Californians in Republican Districts Feel Betrayed by Looming Health Care Cuts

Natalie Padilla signed up for Medicaid 17 years ago. She had just given birth and needed insurance to bring her son to the doctor. The Bakersfield resident was still in school, and her husband’s work didn’t offer insurance. She was on the program for six months.

About an hour north of Bakersfield, Rodolfo Morales-Ayon, a 21-year-old community college student, relies on Medicaid today. He’s studying political science and wants to go to law school. Morales-Ayon grew up in Pixley, a small Central Valley town where air quality is poor and asthma and respiratory infections are common.

Farther south in Orange County, Josephine Rios’ 7-year-old grandson has cerebral palsy and needs Medicaid to pay for his medication and specialized wheelchair, which cost $22,000. Elijah is a lively boy, Rios said, but his disability means he’ll likely need Medicaid for his entire life.

All three live in areas of California where their Republican representatives recently voted on a federal budget bill that would all but guarantee cuts to the Medicaid insurance program, which is known in California as Medi-Cal.

Although the details will take months to iron out, the nonpartisan Congressional Budget Office released a report (PDF) last week indicating that it was impossible for House Republicans to meet their goal of eliminating $880 billion in spending over the next 10 years from the committee that oversees Medicaid and Medicare without cutting from either of the social safety net programs. Medicaid provides health insurance for people with disabilities and low income. Medicare insures seniors over 65.

The Senate voted on a narrower budget bill that is less likely to hit Medicaid, but the chamber will have to come to an agreement with the House later in the year. President Donald Trump has praised both budget bills, while at the same time indicating he doesn’t want to cut safety net programs for the poor. Congress is also rushing to avert a government shutdown Friday with a separate budget bill.

“Medicare, Medicaid — none of that stuff is going to be touched,” Trump said in a February interview with Sean Hannity on Fox News.

But Republican lawmakers want a deal that would offset the cost of extending Trump’s first-term tax cuts that are set to expire at the end of this year, and Medicaid represents the largest share of federal funding to states.

California’s behemoth Medicaid program insures 14.9 million people, more than one-third of the state’s population. Republicans hold nine House seats in California and represent 2.5 million Medicaid enrollees. All nine voted to approve the House GOP budget bill at the end of February.

Some of the state’s most conservative areas benefit disproportionately from Medicaid, including Rep. Jay Obernolte’s district in San Bernardino County’s high desert and Rep. Doug LaMalfa’s district in the far northern counties, where 48% and 43% of the population have Medicaid respectively.

Other Republicans represent swing districts where voting against Medicaid could be risky politically. Rep. David Valadao in the San Joaquin Valley represents the greatest share of Medicaid enrollees in the state at 67%. He voted to advance the House bill. Six years ago, his vote to eliminate the Affordable Care Act likely cost his reelection for a term.

In contrast, California’s Democratic state lawmakers have taken every opportunity to expand the Medicaid program, which grants full-scope health coverage to people with low income (for instance: an individual making less than $20,783 or a family of four making less than $43,056 annually).

The number of people with Medicaid in California has increased 31% since 2014 when the Affordable Care Act allowed states to enroll people who made slightly more than the federal poverty threshold. California has also expanded in other categories, using about $8 billion annually of state money to insure undocumented immigrants.

Today, the state spends $161 billion on Medicaid (PDF), the majority of which comes from the federal government.

Republicans have focused talks on rooting out “waste” and “fraud” in federal programs, but early proposals appear to aim at the fundamental payment structure of Medicaid. Experts say those types of cuts may require states to pay more for the programs, putting the political and financial onus on state lawmakers.

“Many of these proposals are about having states be left holding the bag,” said Edwin Park, a public policy research professor at Georgetown University. “If states have less funding available, then it’s impossible for them to sustain their current levels of spending.”

‘Some people will die without it’In a statement on the House floor following the initial budget vote, Valadao said extending Trump’s 2017 tax cuts would make a real difference for “working families, farmers, and small business owners” but acknowledged that many of his constituents need Medicaid.
“I’ve heard from countless constituents who tell me the only way they can afford health care is through programs like Medicaid,” Valadao said that day, indicating he could vote differently later in the year on a final proposal. “And I will not support a final reconciliation bill that risks leaving them behind.”

But some California voters still feel like their representatives have failed them by advancing a bill that will likely lead to Medicaid cuts.

“For our representative David Valadao, this is a betrayal. It’s nothing less than that,” Morales-Ayon, a district voter, said. Morales-Ayon voted for Valadao’s Democratic opponent last fall.

Morales-Ayon had Medicaid as a child because his parents’ jobs didn’t provide insurance. Per capita earnings in Valadao’s district are about half as much as statewide earnings, according to census data.

“People need these resources to manage their day-to-day lives,” Morales-Ayon said.

Padilla, who also lives in Valadao’s district, now works as a pharmacy technician at Mercy Hospital Southwest in Bakersfield. She traveled with her union to Washington, D.C. several weeks ago to try and make an appeal to Valadao not to vote for any Medicaid cuts. Staff told the group that he was too busy to see them, Padilla said.

Padilla grew up in the district and said multiple family members, including cousins and her 84-year-old grandmother, have Medicaid. Her family who rely on Medicaid have low-paying or part time jobs that don’t offer health insurance. Any reductions in coverage would be “devastating,” she said.

“This is the raw, honest truth of hardworking people,” Padilla said.

In Orange County, Rios, a certified nursing assistant for Kaiser Permanente, voted and rallied for Republican Rep. Young Kim, but these days she’s consumed by the thought of what will happen if Medicaid is cut. She’s worried that she’ll lose her job and that patients will lose access to health care.

Most importantly to her, Rios said, her grandson Elijah with cerebral palsy might lose insurance. Elijah’s cerebral palsy medication costs $5,000 each month, she said.

“It’s not a Republican thing. It’s not a Democratic thing. Forget the political BS, this is a human thing,” Rios said. “Some people will die without it. Some people’s lives like my grandson’s are at risk without it.”

Rios, who has worked in health care for more than two decades, said she voted for Kim because Kim spoke compassionately about her constituents during her election campaign and also supported health care workers. But the budget vote was a “slap in the face.”

“I’m very disappointed and very frustrated that she voted and she didn’t fight harder to keep Medi-Cal uncapped not only for her constituents like myself but for the young children who need it,” Rios said. “She needs to remember why we elected her into office.”

In a statement on her website, Kim joined other Congressional Republicans in emphasizing that the bill passed was procedural and didn’t make cuts to any specific programs. The vote simply allowed the GOP to “move the ball forward,” Kim said in the statement.

“As this process moves forward, I will continue to make clear that a budget that does not protect vital Medicaid services for the most vulnerable, provide tax relief for small businesses, and address the cap on state and local tax (SALT) deductions will not receive my vote,” Kim said in the statement.

In her district, which covers portions of Orange County and the Inland Empire, 21% of people use Medicaid.

An ‘existential threat’ to health clinics

But some health care providers say even the procedural vote was “too risky” for their liking.

“It is an existential threat from our perspective,” said Francisco Silva, chief executive of the California Primary Care Association, which represents more than 1,200 community health centers in California.

Community health centers, also known as federally qualified health centers, predominantly serve communities with low income. In some areas of the state, Medicaid is the only reason why health centers and hospitals can piece together enough revenue to stay open, Silva said.

Marisol De La Vega Cardoso said any Medicaid cuts risk destabilizing community health centers at a time when poverty is increasing. De La Vega Cardoso is a senior vice president at Family HealthCare Network, the second-largest community health center network in the country.

“Unfortunately we might be forced to cut back on services that are so needed,” De La Vega Cardoso said.

Dr. Richard Thorp, a longtime internal medicine specialist in Paradise, is very concerned about how Medicaid cuts may destabilize the workforce in an area that already struggles to recruit doctors. Republican LaMalfa has represented the district that includes Paradise since 2013.

The once idyllic town in the Sierra Nevada foothills outside of Chico was the site of California’s deadliest wildfire in 2018, which also destroyed the local hospital. More than 80% of the population never returned to live in Paradise, and Thorp’s medical group dropped from 15 primary care doctors to one full-time doctor supported by four advanced practice staff.

“We have significant manpower and pipeline issues,” Thorp said. “As you make these cuts it makes it less and less feasible to practice in Butte county.”

LaMalfa said in a statement online that the House budget bill was a first step in “reining in Washington’s out-of-control spending” and that a “typical family in NorCal” would see taxes go up without the federal government cutting spending. The statement made no mention of Medicaid.

“It’s time to prioritize policies that grow the economy, cut waste, and ensure a stronger financial future for the American people.”

Supported by the California Health Care Foundation (CHCF).