January 20, 2019
Health Care Under Trump: The California Perspective

Health Care Under Trump: The California Perspective

by Amanda Z. Naprawa  

Many people, from all walks of life, are concerned about the future of health care in America under a Trump administration. President-elect Trump and the Republican-controlled House and Senate have made it clear that repealing the Affordable Care Act (and thereby removing insurance for nearly 20 million Americans) is a top priority. Medicaid and Medicare will also face serious challenges, and Trump’s likely choices for his cabinet are fueling concerns that science and scientific inquiry will be stifled during the next four years.

To address the concerns expressed by leaders in medicine and public health in the face of this new uncertain future, the UC Berkeley School of Public Health brought together a panel of public health experts to give insight into what changes we can expect for health care, particularly in California, under a Trump presidency. Held on December 7, the event was moderated by the School of Public Health’s Dean Emeritus Steven Shortell, PhD; panel members were Sandra Hernandez, MD, President and CEO of the California Healthcare Foundation; Anthony Iton, MD, JD, Senior VP of Healthy Communities for the California Endowment; and Karen Smith, MD, Director of the California Department of Public Health.

The current health care landscape in California

The Affordable Care Act (ACA), which the president-elect and congressional majorities have stated they plan to repeal, has been very effective in decreasing the number of uninsured Americans. Twenty million Americans have become insured under the ACA, and the rate of uninsured Americans has fallen to a historic low of under 10 percent.California is home to 5 million of those newly insuredindividuals. Ninety-one percent of Californians now have insurance coverage, and virtually every child in California has health insurance.

The ACA has also had measurable impact and cost savings due to its expansion of preventive health services, such as well-baby visits, vaccinations, well-woman visits, and obesity and blood pressure screenings. What will happen if health care reform is repealed is of grave concern to those who work in this field.

Concerns for health care under a Trump administration

One major concern among public health experts is the financial effect that the repeal of the ACA would have on the ability of states to continuing meeting the health care needs of their populations. In California, according to Dr. Hernandez, if the state loses even just half of the federal subsidies it currently receives for Covered California (the health insurance marketplace for Californians) and Medicaid expansion, it will leave the state with a $20 billion shortfall. This, in turn, will require California to implement new ways of delivering and improving health care, since, as Dr. Hernandez pointed out, “If we are going to stay on the path of improving health, we are not going to be able to do it as we have in the past. You cannot take the infrastructure of today and somehow fill this $20 billion gap.” Dr. Smith added that, if there is a repeal of the ACA without replacement, the state will face the “single largest hit to public health infrastructure in history.”

Also of concern are the way in which the negative and exclusionary tones set by the Trump campaign might impact public health when he takes office. Dr. Iton discussed the role of “narrative” in shaping policy, because it ultimately dictates where funds are directed. Donald Trump’s narrative of “exclusion” results in the creation of “the other,” who is “dehumanized and viewed as a threat.” This focus on “otherness” creates a sense of scarcity and ends up pitting populations against each other for resources. Dr. Hernandez agreed, noting that “the amount of antipathy and hatred of the other that has been stimulated as a result of this election is hard to put back into the bottle.” Drs. Hernandez and Iton agreed that California must be bold in defending targeted and marginalized populations, such as undocumented immigrants, minorities, and the LGBTQ population to make sure that these individuals are not left behind.

Finally, the panelists all expressed concern about the devaluing of science and data that was showcased during the Trump campaign and is likely to carry forward into his administration. The “anti-empiric, anti-scientific environment is a profound phenomenon,” asserted Dr. Hernandez, and one that makes the delivery of evidence-based health care difficult. For instance, in addition to denying the existence of human-caused climate change, Donald Trump has expressed worrisome and completely unsubstantiated anti-vaccine sentiment. Both of these arguments fly in the face of well-established and accepted scientific opinion, thereby creating policies that may further strip science of its legitimacy.

Is there room for optimism?

Although the Trump years will likely prove to be a challenging time for public health and health care, the panelists identified some things we can be optimistic about. For one thing, Dr. Smith noted, while the Affordable Care Act has been tremendously successful on some fronts, it has not solved the overwhelming problem of how to make being healthy affordable. This may be the time to evaluate some of the flaws in current health care reform and to find common ground on ways to reduce costs. Additionally, “access to healthcare [alone] is never going to fix the problem,” Dr. Smith said, because it’s also necessary to have the right conditions that engender health. This requires getting communities engaged and invested in their own health so that they can pressure their representatives to fund needed changes.

Additionally, Dr. Iton noted that since the election there has been an unprecedented amount of communication and coordination from different groups who are all realizing that many other policy goals (fair housing, access to education, clean environment) have commonalities with public health and health care policy. This may result in a consolidation of energy that can be focused on common goals that support community health—what Dr. Iton described as a “catalytic time for California.” As Dr. Shortell stated at the end of the evening, “I have no doubt that we are being forced to do something that we would not have done otherwise, and that we are being forced to be creative and to think of things we would not have thought about.”

Also see The 2016 Election Results and Community Health.