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 and further dismantling abortion rights, which are 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which as of this year is available to all income-eligible immigrants, is too expensive and should be “delayed or repealed entirely.”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 — though they expect the new administration to put California’s new laws to the test.

“We have their playbook from 2017, and almost everything they tried to do, California helped stop through our advocacy … or through court cases,” said Rachel Linn Gish, communications director for Health Access California. “In that way we are in a much stronger position than before.”

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. 

Republican lawmakers in general have shifted away from talking about eliminating the program entirely, but some leaders, including Vice President-elect J.D. Vance have suggested changes that would make insurance more expensive. Vance during the campaign said he wanted to increase choices for consumers and “make the health insurance marketplace function a little bit better.”

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, which includes public health, state hospitals and social services.

And much of California’s policies can only be fully realized with sufficient money in the bank.

With the state grappling with a third consecutive deficit next year, the most immediate and 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 during his presidency, making assistance available to middle-class families for the first time. Those  subsidies will 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, and without federal assistance other out-of-pocket costs such as deductibles and copays will most likely spike as well. 

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%.

“You’re talking about a world where we’re doubling how much people pay,” Linn Gish said.

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.  The program could face uncomfortable 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 many of us have who have worked with 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. “There are many who are struggling who need their government to help.”

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 expanding eligibility for them  in 2015.

Some California Republicans have strayed from the party platform when it comes to health care for undocumented immigrants. The Central Valley relies heavily on immigrant labor, and a handful of state Republicans from those communities supported expanded access to health insurance for undocumented residents. 

The state GOP, however, still officially opposes coverage for undocumented immigrants and several Republican lawmakers want the state to undo that health care expansion.

Gov. Gavin “Newsom and Democrat lawmakers insist on expanding free health care for illegal immigrants to the tune of $5 billion per year. In the midst of a multi-billion dollar budget deficit, hospitals and maternity wards shutting down, and a massive influx of migrants illegally crossing our open border, we should not be expanding this costly government program,” Jones, a Republican from San Diego said.

Immigrants who came to the United States in their youth and who are protected by the Obama-era program known as Deferred Action for Childhood Arrivals (DACA) for the first time can enroll in Covered California thanks to expanded eligibility under the Biden administration.

Liberal lawmakers and policy advocates hailed the expansions as a long-sought-after victory, but they remain controversial among California Republicans. Many lawmakers and advocates expect these expansions to be challenged over the next four years. 

“Anything that has Biden’s fingerprints on it is going to be the first touched. The DACA expansion is going to be high on the list,” Linn Gish said.

This year a bill expanding Covered California to all undocumented immigrants, not just those who came to the U.S. as children, stalled in committee. That measure would have allowed immigrants who make too much money to qualify for Medi-Cal to purchase insurance.

Arambula, who authored the bill, said those populations are “unjustly excluded” from buying insurance at full price even if they want to. He plans on reintroducing the measure, which could be implemented without federal approval. 

Family planning and abortion cuts

On the campaign trail Trump took credit for appointing the Supreme Court justices who ended the national right to abortion by overturning Roe vs. Wade, but he said he would not support a national law banning abortion.  

Still, California Democrats aren’t taking any chances on abortion rights. They passed more than two dozen laws to protect access to abortion, contraceptives and gender-affirming services in the last three years.

In 2022, voters also protected abortion as a right in the state constitution. 

Democratic lawmakers say they have more work to do. 

Bonta said she plans on introducing bills to further protect reproductive rights on the first day of the legislative session. Those bills would require hospitals to provide emergency abortions, protect birth control for Medi-Cal recipients and ease the regulation of birth centers. Bonta said lawmakers are working quickly and she expects many of the bills introduced in December to have urgency clauses that allow immediate implementation.

“It’s going to be a huge change within the health care space,” she said.

The first time Trump was president, he also dismantled Title X regulations that fund the federal family planning network by instituting a “gag rule” prohibiting clinics from performing or referring for abortions. The clinics funded have historically provided contraceptives, abortion care, sexually transmitted infection testing and treatment, gynecology services and postpartum care. After the rule change, the number of people served by Title X clinics dropped 60% nationally as a result of clinics exiting the program, according to the Kaiser Family Foundation, an independent health policy research center..

In California the number of people served dropped from 1 million to fewer than 200,000, said Amy Moy, co-CEO of Essential Access Health, which administers the state’s Title X money. 

California dedicated $10 million to bridge the gap, but Moy said if there is another federal cut, clinics say to expect longer wait times and fewer providers.

“We will be having to test the bounds of our guardrails and see what we can do here, but we are committed to working with partners and state leaders to do everything possible,” Moy said.

Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

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WASHINGTON (AP) — President Joe Biden signed Democrats’ landmark climate change and health care bill into law on Tuesday, delivering what he has called the “final piece” of his pared-down domestic agenda, as he aims to boost his party’s standing with voters less than three months before the midterm elections.

The legislation includes the most substantial federal investment in history to fight climate change — some $375 billion over the decade — and would cap prescription drug costs at $2,000 out-of-pocket annually for Medicare recipients. It also would help an estimated 13 million Americans pay for health care insurance by extending subsidies provided during the coronavirus pandemic.

The measure is paid for by new taxes on large companies and stepped-up IRS enforcement of wealthy individuals and entities, with additional funds going to reduce the federal deficit.

In a triumphant signing event at the White House, Biden pointed to the law as proof that democracy — no matter how long or messy the process — can still deliver for voters in America as he road-tested a line he will likely repeat later this fall ahead of the midterms: “The American people won, and the special interests lost.”

“In this historic moment, Democrats sided with the American people, and every single Republican in the Congress sided with the special interests in this vote,” Biden said, repeatedly seizing on the contrast between his party and the GOP. “Every single one.”

The House on Friday approved the measure on a party-line 220-207 vote. It passed the Senate days earlier with Vice President Kamala Harris breaking a 50-50 tie in that chamber.

“In normal times, getting these bills done would be a huge achievement,” Senate Majority Leader Chuck Schumer, D-N.Y., said during the White House ceremony. “But to do it now, with only 50 Democratic votes in the Senate, over an intransigent Republican minority, is nothing short of amazing.”

Biden signed the bill into law during a small ceremony in the State Dining Room of the White House, sandwiched between his return from a six-day beachside vacation in South Carolina and his departure for his home in Wilmington, Delaware. He plans to hold a larger “celebration” for the legislation on Sept. 6 once lawmakers return to Washington.

The signing caps a spurt of legislative productivity for Biden and Congress, who in three months have approved legislation on veterans’ benefits, the semiconductor industry and gun checks for young buyers. The president and lawmakers have also responded to Russia’s invasion of Ukraine and overwhelmingly supported NATO membership for Sweden and Finland.

With Biden’s approval rating lagging, Democrats are hoping that the string of successes will jump-start their chances of maintaining control in Washington in the November midterms. The 79-year-old president aims to restore his own standing with voters as he contemplates a reelection bid.

The White House announced Monday that it was going to deploy Biden and members of his Cabinet on a “Building a Better America Tour” to promote the recent victories. One of Biden’s trips will be to Ohio, where he’ll view the groundbreaking of a semiconductor plant that will benefit from the recent law to bolster production of such computer chips. He will also stop in Pennsylvania to promote his administration’s plan for safer communities, a visit that had been planned the same day he tested positive for COVID-19 last month.

Biden also plans to hold a Cabinet meeting to discuss how to implement the new climate and health care law.

Republicans say the legislation’s new business taxes will increase prices, worsening the nation’s bout with its highest inflation since 1981. Though Democrats have labeled the measure the Inflation Reduction Act, nonpartisan analysts say it will have a barely perceptible impact on prices.

Senate Minority Whip John Thune, R-S.D., on Tuesday continued those same criticisms, although he acknowledged there would be “benefit” through extensions on tax credits for renewable energy projects like solar and wind.

“I think it’s too much spending, too much taxing, and in my view wrong priorities, and a super-charged, super-sized IRS that is going to be going after a lot of not just high-income taxpayers but a lot of mid-income taxpayers,” said Thune, speaking at a Chamber of Commerce event in Sioux Falls. The administration has disputed that anyone but high earners will face increased tax scrutiny, with Treasury Secretary Janet Yellen directing the tax agency to focus solely on businesses and people earning more than $400,000 per year for the new audits.

The measure is a slimmed-down version of the more ambitious plan to supercharge environment and social programs that Biden and his party unveiled early last year.

Biden’s initial 10-year, $3.5 trillion proposal also envisioned free prekindergarten, paid family and medical leave, expanded Medicare benefits and eased immigration restrictions. That crashed after centrist Sen. Joe Manchin, D-W.Va., said it was too costly, using the leverage every Democrat has in the evenly divided Senate.

During the signing event, Biden addressed Manchin, who struck the critical deal with Schumer on the package last month, saying, “Joe, I never had a doubt” as the crowd chuckled. Later, outside the White House, Manchin said he has always maintained a “friendly relationship” with Biden and it has “never been personal” between the two, despite Manchin breaking off his negotiations with the White House last year.

“He’s a little bit more vintage than I am, but not much,” Manchin said of Biden.

Though the law is considerably smaller than their initial ambitions, Biden and Democrats are hailing the legislation as a once-in-a-generation investment in addressing the long-term effects of climate change, as well as drought in the nation’s West.

The bill will direct spending, tax credits and loans to bolster technology like solar panels, consumer efforts to improve home energy efficiency, emission-reducing equipment for coal- and gas-powered power plants, and air pollution controls for farms, ports and low-income communities.

Another $64 billion would help 13 million people pay premiums over the next three years for privately bought health insurance under the Affordable Care Act. Medicare would gain the power to negotiate its costs for pharmaceuticals, initially in 2026 for only 10 drugs. Medicare beneficiaries’ out-of-pocket prescription costs would be limited to $2,000 annually starting in 2025, and beginning next year would pay no more than $35 monthly for insulin, the costly diabetes drug.

Rep. Jim Clyburn, D-S.C., a powerful political ally to Biden, noted during the White House ceremony that his late wife, Emily, who battled diabetes for three decades, would be “beyond joy” if she were alive today because of the insulin cap.

“Many seem surprised at your successes,” Clyburn told Biden. “I am not. I know you.”

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