Unclear future for health care

President-elect Donald Trump probably does not lose much sleep over it, but millions of Californians have spent wakeful nights since his election wondering what will happen to their health care if he follows through on his promise to “eliminate Obamacare on Day 1.”

That day is just weeks away now. If the promise is kept (and Trump so far shows signs of ignoring some promises he made during the election season while carrying out others), it could affect about 4.6 million Californians whose health insurance is at least partly funded by outgoing President Barack Obama’s Affordable Care Act (ACA).

They either buy insurance plans under the Covered California exchange or they’ve joined the federally-subsidized Medi-Cal, the state’s low-income health care plan, since Obamacare began subsidizing expansion of the program in 2014.

Of course, unless Congress has acted prior to Trump’s inauguration, he won’t be able to do away with all this on Day 1. Most analysts say it would take an act of Congress to undo state exchanges and the Medicaid expansion of which Medi-Cal’s growth was a part.

But even if it doesn’t happen on Trump’s first day, when he’s also promised to reverse many Obama executive orders in areas like immigration, oil drilling and environmental regulation, changes will come.

House Speaker Paul Ryan of Wisconsin has in the last couple of weeks unveiled the general outlines of a Republican plan to “replace” the ACA, which now provides health care to about 20 million Americans who couldn’t get it before.

Ryan’s plan, almost certain to be adopted by Trump with only small changes, would offer tax credits rather than direct subsidies to help people pay for insurance. It would keep Obamacare’s protections for persons with pre-existing conditions. Trump has also said he wants to keep Obama’s rule allowing young people to retain coverage under their parents’ policies up to age 26.

But Ryan’s blueprint would not force anyone to buy insurance, nor would it impose fines on individuals who don’t buy into the system, as the ACA does. That means less money will be coming into the insurance system, which in the Ryan plan translates to much higher deductibles and higher premiums as policy-holders age.

Ryan would also add a high-risk pool to the insurance picture, much as high-priced auto insurance is available to high-risk drivers. This would mean high-premiums for persons with cancer and chronic conditions that are expensive to treat. So much for that pre-existing condition protection.

These provisions, of course, will be subject to tweaking and to input from Trump’s new secretary of Health and Human Services, current George Rep. Tom Price, who has long sought to dump all of Obamacare.

The bottom line on all this that most individuals now covered under Obamacare will likely see premiums rise and coverage drop, in spite of Trump’s oft-repeated promise to replace Obamacare with better insurance at lower prices.

In California, that will likely affect about 3 million persons now on Medi-Cal that’s subsidized by the ACA, and many of the almost 1.4 million who buy policies from companies selling plans in the Covered California exchange.

Most affected of all will be young people: The share of children covered by Medi-Cal or the state’s Healthy Families program grew from 32.8 percent in 2009 to 40.3 percent in the most recent figures reported by UCLA’s Center for Health Policy Research.

That helps explain the several protest rallies involving nurses, doctors, patients and healthy senior citizens that have been held around the state in the last month.

“The actions threatened by Trump and the Republican Congress are a direct attack on health care for the most vulnerable,” said one doctor at a Los Angeles rally. “California has done more to expand health care access than any other state. We need a massive effort to protect California’s…progress toward health care for all.”

Unless similar rallies spread far beyond California and draw huge crowds, don’t expect much sympathy for those views from Republicans in Congress. Most have wanted to ax to Obamacare since before it took effect, and with the backing of the President-elect, there’s nothing to stop them from moving now against those who benefit most from Obama’s law: the poor, the very young and the legal immigrants.