SACRAMENTO >>The last time Donald Trump was president, his health care policies chipped away at the Affordable Care Act and helped eliminate federal abortion rights, leaving states to fill the gaps.
In his second term, experts predict Trump’s agenda to be similar and warn that health care will get more expensive and harder to access for millions of people.
Congressional Republicans, newly empowered by Trump’s victory and the Senate moving to GOP control, have made it clear that they intend to try to implement long-standing conservative goals that include decreasing government spending on health care currently protected in about half of the country, including California.
Newly nominated Health Secretary Robert F. Kennedy Jr. has also pushed erroneous claims about vaccine hazards and exaggerated the risks of water fluoridation that could have ripple effects across state public health efforts.
The Democratic supermajority in the California Capitol, however, has spent the past several years passing laws to stymie future conservative administrations on health care, said Mia Bonta, chairperson of the Assembly health committee and a Democrat from Oakland.
Legislators have protected insurance coverage of abortion and transgender care. They have expanded health insurance programs to low-income undocumented immigrants and paid for it with state funds. They have taken pieces of the Affordable Care Act and written it into state law, expanding the enrollment period and banning lifetime limits on coverage. And they’ve invested millions of dollars into public health after the system languished for a decade.
“We were able to be very deliberate in the past several years to Trump-proof our health system moving forward,” Bonta said.
Not all state lawmakers have been happy with California’s health care expansions. Senate Republican Minority Leader Brian Jones, for instance, said public insurance for undocumented immigrants, which as of this year is available to all income-eligible immigrants, is too expensive and should be “delayed or repealed entirely.”
But Democratic lawmakers and health care advocates say they are better prepared than the first time Trump took office.
Affordable health care at risk
During his first term, Trump tried and failed to repeal the Affordable Care Act. He has said for his second term that he has “concepts of a plan” for the program that insures more than 21 million Americans.
Eliminating the health insurance marketplace, which is also known as Obamacare, has grown deeply politically unpopular even among Republican constituents. Since Trump’s first term, the number of people enrolled has grown by more than 9 million nationally. That political leverage is something that California advocates believe will help protect the program.
“More people are enrolled in (Affordable Care Act) marketplaces than ever before,” Linn Gish said.
But in many ways the state’s Achilles heel is federal funding. Federal spending on California health care programs is more than three times greater than the state’s share. That’s more than $117 billion from the federal government to support Medi-Cal and the Affordable Care Act compared to $35 billion from California’s general fund for all state health spending.
With the state grappling with a third consecutive deficit next year, the most likely federal health care cut will be difficult to prevent: financial assistance for middle-class families.
Outgoing President Joe Biden approved two rounds of Affordable Care Act subsidies, making assistance available to middle-class families for the first time. Those subsidies expire at the end of 2025, and Trump and congressional Republicans have signaled that they don’t want to renew them.
Without them, premiums will increase by an average of $1,000 annually for residents with insurance through Covered California, the state’s Affordable Care Act program. Premiums are already set to increase by about 8% next year.
Prior to Biden’s push to lower health care premiums, many Californians paid upwards of 18% of their income on health insurance, according to Covered California data. Federal assistance capped that expense at 8.5%.
In 2023, California lawmakers established a backstop of state funding to help more people afford health insurance, but those reserves can’t make up the gap if federal funding stops.
Health care for immigrants
Medi-Cal, the state Medicaid program, offers expansive benefits to all low-income individuals regardless of immigration status. It could face cuts with a less-than-friendly federal administration.
Federal dollars cover about 70% of Medi-Cal’s program costs, while the state invests approximately $30 billion in general fund spending.
“The largest concern we have who are working our state budget is the resources we will be receiving from the federal government this upcoming year,” said Assemblymember Joaquin Arambula, a Democrat from Fresno who has focused on expansions for undocumented workers.
About 7 million more Californians qualified for Medi-Cal after Affordable Care Act rules allowed the state to bump up income limits in 2014, and about 1.8 million undocumented immigrants have gotten Medi-Cal coverage after the state began expanded eligibility in 2015.
