As far-reaching Republican health legislation heads to a vote on the House floor Thursday, Californians up and down the state are wondering what it could mean for them.
A majority of the state’s residents would not see significant changes to their coverage because they get insurance through their employers or through Medicare, the federal program for the elderly.
But the GOP proposal could have a big impact on the nearly 14 million Californians – about one-third of the state’s population – who are covered by Medicaid, the health program for low-income people, known as Medi-Cal in California.
The GOP plan would also likely scramble the health care calculations of people who buy their own coverage, especially if they do so through Covered California, the state’s insurance exchange, and get federal help with their premiums.
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The Republicans want to end Medicaid’s open-ended funding and replace it with a more limited federal contribution – either a lump-sum payment or a specified amount per enrollee.
The GOP also hopes to end the Affordable Care Act’s expansion of Medicaid, which has brought coverage to 3.7 million Californians and helped reduce the percentage of uninsured people in the state by more than half.
An analysis released Wednesday by the state estimated that California would lose $6 billion in federal funding for Medicaid in 2020, increasing to $24 billion by 2027 if the Republicans are able to make the changes they want. That could force significant cuts.
The proposed legislation, which still faces strong headwinds from within GOP ranks, would provide tax credits to help people buy insurance. But the overall amount allocated would be significantly smaller than under Obamacare. That could hit a lot of people hard. But some would be better off than under current law, depending on their age, income and the cost of health coverage where they live.
We interviewed a handful of residents in the Sacramento area and the Central Valley about their personal health care concerns and how the GOP plan might affect them.
A lifesaver for chronic illness
“Nobody knew that health care could be so complicated,” President Donald Trump famously said last month when discussing plans to repeal and replace the Affordable Care Act.
Rachel Thompson, a Roseville single mom with two children, did.
Since her divorce in 2015, Thompson, 53, has been navigating the minefield of health insurance options for herself and her two kids: Anya, 17, and Lukas, 11.
It wasn’t easy, but now Thompson has a subsidized plan for herself through Covered California, the state health insurance exchange, while her children are covered by Medi-Cal, the state’s version of the federal Medicaid program.
“It took jumping through a number of hoops to get them covered under Medi-Cal. It was more than I’ve ever had to do for the IRS,” said Thompson, a social media consultant and author who writes about surviving childhood sexual abuse. “But it’s a big financial relief to me, especially as a single mom.”
Each month, Thompson receives about $560 in tax credits for her Covered California plan and pays $159 of her own money. She also benefits from “cost-sharing subsidies” that reduce her out-of-pocket expenses, such as the copays for her migraine medication.
Those pills used to cost her $200. Now they’re $10.
“I wouldn’t have been able to afford insurance otherwise, with the car payment, car insurance, rent, groceries and everything else,” she said.
Meanwhile, her children’s Medi-Cal coverage is free.
“It’s been a lifesaver,” said Anya, who struggles with anxiety and obsessive-compulsive disorder, and manages both with medication.
The GOP plan to replace Obamacare would touch nearly all aspects of the family’s coverage. It would likely mean fewer tax credits for Thompson and the loss of her cost-sharing subsidies for out-of-pocket expenses. It also would dramatically alter the way Medicaid is funded, cutting federal support for states.
“I’m concerned about whether my kids will still be covered,” Thompson said. “I’m concerned about how the tax credits will work for me as a single mom as well. I’m worried the premiums will go up to the point where I can’t afford it.”
In addition to the financial considerations, the family frets about potentially losing benefits that are covered under Obamacare, including mental health care.
“I don’t know what I’d do without mental health coverage, because that’s such a huge aspect of my life,” Anya said. “My medications are quite expensive.”
She’s even more fearful about the possible loss of health services for women, including birth control. The GOP plan would partially defund Planned Parenthood and restrict access to coverage for abortions.
“I get really bad periods,” she said. “I’ve been considering going on birth control to monitor and regulate that. If that gets defunded and taken away, what’s going to happen to everybody who needs that care?”
A fortuitous decision
Early last year, Barbara Piceno was feeling the best she’d ever felt.
She had reached her optimal weight due to exercise and healthy eating. She was taking classes in English and life-management at Butte College. And she was working part-time operating an embroidery machine.
But severe abdominal pain struck her suddenly in February 2016. An ultrasound a few weeks later revealed a non-cancerous tumor in her uterus the size of a full-term baby’s head, said Piceno, 52, of Chico.
“It hit me out of nowhere,” she said.
So began a long series of tests and treatments, culminating in major surgery in May to remove the tumor and her uterus.
A fortuitous decision just a few months earlier saved Barbara and her husband Ramiro, 36, tens of thousands of dollars in medical bills: They had enrolled in a health plan through Covered California, the state’s insurance exchange. Before that, they had been uninsured. They decided to sign up after having to pay the Affordable Care Act’s tax penalty for going without coverage.
All told, Piceno and her husband, who installs office furniture, shelled out about $8,000 from their own pockets for her medications and care last year, a fraction of the total cost of her treatment, which exceeded $100,000.
“The whole thing was just a miracle,” Piceno said. “For one, Covered California saved my life. And it saved us financially. Without insurance, we would have been in debt the rest of our lives. We live paycheck to paycheck.”
Piceno and her husband receive about $770 per month in tax credits for their Covered California plans and pay $150 out of their own pockets for their premiums.
She is grateful, but understands that many others couldn’t find affordable coverage under Obamacare because they made too much money to receive tax credits, which are based on income.
She believes insurance should be affordable for everyone, based on income and the cost of living in their communities.
Piceno, who is on disability because of her ongoing health challenges, said she and her husband couldn’t afford to pay more for health insurance than they do now. However, under the Republican plan, the couple likely would receive less federal help because the credits would be based mostly on age rather than income.
“Especially for people like us who are low-income, the rent is so expensive, food is so expensive, how do you live, pay rent and pay your insurance?” she asked.
On paper, Bill Schlack and his wife Susan look like Affordable Care Act winners.
Since 2014, they have purchased plans through Covered California, the state’s Obamacare insurance exchange, and have received hefty tax credits to lower their monthly premiums.
This year, their tax credits are so generous they pay just $4.08 per month out of pocket on premiums.
“This has been very valuable to us,” said Schlack, 64, of Fair Oaks, who spent more than $600 per month on premiums before Obamacare kicked in.
But Schlack has a counterintuitive perspective on the ACA, and on the Republican plan to replace it.
Though he’s grateful for the generous financial help he has received from Obamacare, he’s concerned that the law hasn’t done enough to contain the growing cost of health care.
“It’s really good for the government to step in and cover the premium increases and the cost increases,” Schlack said. “But we can’t keep borrowing money to do this. And the fundamental issue is that health care makes up 18 percent of GDP, not that it’s too expensive for Bill and Susan.”
Schlack and his wife run a website-building company called Get Your Net In Gear. It’s not a full-time endeavor for him, though, because a bout with meningitis about five years ago limited his ability to work.
The meningitis scare has informed his opinions on health care. The bill for his hospital stay, before his insurance paid, was $120,000.
“We need to protect people from catastrophic events, but we need to do that in the context of managing costs,” he said.
He hopes the GOP health plan will help consumers “be aware of what costs are and help put decisions in people’s hands.”
Schlack and his wife currently have a high-deductible bronze plan from Covered California, and receive more than $1,500 a month in tax credits.
Under the GOP plan, which bases tax credits on age more than income, the couple would most likely receive significantly less.
In January, Schlack will age into Medicare, the federal health program for people 65 and older. But his wife still has a few years on the private insurance market before she becomes eligible.
“If our benefits from the new system are not as great as under Obamacare, but if Obamacare is not sustainable,” he said, “we need to start moving to a sustainable plan.”
‘I am going to be uninsured again’
April Hare isn’t thrilled with the health plan she has through Covered California, the insurance exchange established under the Affordable Care Act. She can’t always see the doctors she wants, her insurer doesn’t always agree to cover medications, and her monthly premiums are about $100 higher now than when she first signed up in 2014.
At times, Hare said, her experience with Covered California and the Blue Shield plan she purchased has been a “nightmare.”
But she said she is thankful for the insurance anyway and doesn’t know what she would do without it. She has rheumatoid arthritis and is starting to get asthma. As soon as she heard about the Republican proposal to repeal and replace Obamacare, she thought, “I am going to be uninsured again.”
Hare, 40, stays at home with her 9-year-old son, and spends much of her time volunteering at his elementary school. The rheumatoid arthritis sometimes makes her joints stiff, and she thinks about what the disease could mean for her in the future. She is waiting to see a rheumatologist to learn more about the illness. The medication she takes, methotrexate, costs about $160 a month, and the insurance covers all but $5.
Her husband Mike, who is 44, earns about $46,000 a year painting cars, Hare said.
Under the proposed GOP replacement plan, Hare and her husband could lose federal subsidies that help them purchase insurance. She said the couple pays about $1,850 in premiums each year, while the federal government pays the other $4,740. Their son qualifies for health insurance under Medi-Cal, California’s version of the federal-state Medicaid program for low-income people. She pays $13 a month for his coverage.
The Hares might receive a tax credit under the GOP plan, but it likely would be significantly less than the federal subsidies they get under the Affordable Care Act. The big unknown is whether insurers will raise their premiums. She doesn’t know exactly how much their insurance would be under the new plan, but she worries they wouldn’t be able to afford it if it cost more overall than they pay now.
“Our mattresses aren’t lined with $100 bills,” she said. “I can’t call the water company and tell them, ‘I am not going to pay you this month.’ I can’t tell my son, ‘We don’t get food this month because we have to pay for health insurance.’ ”
Life after the Affordable Care Act
Merlin Zuniga said she started having panic attacks in 2012, and she learned she had depression and anxiety shortly after.
Because she was uninsured, a trip to the hospital left her owing thousands of dollars she knew she could never pay. “I was drowning in bills,” said Zuniga, 32, of Bakersfield.
Then doctors gave her more bad news: She had a thyroid disorder and lupus erythematosus, a chronic inflammatory disease that would require lifelong monitoring.
So when the Affordable Care Act allowed states to expand Medicaid to low-income adults without children in 2014, Zuniga was thrilled to receive free health coverage from California’s version of the federal-state program, known as Medi-Cal. “I was super excited,” she said. “I had been uninsured for so long and I really needed a lot of medical attention.”
Zuniga used her Medi-Cal card to get appointments with a rheumatologist and an endocrinologist and to pay for medications. The program also paid for mental health visits.
Now, Zuniga said she is “extremely fearful” about what could happen to her health insurance — and her health — if the Republican-controlled federal government eliminates funding for the Medicaid expansion. She said she doesn’t have much money to spare after paying her mortgage and other bills, and she couldn’t afford to purchase a plan. She works part-time as a waitress, a job that doesn’t include health insurance.
“I am really stressed out,” she said. “What the heck am I going to do if this goes through and I don’t have health insurance anymore?”
Zuniga, who has a sociology degree from Cal State Bakersfield, said she had hoped to attend graduate school in the near future. But now she is putting that plan aside and looking for a full-time job with health benefits.
She still has occasional panic attacks, and some days the depression keeps her in bed. Other days, she gets achy and exhausted. Zuniga said that she is worried her health would worsen if she lost insurance and were unable to see doctors.
“If your health is not good, you can’t do anything,” she said. “I am treating that as the biggest priority in my life.”
Zuniga has been following the news daily, knowing that whatever happens in Washington could impact her directly. Lately though, she has felt overwhelmed by worry about what could happen. “It is too much,” she said. “I think I need to unplug a little bit.”
This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.