On March 20, Drew Altman, Ph.D., President and CEO of the Henry J. Kaiser Family Foundation, sat down with UCSF Professor, Dr. Andrew Bindman, to discuss “Healthcare in Trump’s America” (which you can watch here). The session was held while the GOP’s proposed health reform bill was still pending and covered both the specifics of the American Health Care Act (“AHCA”) as well as broader concerns for healthcare going forward under the new administration.
According to Altman, the current administration and GOP-led Congress are trying to fundamentally alter “the social contract around healthcare in America”. Conservatives disagree that the federal government should play such a large role in healthcare and this is reflected in their proposals, which focus less on providing healthcare and more on cost-savings and taxes. This, says Altman, has led to a “fundamentally dishonest debate where everyone is claiming that their approaches will accomplish the same thing as what the [Affordable Care Act (“ACA”)] accomplishes, when in fact they have very different objectives.” As Altman notes, “We can have a nice national debate about those different goals and objectives, and what they might accomplish, but were not.” That is because while the talking points have been about healthcare, the actual GOP bills are not about healthcare at all, but about taxes and tax cuts.
GOP leaders like Senator Paul Ryan have long desired to lessen the federal government’s role in healthcare delivery and spending. For this reason, many of the ACA replacement proposals reduce or limit federal Medicaid spending and/or limit government subsidies for purchasing insurance on the healthcare marketplaces. Other cost-containment strategies, says Altman, include moving from having more comprehensive health coverage to less coverage. Altman further asserts that these fundamental changes are an attempt to “rewrite the social contract on healthcare” where we no longer respect the needs of the least fortunate among us. This is leading to “profound changes in healthcare” with real consequences for people.
The AHCA, which the House passed in May, offers an example of what Altman means by the administration’s approach to fundamentally changing the structure of healthcare. Under that plan, the federal government would no longer match state Medicaid spending dollar for dollar. Instead, states would receive either a set amount of money per enrollee group (per capita cap) or a block grant for use in whichever Medicaid programs the state saw fit. In addition, the bill would have effectively ended the Medicaid expansion (which has covered 3 million in California alone). As a result, California would stand to lose over $15 billion in federal funding.
Loss of federal funding for Medicaid, and repeal of the ACA would be extremely troubling for Californians, particularly those who have received insurance under the expansion. Under the ACA, California has reached historically low rates of uninsured (7%). 13.5 million Californians are currently on Medicaid, including those covered under the expansion. If the federal government were to significantly reduce its contributions to Medicaid, California would be short several billion dollars. The state would then have difficult decisions to make about which programs and benefits to keep. According to Altman, the state would likely reprioritize some programs over others to reach the most vulnerable populations, such as those with HIV, the homeless, and women and children.
Yet, even in the face of potentially drastic changes to our federal healthcare system, California looks to make progress in healthcare. Altman noted that a movement for a single payer system is growing in California, and in fact, Lt. Governor Gavin Newsom has indicated that single payer may be part of his gubernatorial election platform in 2018. Additionally, state senators have proposed new state legislation that would require greater transparency on drug prices and particularly price hikes.
Despite the somewhat dismal federal picture on healthcare, Altman explained that recent polls have shown that the public is coming around to the ACA. The Kaiser Family Foundation has tracked public opinion of the ACA since the law’s inception. According to Altman, poll numbers typically fall along party lines with Republicans generally in disfavor and Democrats in favor of the ACA. However, the Kaiser Family Foundation has noted that the dynamic is changing.
On a final note, Altman reminded the audience that “our progress has always been punctuated by very difficult reversals.” Altman explained that he believed that, in the long run, the country arches toward progress, but that progress only happens if everyone tries as hard as they can.