California Health Programs At Risk Under Trump 2.0
57:51 Share

We could all use a little help navigating the news these days. The Consider This podcast wants to give you a hand. Six days a week, we'll help you make sense of the day's biggest news story and what it means for you in less than 15 minutes. Listen now to the Consider This podcast from NPR. Hi, I'm Bianca Taylor. I'm the host of KQED's daily news podcast, The Latest.

Powered by our award-winning newsroom, the latest keeps you in the know because it updates all day long. It's trusted local news in real time on your schedule. Look for the latest from KQED wherever you get your podcasts and stay connected to all things Bay Area in 20 minutes or less. From KQED.

From KQED in San Francisco, I'm Alexis Madrigal. Look, you know what's coming. As the Trump administration takes office, many of the health programs that California voters wanted for our state will be under fire.

Those include categories like trans health care, homelessness services and abortion access. But the incoming administration is targeting a wide swath of our health care infrastructure, including Medicaid and its state version, Medi-Cal, which would cut services for millions of lower income Californians.

We've got policy experts and Mia Bonta, the chair of the Assembly's Health Committee, here to explain what's happening and take your questions about what legislators are doing about it. It's all coming up next after this news.

Welcome to Forum. I'm Alexis Madrigal. It's become one of those cliches that has bipartisan support. It goes, elections have consequences. And this time around, those consequences could be enormous here in California if the Trump administration follows through on the plans we've seen in the Project 2025 playbook or bandied about by Trump advisers.

But our country's federal structure means that there is a layer of government between whatever happens in D.C. and the people of the country. States play a huge role in the actual execution of policy. And in a place like California, our state government could mitigate changes that get pushed through at the federal level.

Here to discuss that, we've got the chair of the State Assembly's Health Committee, Assemblymember Mia Bonta. Welcome. Thanks so much. It's a pleasure to be here. We're also joined by Angela Hart, senior correspondent covering health care politics and policy in California and the West with KFF Health News. Welcome, Angela. Good morning.

And we've got Mark Peterson, professor of public policy, political science, health policy and management and law. It's a lot of things to be a professor of Mark at UCLA. Also a senior fellow at the UCLA Center for Health Policy Research. Welcome, Mark. Thank you. It's good to be here. So Assemblymember Bonta, let's start with you. You know, as chair of the Assembly Health Committee, what are some of the biggest threats to the state's plans and programs from the incoming administration?

I think some of the biggest threats to Californians related to health care is really just whether or not we will have the Affordable Care Act subsidies. Health care is incredibly expensive. It's incredibly expensive to the individual. And with the potential banter that has been going on for quite a while with this administration, we face the reality that

that more than 2.37 million Californians, for instance, will be facing higher health insurance premiums. So that's kind of just hits the pocketbook right away for every single Californian. And when you say Affordable Care Act subsidies, are those for people who are buying their insurance through Covered California? Yes. So private insurance. Private insurance.

What about the threat to Medicaid and the sort of state's version, Medi-Cal? How could that be? How might that change in the Trump administration? That's an even bigger threat than the Affordable Care Act. So right now we have 14 million Californians on Medi-Cal. And essentially the federal government funds every three quarters of that. So California pays out $1.

$1 from its state budget, from its general fund. We receive the federal government spending about $3 of that. So any changes to Medi-Cal are going to severely impact California's ability to be able to make sure that every individual has health care, who's low income, a child, elders, people with disabilities.

Mark, nationally, we've got Medicaid. How has the Trump administration or previous GOP administrations, what have they said about how they'd like to reform that particular program or change it or whatever the verb might be?

Well, the longstanding approach of Republicans in Congress, and then that Trump signed on to effectively during the repeal and replace activities in 2017 that failed, was to turn the Medicaid program from an entitlement in which states and individuals got the funding as they needed it for the coverage they received,

were guaranteed under the program to a block grant, a budgeted amount of money each year that would be sent to the states based on a formula, however much demand for healthcare either rose or declined. So it would be a very sharp reduction in spending, a lot more flexibility, but flexibility with very little, in a way, of resources to provide care. Now, I want to emphasize that when Republicans and Trump came in in 2017 and tried to do that,

it failed dramatically with larger margins in the House and the Senate than they have now, particularly in the House. So it's not as though this will be an easy thing for them to do, particularly with the size of the Republican majority in the House in this next Congress. And facing a midterm election in 2026,

Mark, I mean, you know, just hearing you talk, I mean, basically cutting health care for poor people seems like a bad idea. So what is the argument on that side? Like, what is the what are they saying they want to do?

Well, their argument is that the Medicaid program is extremely inefficient, that it requires things that are not productive to health, that there should be more opportunity for state innovation. And in particular, they go back to the argument that in 1965, when the Medicaid program was enacted along with Medicare, it was intended for very poor people who simply had no means of their own to provide for their care.

They argue now, particularly under the Affordable Care Act and the Medicaid expansion, that health care coverage paid for by the taxpayer is going to a lot of people who should be able to take care of themselves on their own. And I mean, with 14 million, I mean, we're talking a third of the state is on Medi-Cal, right? Yeah. Yeah.

Angela Hart, when you're talking to people in Sacramento, you know, some of Bonta's colleagues, what are they telling you that they're that they're worried about or what they're watching with the incoming administration? I think you cannot underestimate the impending and the threats to Medicaid alone, you know,

I just want to draw everyone, like the attention is on, as the Assemblywoman talked about, broader Medicaid cuts. But under that umbrella, there's a tremendous amount of state initiatives and programs that are really serving millions of Californians. Under that umbrella, I'm talking about the state has muscled enormous resources and energy into using Medicaid to actually help solve homelessness and address homelessness.

The state, for example, funds home-delivered healthy meals for people with chronic diseases. The state just got approval to use Medi-Cal to cover rental payments and housing assistance. The state is also using it to address the mental health and behavioral health crises and substance use issues.

You really can't overestimate the threats that are coming from the federal government. And I also just want to draw attention to the expansion of Medi-Cal to undocumented immigrants. This is mostly funded with state funds.

But we're already seeing such fear in the immigrant community, immigrant communities around California, and a reluctance to even start using and have people sign up for that program. So I think the threat is from federal dollars and the federal share of money that the state gets to implement Medi-Cal for a third of Californians. But it doesn't stop there. If you look, the governor has muscled

so much political capital into initiatives. It's a bit wonky, but called CalAIM, which is an enormous initiative to transform Medi-Cal into looking at the needs of a whole person, right? Not just their healthcare, but

If they're homeless or if they have food insecurity, the state's even using Medi-Cal to cover asthma services for in-home. Like you can replace your carpet if it's triggering asthma, for example. So there's just a lot under that umbrella. And at a budget briefing on Friday, the governor sort of made no bones about the risk and his officials' concerns.

He wasn't there, but his officials made no risk in a document he put out that there is so much risk coming down the pike in the coming year. And that's because some of them are bonded like that program, CalAIM, as well as some of the other kind of innovative things that California is trying to do are dependent on waivers from the federal government, right? Like the federal government basically says like, OK, we're going to sort of let you do this thing that wouldn't narrowly be covered under the scope of the law normally.

Right, exactly. And those waivers, many of them were set to expire at the end of 2025, beginning in 2026. So every single time California decides to do something innovative, whether it's making sure, I've been pushing, for instance, that we...

make medically supportive meals a part of CalAIM or extend the CalAIM innovation around making medically supportive meals something that we can all depend on, that requires a federal waiver. Anytime we want to do something that is more focused on, for instance, social drivers of health and thinking more globally about what health means, we require a federal waiver. So in a scenario where the

Trump administration is focused on trying to essentially leverage Medicaid in instances where California policy differs from federal policy or the administration's policy, we stand at risk of losing those waivers.

Yeah, Mark, you know, I was going to say listeners might be saying, well, why are we replacing carpets or providing meals or dealing with mental health? And part of it is right. There's this entire research framework around the social determinants of health. Right. I think that's the term term of heart, which basically say, like, you know, health care is kind of the end of this pipeline that begins with, you know, just a person's ability to provide for their life.

Yes, that's absolutely right. And we do know a tremendous amount of research in the last couple of decades about the role of the social determinants of health. And the reality is that healthcare, the delivery of healthcare, is a rescue operation. That's what we do when people become ill. Well, what if we can prevent people from becoming ill in the first place?

which would be both enhancement for their lives and their economic productivity it would also mean we'd be spending less on health care let's keep in mind the united states we spend twice as much per capita on health care any country in the world even though we don't cover everybody in our insurance system so it's a very important point and i just want to say a little bit about the waivers as well which is not only will california not be able to

have ideas expand under Medi-Cal with new waivers. The waivers we have for CalAIM do expire. I want to emphasize that again. They expire, and the idea that the Trump administration would renew them is a small number close to zero in terms of probability.

So we are really looking, even before we talk about major changes in the Medicaid program nationally that would have an impact on California, we are already talking about major losses for the state just by knowing that those waivers will not be renewed. And we also know that with the expansion of subsidies for what the coverage provided in Covered California,

that expansion of subsidies is also disappearing in 2025. And so we are just going to be seeing increased numbers of uninsured, even if nothing else happens.

We'll talk more about that when we get back from the break. We're talking about the state of California's health care programs and how they might fare under the incoming Trump administration. Joined by Mark Peterson, professor of public policy and around health issues, senior fellow at the UCLA Center for Health Policy Research. Also joined by Angela Hart, senior correspondent covering health care politics and policy for KFF Health News.

And Mia Bonta, a state assembly member representing the 18th district in the East Bay and the chair of the health committee. We'd love to hear from you. What questions do you have about possible cuts to California health programs and services? The number is 866-733-6786. Forum at kqed.org. All the social media things were at KQED Forum. We'll be back with more right after the break.

We could all use a little help navigating the news these days. The Consider This podcast wants to give you a hand. Six days a week, we'll help you make sense of the day's biggest news story and what it means for you in less than 15 minutes. Listen now to the Consider This podcast from NPR.

Welcome back to Forum. I'm Alexis Madrigal. We're talking about the state of California's health care programs, how they might fare under the incoming Trump administration. Joined by the chair of the Assembly's Health Committee, Mia Bonta, Mark Peterson, professor at UCLA and reporter Angela Hart with KFF Health News.

We're, of course, taking your questions. Is there a part of your health coverage that you're concerned about in the upcoming administration? Or maybe you work in health care in one of these programs. What are you watching for about how things might change? The number is 866-733-6786. That's 866-733-6786. Forum at KQED.org. You can find us on Blue Sky, on Instagram. We're KQED Forum. Of course, there's the Discord community as well.

Mia, let's talk a little bit about something that I think might be top of mind for a lot of folks, which are the concerns around reproductive health and abortion access. What can the state actually do to ensure that people have that access? Well, the state has already done a great deal. It's not lost on me that in Project 2025, abortion was mentioned 147 times.

And the first mention of it was essentially to declare that abortion care is not health care. So we are facing, again, some significant threats around how the administration might decide to move forward. They've already, we know that Trump is...

indicated some confusion about whether or not he will move forward with a national abortion ban. But we actually don't even need him to do that in order to be able to wreak havoc on our abortion access and health care access, because a lot of what the administration can do is essentially limit the funding associated with that. For instance,

refusing to fund Planned Parenthood that provides the majority of family care services for most Californians. So what can California do? We can continue where we have been going for a long time. We've ensconced abortion as a right.

Within our constitution, we've passed over 13 different pieces of legislation in the last legislative cycle alone related to privacy, access, making sure that we are protecting the pipeline of health care workers, providing access to abortion care, and we will continue to do so.

From your position as you're, you know, in the legislature, you know this, the Trump administration is coming. Do you feel like, OK, we've set up all of the defensive structures around things that California voters wanted and voted for. And now you kind of wait to see what the administration does or sort of how does what's the positioning and how do you feel at this moment? I think I shared with Angela before we got on air that it's a bit of

through chaos theory, right? We have to be able to have provided as much foundational knowledge

legal structure that we can to protect our right to health care access. And a lot of it is just waiting to see what the first steps are. And part of that is, too, right, that it's not totally clear to anyone, I think, certainly not clear to me, like what was kind of rhetoric for the campaign trail? What was, you know, planning by entities outside the Trump administration? What is sort of advisors talking out of school? You know, but if you had to guess,

What would you say the most likely first line of attack on abortion access in California would be? I would believe that it would be limiting the funding associated with

And that, again, brings us back to how Medicaid and Medi-Cal are used, for instance. So if there's a carve-out and an exception that the Trump administration decides to put forward, essentially saying we are not going to provide any funding for anything that we don't consider health care in our administration, that would severely impact our ability, for instance, to be able to pay for the abortion access and care. Mm-hmm, mm-hmm.

get to a couple of comments here. So this, and Angela, I'm going to take this one to you on sort of what you've heard in the legislature. Eric writes, you know, your guest just now said that Medi-Cal is choosing to cover undocumented immigrants. Also, this is not just for emergencies, but for healthcare. Why did the state and governor decide to do this when it's using, you know, diverting the quote resources and funds to

away from actual citizens first. California shot itself in the foot by not showing it has made prudent choices. People may rightly question whether the money it's getting should cover its needs, even if it didn't decide to just deploy non-voter approved programs like this. What have you heard in the legislature about why they've wanted to do that? Not just the legislature, but from the governor himself. I think that there is a wholehearted recognition that

Listen, Californians are paying for this. Undocumented people who are living in California who are, by the way, contributing to the tax base, they're going to the hospital. They're going to the emergency room. They're using health care resources. And if you look at the actual data, including from the UCLA Center for Health Policy Research, that care is much more costly to taxpayers. Our insurance premiums go up.

Healthcare costs writ large go up. Healthcare costs to the state go up. When you're paying for emergency room care rather than, for example, covering someone with diabetes with Medi-Cal who can go and get preventative care, that ultimately in the long run and the argument and the data bore this out, that that actually does save costs in the long term. But this is not just a financial argument. I think

I think leaders across the board, especially the governor, do not shy away from the idea that California is a compassionate state. California is the land of a land where immigrants are play an essential role in the economy. And

This has been a long standing push over a decade, if I'm not mistaken, since I mean, it predated Jerry Brown did the first one expansion to undocumented people up to, I believe, age 18. But you've seen Governor Newsom really like expend a lot of political capital and legislative session after legislative session. And Assemblywoman can speak to this, too, like.

going to use the state's resources. Again, this is discretionary money to say we're going to cover undocumented seniors 50 and over, and then we're going to go 19 to 25. I actually think it was the other way around, 19 to 25, 15 and older, and then the most expensive and biggest section, the middle one, that expansion happened this year. So it's been, as much as it is a

a policy and a financial priority for the state and Democratic leaders and legislature who have the majority. It's been as much, I think, an ideological priority as well. Assemblymember Bonta, you wanted anything to that?

Benjamin Franklin said that an ounce of prevention is worth a pound of intervention. And I think we really need to hold true to the fact that when you save, you save incredible money, you save lives when you focus on prevention. And from a public health perspective, you need to focus on prevention for every person who is a resident in California in order to be able to do that. So I totally agree with Angela that we're focused not only on the cost savings associated with it,

But with the moral imperative that California has laid out that essentially says we value life and we value and place priority on prevention. Yeah.

Mark, I want to throw this one to you. Patrick writes, you know, your guest said that Medi-Cal is being used to pay for housing. Many other items are not, you know, directly, quote unquote, medical. I'm sure that housing is tied to health, but California has also spent billions of dollars with scant record keeping auditing on what the money was spent on and outcomes. Why would Medi-Cal throw money into these untrackable activities? I think unless the state improves its ability to audit and track spending, there's a good argument to scrutinize these activities. Do you agree with that characterization, Mark? Yeah.

Not entirely. It certainly raises a number of issues about how you track these things, but I think it's important to emphasize here that what the state is doing right now is extremely targeted. It's not taking the Medi-Cal program and having it be a house building program. It's not doing things for a broad general population that are not intersecting with the health care side of the equation. What it is doing is recognizing

that even if we want to treat people appropriately with healthcare, often there are barriers to promoting their health status with healthcare if we're also not addressing some of the problems that they are facing in terms of transportation to get to medical care,

or being in a safe housing situation so that their medical situation does not deteriorate, or ensuring that they get the kind of nutrition necessary for the conditions that they're experiencing. So it's more targeted than simply a grand program of putting money into the social determinants of health. It really is going into directly that intersection between the social environment in which people are living, their circumstances, and what their conditions are and how they can be treated in the health care system.

Yeah. Let's, I'm bringing a caller here. She's bringing a Carl in Oakland. Hey Carl. Hello. Welcome. Um, uh, the, uh, discussion is very great and fine. And, uh, I certainly, uh, am, uh, bothered by, uh, what the Trumpists are up to, but, uh,

The Covered California has not been for me. Covered California benefited my life even though I was never poor and didn't have any of these conditions, you know, like not having a place to live.

you know, do things that are good for health. And, uh, and that is because, uh, private, I had pre-exist and still have to some extent, a pre-existing condition. And, uh, uh, uh,

privately owned insurance policies, either I couldn't get them or I could have it for a brief period and then they would jack up the price of my insurance hugely. And

So as soon as Covered California worked, I could get medical insurance again. In this case, through Kaiser, which was not as evil as the other insurance outlets. Yeah, Carl, I appreciate that point, which is just...

People may have forgotten what it was like before we had this set of programs.

Do you just on a political level, Congressman Rabanta, do you believe that there's going to be a repeal and replace of the affordable character? I keep I keep thinking about this. Could you actually undo this? And is it just one of the things that has happened with the politics in this country is now Republicans say that but don't actually want to do it?

I find it hard to believe that there would be a repeal and replace. The Affordable Care Act, and for us, Covered California, had a 67% approval rating. It's more popular than Trump. And I think that's, if you're in a purple state, a red state, or a blue state, the case. So I think...

we there's going to be a fight for sure. We know that the Trump administration had challenges the first time around, and they certainly will the second time around, because there are people like Carl who recognize that creating an opportunity to have pre-existing conditions, not preclude you from getting the health care that you deserve and need, is something that a lot of people experience. Every individual has somebody in their life who

doesn't have the quality of insurance that they need or the quality of health care that they need. So I think it makes it really challenging for Congress to allow to do a repeal and replace. Let's bring in Sina in Walnut Creek. Welcome, Sina.

Hello. Thank you for having this program. I have one question. Why is California not implementing a single-payer plan? Yeah. Sina, thank you for that question. Mark, I know it's something you're interested in. Maybe – I know people know what a single-payer plan is, but –

Just gloss it for us really quickly and then tell us if you think there's any hope of that happening. Yes, it's a terrific question. Single payer means pretty much what that expression suggests, which is you have universal coverage, everybody's in it, and the funding travels through one pathway, one stream, and that's through the budgeting of the state. And so all the expenditures that would happen for providing health care would come through

a state program financed by taxes and then channeled to providers, perhaps with some middleman role for health plans, perhaps not, but by and large everybody's in very strong cost containment and equitable access across the board. Now can California do that?

California has been on a pathway to try to do that as are Oregon and Washington. Here's the big kicker, however, right now, which is why the Trump administration is so important in this conversation. To have single payer, you have to channel all the dollars in the system. That means the money that's currently going to Medicare recipients, which is a significant amount of the funding in the state of California. It means having all the federal dollars

that are part of Medi-Cal come under state control as part of the single payer scheme. It also means getting the money that flows to employer sponsored insurance. And there we have a problem because under the Employee Retirement Income Security Act of 1974, any employer that has self-insured plans

is exempt from state regulation. And so the state can't simply say to those employers, "Why don't we take your money that you're putting into covering your employees and put it into this single pot of money?" So there'd have to be a workaround for that. Without waivers from a Trump administration for Medi-Cal and for Medicare, and there's really not even a waiver structure per se in Medicare in the same way, and without a way around ERISA, the Employee Retirement Income Security Act,

We simply can't bundle all the money into that single payer stream. And the state, therefore, does not have the opportunity to both bring everybody on board into the same system with equitable access and equitable kinds of financial support or prevention of financial barriers. And so it's off the table during the course of the Trump administration. Yeah, I was about to say, sounds like the answer is no.

It's not happening. You know, Angela, I wanted to ask you about a controversial figure, RFK Jr. And, you know, I mean, recently 15,000 doctors signed a letter urging the Senate to reject RFK Jr. as health secretary. Yeah.

What do you know about what could actually, what could he actually do around vaccines, which he's sort of been famously skeptical of? California has, if not among the strongest vaccination mandates in the country for school entry. There are like nearly a dozen, I believe, immunizations that are required just for school entry. And

if you just take a step back, there have been major battles that the state has waged, even under Governor Newsom and Democratic control over these vaccine mandates. These are under liberal politicians. And, you know, Governor Newsom has been sort of put under the spotlight for

an early seeming reluctance to really strengthen these mandates, but he did under a former state Senator Richard Pan, who led an even greater strengthening of vaccine mandates. And it doesn't really end at vaccines. I mean, I think there's no question that California, there's many areas where California, I think, has a target on its back.

and Governor Newsom has a target on his back politically speaking. That's one of them and you can really see like the potential rhetoric ratcheting up but then you also take a step back and look at the public health investments that are critical for communicable disease prevention and although Governor Newsom has reluctantly boosted the public health budget since COVID, he has since tried to claw them back and I think that's another big battleground going forward.

We're talking about the state of California's health care programs, how they might fare under the incoming Trump administration with Angela Hart, senior correspondent covering health care politics and policy in California and the West with KFF Health News. Mia Bonta, state assembly member representing the 18th Assembly District in the East Bay and, of course, chair of the Assembly Health Committee, as well as Mark Peterson, professor of public policy, political science, health policy and management and law at

We're taking your calls, 866-733-6786 and your emails, forum at kqed.org. I'm Alexis Madrigal. Stay tuned.

Welcome back to Forum. I'm Alexis Madrigal. We're talking about the state of California's health care programs, how they might fare under the incoming Trump administration, joined by Mia Bonta, state assembly member representing the 18th Assembly District in the East Bay, chair of the Assembly Health Committee. Mark Peterson, who's a professor at UCLA Public Policy, as well as a senior fellow at the UCLA Center for Health Policy Research. And Angela Hart, who's a senior correspondent covering health care politics and policy with KFF Health News. And I'm Alex Madrigal.

Wanted to turn to another area, Assemblymember Bonta. And it's really, you know, you put a spotlight on maternal health while in the Assembly. And one of the things we know is that maternal health outcomes for black women are just really abysmal in this country.

And yet we've seen this pullback and this targeting of racially targeted programs in this country. So what do you think needs to be done specifically to address some of the problems that black women are facing in their care?

We've already started to do some of that. Then-Assembly Member Dr. Weber and Assembly Member Lori Wilson as well really focused in on looking at the health disparities for Black women in particular as it related to maternal morbidity and mortality. The reality is that we are...

Yeah.

of a look and requirement that hospitals take care when there is a negative incident to really unpack what that is and look at their practices, look at their bias practices associated with that, increasing the number of healthcare workers for more culturally concordant care. So just making sure that the people who are delivering our babies look more like us and are like us and come from a similar background so that we are believed when we come in with

negative symptoms that we need to address. I, this year, am going to introduce already three pieces of legislation around maternal health. One specifically that I think is of major concern is the fact that we don't have enough birth centers in the state of California. So in the last 10 years,

We have reduced our birth centers, and those are centers where healthy women go who are very low risk go to be able to deliver healthy babies. The chances of them coming out of that experience with healthy babies are

More positive experiences from birth are incredibly high. And we've had a shutdown of those birth centers over the last decade, so going from 12 down to four. And a lot of that, we believe, has to do with the...

The permitting process and the investigation process around whether or not they should be able to stand costing birth center practitioners tens of thousands, hundreds of thousands of dollars, which just make it impossible for them to be able to have those. Thanks for all that. Let's bring in Cynthia in Oakland. Welcome, Cynthia.

Thank you. I'm a public sector worker, and I actually am a social worker that works with an unhoused population, general assistance clients, CalWORKs families, and I cannot overly stress that

how the Medi-Cal expansion has made a tremendous difference in the lives of the public that I'm proud to serve. And for instance, the general assistance population was not eligible

for Medi-Cal up until maybe five or six years ago. I can't remember when the exact transition was. And I had people that needed, you know, some minor surgeries. And I was so happy about the expansion that I did the Medi-Cal applications with them.

with my clients. But it really has affected the overall health and well-being physically and mentally of our customers. And we need to preserve these social services safety net. But moreover, every Californian

Should have every Californian, regardless of status, should have a human right to health care. And it's part of our investment in the human infrastructure. Yeah. Hey, thank you so much, Cynthia, in Oakland. Let's go directly to Hunter in Sonoma. Welcome, Hunter. Hi. Can you hear me OK? Yes, sure can. Go ahead.

Okay, so I'm a nurse and I work with Medi-Cal and Medicare patients every day, every day. And I cannot tell you the difference in benefit. Medi-Cal patients get far more benefit than people on Medicare.

And I think it creates resentment in those that really understand it. Medi-Cal patients get transportation benefits. They get custodial care benefits in nursing homes that Medicare people don't get. And it's just really created a real divide in who gets what.

their co-pays are a lot smaller. And I just find that, you know, my Medi-Cal patients get so much more. And the other thing I wanted to say is, you know, I work for a great company that provides vaccines free

for everybody. And we give shots all the time in the fall. And we also have a patient care at home program where we visit people in their homes for their life that can't get out of their home. You know, Medicare doesn't really provide everything that's needed to take care of the elderly in this country. So that's my comment. I'll take the rest off the air. Hey, Hunter, appreciate that.

Assemblymember Bonta, I mean, this is interesting, right? Because Medi-Cal expansion, the sorts of things that we've been talking about, CalAIM, these are good things for the people who are receiving them. But what I feel like Hunter is gesturing at is that

It maybe isn't equitable and some along some other dimension that like, you know, you have older folks who can't get that same kind of care. And it just poses this difficult question of, you know, when the government does something good for someone, but they can't do it equally across the border or there's different populations that aren't getting exactly the same thing. It can breed resentment. Like what's your response to that?

I think Hunter is laying out two things that kind of strike me. One is the extent to which California specifically has really prepared for the reality that we are facing a silver tsunami, and we have so many people who are going to need elder care. And the reality, quite frankly, that our elders, because of the way that we've structured our health care system,

struggling with the higher costs in acute care that they need in being able to be cared for. So I fundamentally agree with what Hunter is saying. Our health care system is incredibly complex. It causes us to make tradeoffs all the time in terms of what level of care we are going to provide to whom. And we certainly have an issue of not really attending to our elders in the way that we need to. Yeah, yeah.

Just returning to the question of the incoming Trump administration, Mark, I wanted you to we haven't talked about the different appointees or prospective appointees in the in the Trump administration and how they may shape the policies that that roll out. Are there people, you know, aside from RFK Jr., that you can have your eye on that maybe have would take policy in a really different direction?

Well, first of all, we're not going to, we don't know yet who is going to finally be confirmed. The Mugnosah requires Senate approval, and so there's a lot of uncertainty there.

Dr. Oz is another one of the interesting nominations coming forward to run the Center for Medicare and Medicaid Services, which oversees obviously Medicare and Medicaid. And as far as I know, other than having been a doctor of a particular type, he has no experience at all in running large-scale programs and certainly not-- Medicare is one of the largest single-payer government finance programs in the world.

Medicaid is, in terms of the population covered, is even larger than Medicare. And so these are massive enterprises in which people depend tremendously. And the idea that another television celebrity, who, by the way, was his colleagues at Columbia wanted him dismissed from the university for promoting drugs,

not supported interventions for improved health is not the kind of person you want to have running these programs. And in other terms,

Others do not seem so far out of the norm for, say, a Republican administration. But I think between RFK Jr. and Dr. Oz, who are the centerpiece leaders or would be the centerpiece leaders of what's going on in the federal health side, that's the part that's very frightening. But we don't know exactly whether they're going to make it through confirmation or not.

Angela, there's a listener on Discord who writes, you know, I'm concerned about my father who receives Medi-Cal and Veterans Administration benefits for all of his health care as well as Meals on Wheels. Can you speak to any potential loss of benefits for veterans and what can be done? Thank you. I'm a veteran myself, and so I have been worried about that and worried.

I think that there is some trepidation, again, a kind of a black flash to the last Trump administration 1.0 of privatizing. That being said, you know, like so much of this, we just we don't know. I think that what we've also seen, I think if there is a privatization push similar to like block granting Medicaid, there might be in tandem some kind of cut.

But I also think that the veteran community has been really vocal about expansions and preserving benefits and expanding benefits and receiving care outside the VA system. So I just think it's important, as in all of health care, to advocate and push for the care that you need and deserve. Yeah.

Mark, another topic, just trying to make sure we get to things people might be interested in. You know, you work at a big tier one research institution. I mean, do you see prospective changes to medical research as well as just, you know, provision of health care?

It's a very interesting question, and I do. And again, here we're operating in a realm of speculation, but we know a couple of things. One is we know that President Trump, President-elect Trump, coming in very soon, has said very explicitly that in his administration, gender equity and notions of supporting transgender care, for instance, are simply off the table. And some of the major research enterprises, such as a center I'm involved with,

that works on HIV/AIDS both internationally and domestically has among its research portfolio programs that interact directly with the transgender population in LA County.

Is that at risk now because the administration is going to go after it? The other is the administration coming in has made a very big case about how they're going to go after anyone who has DEI programs, diversity, equity, and inclusion programs. Well, that's the University of California. It's UCLA. And there's a lot of federal funding that comes into the research enterprise on the health care side. And we are an institution that uses DEI procedures. So will that make us a target for cutbacks?

Assemblymember Bonta, talk to me more about trans health care and the possible threats to it here in the state.

I think just to go back to the earlier question, we are dealing with an administration who very clearly doesn't believe in science and who has appointed nominees who also decide not to believe in science and research. So we are going to be facing serious issues with that. Trans care for sure is under attack. Gender affirming care is under attack in the state of California.

and in the country. We have very clearly strong stances being taken where we've kind of entered into the phase of cultural wars as opposed to what is best for healthcare and what is really important from a research and data standpoint. And we will need to, in the state of California, I'm sure, continue to push on caring for our trans community. Yeah.

Kathy writes, my 68-year-old developmentally disabled sister has her medical needs met by Medi-Cal and Medicare. She's in full 24-hour care in a group home. I couldn't provide for her without these services from the state.

Should I be worried? Angela, do you want to, how would you answer that? I think it's important to just be up front with people. So I'm sorry to say that I think everyone should be prepared for an uncertain future with healthcare. You know, in Covered California, with Medicare, with Medi-Cal, with CalAIM, all of these big expensive programs we're talking about, CalAIM is $12 billion alone.

Listen, this is a land of haves and have nots. Getting the care that you need is a constant battle with insurance companies, with doctors and with state programs. And I think that even now, if you look at the tremendous expansion that has happened, historic...

low of uninsured rate in California, you know, coverage doesn't always equal access. People still struggle to get timely care for doctor's appointments and access to specialty care. And CalAIM covers a sliver of the 14, 15 million Californians, and not to mention those who

are eligible but can't even get that program. So I think the caller is right, unfortunately, to worry, but I also am an optimist, and I feel like even within the pending cuts and perils for health care and even within the current, you know, kind of areas where there is inadequate access to care, you've got to fight back, and you have to really push –

for what you need in the healthcare system. And I think that's a message that's true no matter where you get your coverage from, Medicare, Medi-Cal, Veterans Care and beyond. - You know, Mark,

Art writes in to say, you know, is there anything California can do on its own to mitigate, prevent hardship from losing federal support? You know, we've heard from Assemblymember Bonta about, you know, the different bills that the, you know, have gone through the legislature and different things. Are there other areas that you see where the, you know, the assembly or the California legislators and governor could do more to prevent that hardship?

We are very fortunate in that California is a huge state. It has the fifth largest economy in the world and it has a general social political commitment to trying to bring about as much equity of opportunity as possible. There are limitations to what we can do with the loss of federal dollars, but we have the wherewithal within this state

in its economy and its resources to do much to try to hold back the wave of retrograde approaches to healthcare for the next four years. Now, unfortunately, we're also dealing with a lot of other problems that are going to be very expensive to handle. But we are in a much better position as the state of California than if we were one of

most other states in the country, even those with similar kinds of political values. Yeah. I mean, do you think it like when we look back, we'll see that California fared better than Oregon or something, a state that might be trying to do many similar things?

Probably in many respects. We also have more challenges in some ways. And so, as I say, we're grappling with that balance. But I have certainly been feeling that in a sense in California there are things that nobody else can do in this country and we can do it despite what is happening in the nation's capital. Mark Peterson, professor of public policy, political science, health policy and management at UCLA and a senior fellow at the UCLA Center for Health Policy Research. Thanks so much for joining us. Thank you very much.

Angela Hart, senior correspondent covering health care politics and policy in California and the West for KFF Health News. Thank you so much for joining us. It's been lovely. And Mia Bonta, state assembly member representing the 18th Assembly District in the East Bay and chair of the Assembly Health Committee. Thank you so much for joining us this morning. Thanks for focusing on this.

We've been talking about the state of California's health care programs and how they might fare in the incoming Trump administration. Of course, we'll stay on this over the coming years. I'm Alexis Madrigal. Stay tuned for another hour of Forum Ahead with Mina Kim.

Funds for the production of Forum are provided by the John S. and James L. Knight Foundation, the Generosity Foundation, and the Corporation for Public Broadcasting. We could all use a little help navigating the news these days. The Consider This podcast wants to give you a hand. Six days a week, we'll help you make sense of the day's biggest news story and what it means for you in less than 15 minutes. Listen now to the Consider This podcast from NPR.