President Trump and Republican Senate Majority Leader Mitch McConnell have abandoned “repeal and replace” Obamacare (the Affordable Care Act) and instead embraced a straight-out repeal of Obamacare as requested by President Trump, the House Freedom Caucus and Senators Cruz, Lee and Paul. Their calculation is that this threat will cause Democrats to join forces with them on a repeal and replace alternative. One might ask “what are they smoking?” “Why this crusade against coverage for low, moderate and middle income Americans, why this crusade to deny coverage for sick people?”

The Congressional Budget Office projects that, as compared to current law (ObamaCare), this repeal would increase the numbers of uninsured by 32 million, increase premiums by 100% in the individual markets and cause insurers to leave the individual market, such that 3/4th of nation’s population would have no insurer participating in the individual market.

Most but not all Congressional Republicans want to repeal and replace the Affordable Care Act, but they lack any coherent vision or level of agreement on what the replacement should be and they have been unwilling to share their visions with the American public, the Congressional Budget Office and their Democratic counterparts. So they are tinkering in the dark with a variety of ideas, nearly each one worst than the next as they try to bring the two wings of their party together on a jury rigged bill for which they hope to get 50 votes. 

Medi-Cal covers about 14 million Californians and costs about $90 billion. It covers about a third of all Californians, pays for nearly 70% of all nursing home residents and pays for over half of all births in California. About 5.5 million children depend on its coverage. Enrollment in the program has grown from just under 8 million at the end of 2013 to about 14 million today. In California’s rural communities, Medi-Cal is the most important payer, accounting for coverage for nearly half of area residents and key to the financial stability of local hospitals, clinics and doctor’s offices.

Single payer health care in essence means Medicare for All, but with improvements to eliminate all copays and deductibles and to add long term care benefits. There has been fury about the Assembly Speaker’s decision to take a pause and ask the proponents to figure out the financing. In my opinion, this is totally warranted and in fact overdue.

Eight years ago, I voted for Steve Zimmer believing he’d be a breath of fresh air for LA’s school children; boy was I proved wrong. He’s been on the wrong side of so many issues I care deeply about – opposing better accountability for the District’s failing schools, increasing fiscal irresponsibility for unfunded employee and retiree pensions, denying authorization and renewals of qualified charter schools, and increasing funding for a bloated, unresponsive central bureaucracy. I’ll give you just one glaring example: LAUSD has been plagued by very low graduation rates; Zimmer’s solution was to reduce the requirements to graduate in the core subjects from a C to a D. The problem is that high school graduates with a D in the core subjects are not eligible to enroll in California’s UC and Cal State systems. I’m not prepared to give him another 5 and ½ year term. We need new blood and a fresh attitude that puts the kids first on the LA School Board.

The Trump Administration and House Republicans are back for another try at repealing and replacing the Affordable Care Act. The salient new added-on features are state waivers of 1) community rating, and 2) essential health benefits. What does this all mean?

Some of us remember learning and mostly failing at the limbo in our younger and suppler years. President Trump and the Freedom Caucus in the House are engaged in the same dance moves. The consequence is not whether you embarrass yourself and fall on your ass (inevitable at some point), but rather how little coverage you will have left when you get sick (also inevitable at some point with dire financial consequences if you are uninsured or underinsured).

Despite the best efforts of the Trump candidacy and Trump Presidency to dissuade Americans from enrolling in the Exchanges, they seem to have had little effect so far. Enrollment has grown from 8 million in 2014, to 11.7 million in 2015, to 12.7 million in 2016, to 12.2 million in 2017. In state based Exchanges like California, enrollment grew from 2.6 million in 2014 to 2.9 million in 2015, to 3.1 million in 2016 and to 3.1 million in 2017. In other words within a steadily improving economy, with ever more people at work, Exchanges are holding their own and proving their mettle.

The Republican House proposal would do the following:

1.     Eliminate the penalties on individuals and employers requiring the purchase, offer and acceptance of health coverage beginning in 2017.

2.     Reduce the federal Medicaid matching rate for the new eligibles to the state’s traditional match beginning in 2020; in California this would reduce the match from 90/10 to 50/50 for new medically indigent adult eligibles from that point forward.

3.     Cap the growth in federal Medicaid matching payments to the growth in the medical CPI beginning in 2020

4.     Repeal the income and cost adjusted refundable tax credits for individual coverage and replace them with flat, age adjusted refundable tax credits beginning in 2020. Extend them to out of market plans.  

5.     Appropriate $80 billion for state grants to stabilize the individual market beginning in 2018

6.     Replace the 3/1 age rate band with a 5/1 age rate band in 2018

7.     Eliminate the 60% actuarial value floor for coverage sold in the individual and small employer markets beginning in 2020

8.     Require a 30% premium surcharge on individual coverage if an individual is uninsured for more than 63 days a year

9.     Repeal the surcharges on the Medicare payroll tax for high income individuals in 2018 – savings of $275 billion

10.  Repeal the annual tax on health insurers in 2018 – savings of $145 billion

11.   Delay the Cadillac benefits excise tax until 2026 – savings of $48 billion.

The Congressional Budget Office made several key findings in their analysis of the Republican “repeal and replace” of the Affordable Care Act legislation today: 1) the numbers of uninsured Americans will increase by 24 million by 2026-- i.e. that many people will lose coverage due to the House Republican plan, 2) the deficit will be reduced by $337 billion by 2026, 3) private individual insurance premiums would rise by 15-20% over the next two years then fall by 10% by 2026.