WASHINGTON — California has done more over the last decade than almost any other state to expand health insurance, bolster services for its most vulnerable residents and improve the quality of its clinics and hospitals.
Sick patients are getting more help managing diabetes, heart disease and other chronic illnesses. Women are giving birth more safely, health records show. And the share of working-age Californians without health coverage tumbled from nearly 1 in 4 to just 1 in 10 before the current economic crisis — one of the steepest declines in the nation.
But the gains — largely made possible by the Affordable Care Act, or Obamacare — now hang in the balance of the presidential election.
The Supreme Court, poised to get another justice appointed by President Donald Trump, is weighing whether to scrap the health care law. And Trump, who has pledged for four years to dismantle it, hasn't indicated how he'd replace its core protections should he win a second term.
"The stakes have never been higher," said California Atty. Gen. Xavier Becerra, who is defending the law at the Supreme Court against an effort to nullify it by the Trump administration and a group of Republican-led states. Becerra and others in California are also fighting to stop administration efforts to relax rules dictating protections that health insurers must provide.
For his part, Trump insists he will safeguard sick Americans. "Will always protect pre-existing conditions!!!" he tweeted recently.
Despite years of promises, however, the president has never produced a plan to do that. And he has made little secret of his hostility to California, claiming in another recent Twitter post that the state is "going to hell."
Trump's antipathy has fueled widespread concerns among California health care leaders about what a second Trump term might bring, especially if the Supreme Court invalidates all or part of the health care law.
"California has made a lot of progress in recent years, but people don't fully appreciate how much of that depends on the financing and framework of the Affordable Care Act," said Anthony Wright, executive director of Health Access California, one of the state's leading advocacy groups for patients. "If the law is wiped away, much of California's progress collapses with it."
Former Vice President Joe Biden, the Democratic nominee, has defended the 2010 law, proposing a host of initiatives to build on its protections.
Biden has also said he would work to restore women's access to abortion and other reproductive health services, reversing a four-year effort by the Trump administration to restrict abortion and shift federal money to organizations like so-called crisis pregnancy centers that don't offer a full range of family-planning services.
"If this administration has a second term, I'm afraid it will have grave impact on Californians' access to sexual and reproductive health," warned Julie Rabinovitz, president of Essential Access Health, a leading family-planning advocate.
The most visible sign of California's health care progress is the expansion of coverage fueled by the state's decision to expand Medicaid eligibility and build Covered California, the state's insurance marketplace.
Although insurance premiums have risen for some Californians as access has expanded, medical care has also become more affordable for many. Between 2013 and 2017, the share of Californians who skipped care in the previous year because of cost dropped by a quarter, according to data from the nonprofit Commonwealth Fund.
The insurance gains also translated into better care for many Californians, said Thomas Priselac, a leading hospital executive in the state who has headed the Cedars-Sinai Health System in Los Angeles for more than 25 years. "Quality medical care starts with having access to it," he said.
California's coverage expansion has had broader effects as well, driving profound changes in how patients — rich and poor — receive care.
At Northeast Valley Health Corp., a network of clinics serving low-income patients in the San Fernando and Santa Clarita valleys, doctors and nurses now work with clinical pharmacists to help diabetics better manage their blood sugar, a change the health care law helped bring about.
The clinics have also added care coordinators to keep track of patients with chronic diseases and prevent them from ending up in the hospital or emergency room.
"The Affordable Care Act was terrific in helping us serve more patients," said Kim Wyard, Northeast Valley Health's chief executive. "Also embedded in it was this sense of transforming the health care system."
At Mission Hospital, a community hospital off the San Diego Freeway in Mission Viejo, yet another transformation is underway, this one in how women give birth.
The hospital, part of the Providence Health system, based in Washington state, has been working aggressively to reduce the number of babies delivered by caesarean section.
The effort — supported by a midwife program, specially equipped birthing rooms for natural deliveries and new protocols to identify obstetricians with high C-section rates — reflects the growing scientific consensus that overuse of C-sections in recent decades exposed mothers and newborns to unnecessary risks, some potentially deadly.
Mission Hospital had another incentive, as well: Covered California in 2016 signaled that hospitals with high elective C-section rates could be excluded from health plans on the marketplace.
"That put everyone on notice," said Dr. David Lagrew, who has helped lead efforts to reduce the number of caesarean deliveries at Providence Health's 10 hospitals in Southern California. "It was a big deal."
Between 2014 and 2018, California reduced its share of caesarean deliveries by 5.5% — faster than all but two other states, according to data from the U.S. Centers for Disease Control and Prevention.
The state has taken other steps to bolster insurance protections, beyond what the federal government mandates.
Covered California, for example, requires health plans to exempt some services from deductibles so patients won't skip needed care. Roughly 1.5 million people get coverage through Covered California, and more than 70% are now in a plan in which primary care visits, lab tests or other outpatient services aren't subject to a deductible.
The state also has begun offering insurance subsidies to middle-income Californians, bolstering federal aid provided by the 2010 law to address the difficulties faced by some consumers who earn too much to quality for federal subsidies.
Some of California's health care improvement initiatives might persist even if the Trump administration succeeds in eliminating the health care law.
Nevertheless, California health care officials warn that preserving protections for people with preexisting medical conditions is considerably more complicated than simply directing health insurers to cover sick patients, as Trump has suggested he would do.
The current law doesn't just bar insurers from turning away sick consumers. It also prohibits insurers from charging sick people more, restricts how much more older customers can be charged and mandates that all plans cover a basic set of benefits, another protection that prohibits insurers from discriminating against people with preexisting conditions.
The law also provides billions of dollars to help low- and moderate-income people afford health plans, which are more expensive now that plans aren't allowed to cover only healthy customers.
All of these pieces are critical to really protecting people, said Peter Lee, executive director of Covered California.
"When this administration says it will preserve preexisting condition protections and throw out the rest of the law, that's like saying to people on an airplane in midair, 'Don't worry, we're going to keep the wings, but get rid of the rudder and the landing gear and everything else,'" Lee said.
Perhaps most difficult to replace would be the billions of dollars in federal money that have made Medicaid expansion and the Covered California marketplace possible.
California receives some $27 billion a year from the federal government to subsidize insurance coverage for low- and moderate-income Californians, an amount roughly equivalent to what the state spends annually on prisons, colleges and universities, according to estimates by the UC Berkeley Labor Center.
If the federal government stopped providing that money, picking up the tab would be virtually impossible for California to do on its own, said Dr. Mark Ghaly, the state's Health and Human Services secretary.
"Elections matter a great deal," Ghaly added. "And what happens in the next few weeks could be vital to the future of health care in California."
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