As he campaigns for a return to the White House, former President Trump recently vowed to “never give up” on his call for Obamacare, also known as the Affordable Care Act. Trump and Republicans in Congress came within one vote of repealing the law during his first term, a defeat he considers one of his biggest disappointments.

California, where about 6.6 million people buy insurance under the law, would be particularly hard hit by a repeal.

In terms of raw numbers, no state has more at stake in a potential repeal of the ACA than California, says Larry Levitt, executive vice president for health policy at KFF, formerly Kaiser Family Foundation.

What did Trump say he would do?

Trump wrote on his social media platform at Christmas that the ACA is too expensive and otherwise not good health care, while promising to come up with a much better and cheaper alternative! The costs of Obamacare are out of control, and besides, it’s not good health care. I am seriously looking at alternatives, Trump wrote at the end of November

a message on social media

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We had some Republican senators who campaigned against it for six years and then raised their hands to stop it.

Trump wrote in November.”

It was a low point for the Republican Party, but we must never give up!

Trump has promised since his 2016 campaign to devise a replacement plan, but has not done so.

Republicans, after years of campaigning on a promise to repeal the law, came close in 2017 but fell short when Senator John McCain, the Arizona Republican who had terminal brain cancer, gave the bill a dramatic thumbs down the parties, which was also opposed by two other Republican senators.

Trump has been salty ever since, lashing out at McCain even after the senator, the Republican Party’s 2008 presidential nominee, died in 2018.

Trump, who leads the Republican Party’s primary field by a wide margin, is ahead of President Biden in early general election polls. His party would have a good chance of controlling Congress if he retakes the White House, giving Trump the chance to implement his agenda.

Why is Obamacare such a big problem in California?

Before the law was passed in 2010, 21% of the population under 65 had no health insurance, one of the highest rates in the country, according to KFF statistics. That number had dropped to 7.5% by 2022, lower than the national average.

The federal government spends more than $30 billion a year in California to make this possible. That money covers the vast majority of costs for about 6.6 million people who either qualify for heavily subsidized insurance on the Obamacare exchange or receive Medi-Cal, which was expanded to give more low-income people free insurance to give.

In recent years, the state has begun adding even more people to the list, using state tax dollars to illegally offer Medi-Cal to more than 1.3 million immigrants.

Before the law took effect, lines at expensive urgent care and emergency rooms were long as people with diabetes and other chronic diseases saw their health deteriorate because they lacked access to preventive care, said Dr. Mark Ghaly, secretary of the California Health and Human Services Agency, who previously worked as a primary care physician for low-income people in South Los Angeles.

Since then, the pipes and wiring of our delivery system have changed as vulnerable people have access to primary care doctors and no longer need emergency rooms and clinics to fill that gap.

What would a repeal mean for low-income patients and hospitals?

The most vulnerable people in our society are the people who would lose coverage, said Dr. Elaine Batchlor, CEO of MLK Community Healthcare, which serves about 1.3 million low-income patients in South Los Angeles.

Diabetes is one of the most common conditions among people MLK serves, and without insurance, many patients would forego preventive care until they experience a health crisis, leading to more amputations, surgeries, disabilities and expensive hospital visits that could have been prevented. That’s just one example.

It has a very negative effect on quality of life and life expectancy, Batchlor said.

Cutting coverage for poor and middle-class people is also shortsighted, she says, because it would just send people to the emergency room. Most of those expensive hospital visits and surgeries would have been paid for with public dollars, which cover poor patients, while preventive care would have been much cheaper.

Can the state simply absorb the federal costs of Obamacare?

Few policy makers think that replacing Obamacare at the state level would be possible, given the disparity in resources between state and federal governments.

These would be huge gaping holes, Ghaly said.

The law is also harder to replace at the state level because much of its funding depends on things like negotiated payments to hospitals and insurers and taxes on high-income earners, pharmaceutical companies and insurance companies, all of which can be more easily passed at the federal level imposed. Levitt said.

California could theoretically create its own version of Obamacare, but that would require raising taxes, Levitt said.

Can California afford to continue expanding Medi-Cal to people who live here illegally and are not covered by the federal government?

The state has a projected deficit of $68 billion. But the health care budget for immigrants here illegally does not appear to be on the chopping block.

It’s a down payment on our state’s health and, frankly, its economic and social stability, Ghaly said.

Do other Republicans want to repeal Obamacare?

Repeal of the health care law was the party’s top cause for several election cycles after Obama signed it into law in 2010. The Republican Party-controlled House regularly passed bills repealing the law, which would then die in the Senate.

But the party doesn’t talk much about repeal anymore. That’s partly because the replacement plans were not fully developed or were less comprehensive than Obamacare and, perhaps more importantly, the Obamacare law has increased support in public opinion polls.

We’ve been through this fight before and we’ve seen how this turned out and that was several years ago, said Lanhee Chen, a fellow at the Hoover Institution who ran for state comptroller in 2022 as a Republican. The law was even less good. anchored then than now.

Chen said some conservatives have called for changes, including changing the requirement that insurance companies offer low rates to people with pre-existing conditions.

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rates higher for others. But even that change would be politically controversial.

The push to expand access in the state could be in jeopardy, he said.

California has overcome its skis on many things, he said. You don’t accidentally arrive at $68 billion.