Valley. While Medi-Cal covers more than a third of the state, in the Central Valley is around half of the population, from Fresno to Merced. GOP Majority Leader McCarthy represents Kern county at 45% Medi-Cal, and Tulare County, which has the highest Medi-Cal enrollment of any county at 55%. Yet he proposed cutting Medi-Cal by $16 billion, without any replacement plan in place. We have our work cut out for us, from Bakersfield to San Diego—where we will have events a week from now, and throughout the state.
  • California needs to be an active part of a national campaign, with our stories, our activity, our energy. While there will be a lot of attention on Republican Senators in other states, this can’t be just a campaign in a handful of states—this needs a national campaign.
    1. We need to get out the story of our success, and the stories of people who benefit today and would negatively impacted by these cuts and caps—into the national conversation—through the media, social networks, and the like.
    2. At the reception tonight, we will toast several of the people who told their story, their experience with the health system and helped effect change—we believe individuals and stories like these will again make a difference.
  • California needs to be a model and a leader:
    • We showed how to model the ACA, In 2012 the NY Times headline was “California Tries to Guide the Way on Health Law.” This year, the LA Times headline was “So you think Obamacare is a disaster? Here’s how California is proving you wrong.”
    • We can lead with our campaign—we were the first state to get out a call for stories, getting 100 in the first day. We were the first rally in the country, with 300 people the Tuesday before Thanksgiving. We need to show the rest of the country how it is done, to provide model and mentorship, information and inspiration.
    • Once the fog clears from the federal fight, we will be active in seeing how California can go forward with some type of health reform on our own, as many in this room attempted several times before the ACA. What is possible very much depends on the federal framework and financing. We need to prevent the kind of cuts and pre-emptions and poison pills that could handcuff us. But within those constraints, California must look to continue our progress, step by step, even if other states go in other directions.

Until then, we will continue with our work: Enrollment, consumer protection, addressing costs like prescription drugs and health industry consolidation, health equity. While we engage the federal fight, that’s our continuing work here in California.

Finally, we need to be in solidarity with other issues and communities under attack. We need to work to protect voting rights, civil rights, immigrant rights, women’s rights—all the ways that respect one another as individuals worthy of dignity. That’s what the health care debate is actually about.

Ultimately, this is about whether we actually care for one another—literally and figuratively. There’s a reason that health care has been the flashpoint for this ongoing debate, because it is so fundamental to who we are, our values, our vision of government. Do we care for one another?

In California, the answer is has been yes. For any other answer, we can’t go back. As we review the timeline in this program of the history of Health Access and of health reform more broadly, we see unmistakable progress toward this goal, even though we’ve seen dark days before—massive budget deficits and awful cuts, ballot measures lost by the closest of margins, and major health reform proposals stalled, vetoed, even repealed at the ballot box. We have survived and continued forward before–it’s the lesson I have learned again and again in the fifteen years that I have been privileged to serve as Executive Director of Health Access, working with this amazing staff, board, and health policy and advocacy community present today.

So today, let’s commit to celebrate our victories, but respond to the threats; to defend Medicaid, Medicare, and the ACA, while continuing to take steps forward at the state level; to be active in the federal fight both nationally and with our California delegation; and to lead at the state level, with our enrollment, our actions, and our next steps. We can’t go back. We can do this. Si Se Puede.

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