Donald Trump won the Presidency despite alienating and offending large sections of the US population and having the largest negatives of any person elected to the Presidency. His actions since becoming President have continued this pattern, but it has now expanded to almost every other nation of the globe, including the United Nations itself.

To quote Lin Manuel in Hamilton, “immigrants, we get the job done.”

The Voyage of the Damned recounts the Jewish refugees on the ship Saint Louis turned away from Cuba, the United States and Canada just before the Second World War. An anti-Semitic group of State Department officials, led by Breckenridge Long, did everything possible to obstruct Jewish immigration to the US in advance of the Holocaust at a time when anti-Semitism pervaded parts of the United States and its government.

n California, we are more threatened than most states by TrumpCare. At the best, President will follow through on his promises and all Californians, (indeed all Americans but the undocumented) will have excellent coverage and lower out of pocket payments for their health care. At the worst, he will follow through on his promises and close to 16 million Californians will lose their coverage. The state of California will lose at least $20 billion annually in federal assistance for its health care programs to low, moderate and middle income Californians if the Affordable Care Act is repealed.

We urge you to build upon rather than repeal the Affordable Care Act. It is the most important advance in health coverage since Medicare and Medicaid were adopted in the mid 60’s. We agree with you on the need to cover every American, the need to reduce escalating prescription drug prices and to further reduce deductibles.

The Congressional Budget Office today released its analysis of the selective repeal of the Affordable Care Act as recently approved by Republicans in the House and Senate. Premiums in the individual market would initially spike by 20-25% and eventually would double due to repeal. The numbers of the uninsured would grow by 18 million in year 1, then increasing to 27 million and eventually grow to 32 million.

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.