The battle over the American Health Care Act has devolved into a question of whether Paul Ryan can save face by passing something out of the House that he knows can’t advance in the Senate. That Republican leadership is considering placating Trump and the Freedom Caucus right by including insurance market changes that have no budgetary component and cannot be part of a Senate bill that goes through reconciliation shows the futility of the exercise. The AHCA is dead. All that’s left is determining who the public will see holding the bloody knife.
What comes after the AHCA? That’s a useful question. As I reported in February, the worker bees inside the Health and Human Services Department are already busy undermining the individual exchange market and implementing President Trump’s blame-game strategy of tagging Democrats with Obamacare failure. “Let it be a disaster,” Trump has said, “and we can blame that on the Democrats and President Obama.”
There’s reason to question whether pointing fingers as millions lose access to care will work. But all of this assumes that the fight will play out only on the terrain of a degrading health-care system. What if the nation’s largest state, the capital of liberal America, goes their own way and shows a counterpoint, by improving a flawed system and realizing the goal of truly universal coverage?
Gavin Newsom, currently the favorite to win the California governor’s race in 2018, wants to create this contrast. So does the state Legislature. And they are following different paths to get there.
Last month, the Legislature introduced SB 562, which would create a single-payer system for all of California’s 38 million citizens, including the undocumented. The Legislature has passed this concept twice, both in 2006 and 2008, only to have it vetoed by Arnold Schwarzenegger. But “concept” is the key word. There aren’t many details in the bill beyond the desire to move to single-payer, where the government acts as the only insurer to bargain down provider costs.
Vermont passed a similar bill into law but abandoned it after they couldn’t figure out how to pay for it. A Colorado single-payer ballot measure got destroyed at the polls last year. And shifting to single-payer would require a waiver from the federal government, allowing California to combine federal dollars into one coherent system. President Trump’s granting such a request is unlikely.
That brings us to Newsom’s pitch, modeled on a program called Healthy San Francisco, which was instituted in 2007 when he was mayor. This is not single-payer health insurance, but it would guarantee universal access to health care. It’s a kind of hybrid between the managed-care craze of the 1990s and the socialized medicine of Britain’s National Health Service.
Under Healthy SF, everyone within the city limits has the ability to get health care, regardless of whether they have insurance or whether they are in the country legally. Community health centers and public hospitals provide primary and preventive care to anyone making up to 500 percent of the federal poverty line who has no other insurance option. This “medical home” develops a long-term relationship with the patient, tracking their health and preventing the use of the emergency room as a primary doctor. They refer patients out to specialty care and hospitalization when necessary. The medical homes are publicly funded, mostly through a citywide employer mandate. The uninsured can access care anywhere inside the city’s borders.
This sits atop the network of public and private insurance programs, ensuring that everyone in San Francisco has access—not just to insurance but to actual health care. Healthy SF fills in the gaps that the Affordable Care Act has been unable to reach. But this is a small program. Enrollment has declined because of people getting coverage through the California exchanges and expanded Medicaid. At the end of the last fiscal year, Healthy SF reported 14,404 participants, who made 50,000 total office visits throughout the year.
If the ACA were repealed, Healthy SF could grow to meet the needs of the uninsured locally. And Newsom wants to take that safety net statewide. This effort is already underway, revealing some challenges with scaling up. California actually already mandates coverage for the uninsured, which some counties interpret more broadly than others. Mitchell Katz, who designed Healthy SF, became head of the Department of Health Services in Los Angeles County, attempting to replicate the San Francisco project there. Called My Health LA, the program aims to serve a much larger population—roughly 400,000 undocumented immigrants, and hundreds of thousands more uninsured. There’s no employer mandate, and the money comes out of county revenues. Still, as of last June 143,000 were enrolled, close to the county’s target, with 176 participating clinics. That’s decent but still below the needs of the uninsured in the county.
Newsom, who snagged an early endorsement from the pro–single payer California Nurses Association, told The Sacramento Bee that he’s working with Katz on taking the medical-home concept statewide. But by its nature, the concept requires a large network of clinics to give all uninsured residents convenient options for care. And even Newsom admits that many parts of California don’t have that health-provider infrastructure in place. “It’s not necessarily something that can be adopted in all 58 counties,” Newsom said, “but it can be adopted… where the majority of California’s population is.”
Could a universal-coverage system in California survive in an age of Trump? The expected degradation of the ACA and increases in the ranks of the uninsured would put stress a Newsom-style system. And scaling it up to ensure that everyone has a medical home would be expensive. There also hasn’t been enough data to test the system’s key theory: that rigorous primary and preventive care will lower overall health costs and save public money.
Beyond that, the universal-care idea differs from the single-payer approach that even Newsom’s supporters prefer. It’s certainly easier to find the money to fill in the cracks of the current system than it is to overhaul it. But what if those cracks become gaping holes?
Newsom isn’t the only gubernatorial candidate who will have something to say about health care, and he isn’t fated to win. However, if California can pull off something approaching universal coverage, the contrast with the rest of the country would be enormous. The Trump administration is signaling the allowance of work requirements in Medicaid, smaller windows to enroll on the individual market exchanges, greater barriers to acquiring insurance, and continued worsening of the value of the coverage insurers can offer. Consider that next to a place where everyone can find a doctor and get the care they need. California has been a beacon for the nation in the past; it can show what a compassionate society can do to guarantee health care as a right and not a privilege in the future.