There is not yet a coherent plan, but there are disparate elements being discussed by Republicans that could be put forward; such as block grants, expenditure caps, vouchers, Exchanges, refundable tax credits, tax deductibility, carrots and sticks for enrollment, high risk pools, multi-state purchasing, underwriting reforms, high deductible plans, health savings accounts, limited benefits, and increased out of pocket.  The vision is tied to increased consumer exposure to the costs of health care – i.e. higher copays, higher deductibles – and reductions in federal health spending. The mantras may become de-regulate, de-federalize and privatize.

The federal government is the largest source of financing for the American health system through Medicare, Medicaid, tax expenditures, and now the Affordable Care Act. This could change under the Trump Administration, and it is vitally important to understand those changes that are being considered.

Those old Crosby Stills and Nash lyrics have been running though my mind as the newly empowered Republicans in Congress and the Trump Administration prepare to run amok on health care coverage for all Americans. No, not jobs, not the economy, not Russian hacking, nor ISIS. It’s taking away health coverage that occupies their attention.

Moby Dick was the mystical Great White Whale that Captain Ahab pursued to the ultimate destruction of his boat, himself and nearly all his crew. The Affordable Care Act has been the Republican Party’s Great White Whale for the past eight years, and now they are finally closing on their prey intent on its repeal and destruction.

As we enter the holiday season, I’d like to take a moment to honor and thank ITUP staff. We have been together for 20 years, you made the program what it has been and helped California to become one of the nation’s leaders in implementing the Affordable Care Act and drastically reducing the numbers of uninsured California residents.

It’s been profoundly depressing to even consider the next two to four years under President elect Trump unless of course you voted for him, which most did not. I am still trying to absorb it all and think about the future. With a few rare exceptions, it gets ever worse with each appointment and every new disclosure (the latest about the Russians). I fear the next four years will be a horror show in this country and around the world, but let's get to know the ideas and figure out how to respond.

Eighteen years ago, I interviewed Daphne Radfar for a position with ITUP; she was to become ITUP’s second employee and my right hand for the last eighteen years in leading the organization from a tiny fledgling to a highly respected health policy think tank. As ITUP grew, we had a staff of four in an office built for two. Eventually we grew to a staff of 12 in a space designed for 7.

Patients are here from all over the country; they come from every economic strata and every ethnic group; their quiet courage facing the challenges of their diseases is extraordinary and infectious. The staff, the nurses, the doctors and mid-level practitioners are utterly dedicated to their patient care mission.

Since the election, I hear lots of quiet conversations in the hospital lounges and the surrounding restaurants with patients and family members wondering what President-elect Trump will try to do to their coverage. In his campaign he said “repeal and replace” the Affordable Care Act (ACA) so that Americans would have the very best health care system in the world.

We are all in this together. Now is the time for all of us to rise to the challenge of an evenly and starkly divided country with one party in charge of all three branches of federal government and likely to pursue matters of its own liking and to its own advantage.

fter two years of 4% increases in health insurance premiums, Covered California premiums will increase by 13.2% in 2017. Savvy shoppers can avoid these increases since many plan’s increases were far lower, and there is now a wide variation in premiums between the most and least expensive plans.

Prices for the lowest cost bronze plans increased only 3.9% (for a three-year average of 3.9%). Prices for the lowest cost silver plans increased 8.1% (for a three year average of 4.8%). Prices for the 2nd lowest cost silver plans (reference plans) increased 8.1% (for a three year average of 4.1%). Prices for the savvy comparison shoppers (i.e. those switching to the lowest priced plan in the metal tier they selected) declined -1.2%. http://www.coveredca.com/news/pdfs/CoveredCA-2017-rate-booklet.pdf 

Clearly there will be lots of strong financial incentives for Covered CA customers to shop around in the coming year; this report will provide some information for those inclined to do so. As you will see by comparing premiums and increases in your region, there are very substantial premium savings to be achieved by switching plans and for some by switching tiers.

The United States has the second highest incarceration rate in the world, behind only the Seychelles Islands (in the middle of the Indian Ocean) and nearly 7 times higher than Canada and 10 times higher than Norway. Within the United States, California’s incarceration rate is about average, twice as high as Maine and Minnesota and half as high as Louisiana.  With the war on drugs, three strikes, mandatory minimum sentences, increased sentences, restrictions on judicial discretion in sentencing and a steady stream of tough on crime bills, California’s prison population increased by 500% between the early 1980s and 2000.

Proposition HHH is a City of Los Angeles proposition to finance municipal bonds to build supportive housing for the chronically homeless. Smith, “Measure Will Test Voters Support for the Homeless”, LA Times 10/20/16 The Los Angeles Area Chamber of Commerce and the United Way of Los Angeles are leading this effort. This bond measure would help build 10,000 dedicated units of supportive housing.  The countywide need is for 25,000 homeless housing units of which only 9,000 currently exist.

David Leonhardt captured the essence of the nation’s challenge for the next decade(s) in his Opinion piece for the New York Times, entitled “A Great Fight of Our Times” appearing on October 11, 2016. He described the economic stagnation facing 1/3rd of our nation’s citizens: lower net worth, greater disparities in life expectancy, more children in single parent families, growing obesity, high levels of incarceration and failure to attend or complete a four year college degree.

Where are we now? The FY 2016-17 Budget projects that Medi-Cal enrollment will increase to 14 million subscribers in 2016-17, at a total cost of $86 billion, of which $19 billion is state General Fund, and the remainder comprise a mix of federal matching funds, local funds and state special funds. Adding in Covered California subscribers means 15.5 million Californians – roughly three in eight Golden State residents – will be covered between the two programs. This November's ballot initiatives will play a key role in financing health care for lower income Californians.

California has made great progress implementing the Affordable Care Act (ACA), with well over 6 million people newly enrolled in either Medi-Cal or Covered California since December 2013. The state strives to improve the quality, outcomes and effectiveness of care and the performance of its safety net delivery systems with its recent renewal of its §1115 Medicaid waiver. Beginning in 2017, the ACA offers another major opportunity for states to meet these goals with a §1332 waiver. These broad waivers would allow states the ability to waive several requirements of the ACA to create new and innovative models to improve and expand health coverage. They are intended to allow state experimentation with different models of coverage. There are five models to use in building towards universal coverage: 1) single payer private systems like Canada,[1] 2) employer mandates like Germany, 3) individual mandates like Switzerland, 4) socialized medicine like Great Britain where the government owns the hospitals and employs the doctors, and 5) a hybrid system like the Affordable Care Act (Obamacare) which combines employer and individual mandates with tax subsidies for those who cannot afford coverage. Depending on which path a state chose, the mandates of the ACA could become superfluous.

Thank heavens that someone finally asked the Presidential candidates about health care policy and the Affordable Care Act (ACA). Republican candidate Donald Trump replied with what sounded like a “word salad” riff on selling insurance without lines/ across state lines and enacting block grants and repealing Obamacare. Presidential candidate Hillary Clinton replied with a defense of the positive accomplishments of the ACA and CHIP, an acknowledgement of growing pain problems and a vow to improve affordability for individuals and small employers and to challenge the unwarranted (in her view) increases in premiums from some health plans and drug manufacturers; she then mentioned the public option as one way to improve affordability. Trump then accused Clinton of supporting Canadian style single payer, which he said Canadians did not like at all and they all come to the US for their health care. She replied that in fact the Canadians like their system a great deal, do not come flocking to the US for health care, but single payer is not what she supports for this country.

This explains and reviews the pros and cons of the California Ballot Propositions in 2016. They are extraordinarily consequential for California's health, for the schools, for criminal justice and for the financing of public services. Please vote.

The Commonwealth Fund contracted with the Rand Corporation to analyze the Clinton and Trump proposed health reforms. They recently analyzed four main proposals by Secretary Clinton to improve the functioning of the Affordable Care Act (ACA): 1) tax credits for individuals whose out of pocket spending exceeds 5% of income, 2) reductions in the maximum premium contribution from 9.66% to 8.5%, 3) capping families premium contributions at 8.5%, and 4) the public option for individuals in the Exchanges. This requires an understanding of how the Affordable Care Act works so each needs a little more explanation.

§1332 waivers allow states to waive specified provisions of the Affordable Care Act as long as they are cost neutral to the federal government, cover at least as many people as are already eligible, cover at least as many services as are already covered and are at least as affordable as the ACA. California’s waiver would seek federal approval so that the state Exchange (Covered California) can offer mirror coverage opportunities for the undocumented, but without any federal or state premium assistance or out pocket assistance.

§1332 waivers allow each state to tailor the Affordable Care Act (ACA) to its own local conditions. Hawaii was the first state to propose a §1332 waiver, and it is a very interesting one because Hawaii already has achieved one of the lowest uninsured rates and some of the lowest premiums in the country. Hawaii seeks to waive the requirement to establish a SHOP purchasing pool for small employers. The state’s rationale was that it’s expensive to establish and very few small employers participated.