SAN FRANCISCO -- If Caroline Cunningham wakes up in her Studio City, Calif., home on Wednesday morning to a President-elect Mitt Romney, she knows the first thing she will do: "I have to rush and get back surgery."
Cunningham, a 62-year-old mental health therapist with spinal stenosis, has health insurance coverage through a temporary program established for people with pre-existing conditions under the Affordable Care Act. The pre-existing condition insurance plans, mandated in every state and subsidized by the federal government, offer coverage to those deemed uninsurable.
But the high risk pools, as they are known, have an expiration date. They are slated to shut down in January 2014 when, under the federal health law, people with pre-existing conditions can buy plans from private insurers through newly created insurance exchanges.
If Romney follows through with his pledge to dismantle President Barack Obama’s signature domestic legislation, and Congress is unable to quickly enact a meaningful alternative, Cunningham worries she will, once again, be uninsured. "I called the Romney campaign and asked them what they’re going to do," said Cunningham. "I hope they wouldn’t dump us."
More than any other state, California has wagered heavily on the Affordable Care Act: It has moved quickly to erect an insurance exchange and establish the high risk pool. It’s also codified federal consumer protections into state law. In 2010, the state signed a $10 billion Medicaid waiver with the Obama administration that has allowed counties here – from Democratic Los Angeles to Republican San Diego – to enroll as many as 500,000 low-income adults into a 'Medicaid-lite' program years ahead of the law’s expansion of the federal-state program for the poor. Similar to the high risk pool, 'Medicaid-lite,' which is officially called the Low Income Health Plan, is envisaged as a temporary measure until January 2014. That’s when California would open up its Medicaid program to millions of poor people, an expansion paid for largely by the federal government.
But if a Romney Administration follows through with its vow to undo the health law, that deadline could come and go without an expanded Medicaid program or a health insurance exchange in place.
"It’s the ballgame at stake," said Anthony Wright, executive director of Health Access California, an advocacy group. "We go from the major reforms to a salvage operation."
The various provisions in the health law and California’s Medicaid waiver were all designed to work in concert. "The fundamental design of health reform in California was a layering of stuff," said Peter Harbage, a policy analyst who has advised Republican and Democratic administrations on health issues. "Phase one, phase two and phase three, and if one of the later phases doesn’t materialize, then people could be left without insurance."
While other states have a higher percentage of uninsured residents – Texas leads the nation with one in four residents lacking coverage – California has the largest number of people uninsured with 7 million, more than the entire population of Massachusetts or Arizona. And while the state legislature is controlled by Democrats, its persistent budget deficit – and a constitutional requirement that lawmakers balance the budget each year – have stymied state attempts to achieve universal health coverage.
It’s not for lack of trying. California last came close to passing universal health insurance legislation in 2008 after nearly two years of nail-biting negotiations. The bill was even supported by former Republican Gov. Arnold Schwarzenegger and modeled after Massachusetts' plan signed by former Gov. Romney in 2006. It would have required all Californians to carry coverage and insurance companies to accept all applicants. But the state’s mounting deficit – at the time it was $14.5 billion -- derailed the effort and cooled any ambition for a state-based solution.
As for California's nascent health insurance exchange, now called Covered California, spokesman Oscar Hidalgo said in an e-mail, "We are moving forward with our mandate to implement the California exchange." Indeed, the oversight board and staff of Covered California have been busy putting into place the state’s online insurance shopping portal and vetting the menu of a la carte insurance products. But there is widespread agreement that the online marketplace would falter if a Romney Administration were to cut off the federal subsidies aimed at helping working-class and middle-income individuals and families to buy coverage on the exchange.
But even in beleaguered California, there remain some who are optimistic that a Romney Administration would not signal the end of a comprehensive plan to deal with the uninsured.
Michael Cousineau, an associate professor of family medicine at the Keck School of Medicine at the University of Southern California and a long-time advisor to state and county officials on health care financing, said Romney's preference for state control could mean his administration might allow California to extend its Medicaid waiver and coverage expansion of low-income adults. "The question is how much money would the federal government put into it?" said Cousineau.
But a new administration in Washington turning off the spigot is not the Golden State’s only worry. On Tuesday, Californians will weigh in on a ballot measure, Proposition 30, that would increase the state’s sales tax by .25 percent and raise income taxes on high-income earners. The initiative’s biggest backer is California Gov. Jerry Brown who has said if the measure fails, he will be left with an $8.5 billion budget hole. That deficit will largely be closed by cuts to public schools, Brown and Democratic lawmakers argue, since the legislature has already slashed $23 billion in funding for health and welfare services, criminal justice and other programs.
Still, health care leaders here say if Proposition 30 fails, and Obama holds onto his job and the Affordable Care Act, the state will nonetheless enter a grim era of budget austerity. In that scenario, where the state is likely to cut weeks off the school year for public school children, Brown might be unwilling, they say, to move ahead with California’s planned Medicaid expansion. "It would be very hard," said Wright, "to move forward with anything that even costs a dime."