What’s Next: The Uncertain Future of Healthcare in America

On November 6, 2016, the country awoke in shock to find that their 45th president would not be the first woman president as so adamantly expected, but rather the first president in recent history with no political experience and with few concrete policy ideas. Because of the lack of media coverage on the candidates’ policy proposals in favor of scandals, during the year and a half campaign, there is much uncertainty as to what a Donald J. Trump presidency means for a multitude of policy issues, including healthcare.

In the Time of Trumpcare

Though one of Trump’s fundamental campaign pillars was to repeal Obamacare, this will prove much more politically difficult than he originally anticipated. To begin with, he will require a supermajority of 60 senate votes to overturn the Affordable Care Act (ACA) in its entirety, and a simple majority of 50 votes to eliminate certain provisions, which could prove difficult even with a Republican House and Senate majority. If Trump were to repeal the ACA with no clear replacement, more than 20 million people could lose healthcare coverage, likely blaming the GOP and his presidency. In fact, over half of Americans either want the ACA to remain the same or to expand.

According to the Wall Street Journal, after “further review”, Trump now intends to keep the requirement that a patient cannot be denied care due to a preexisting condition and the provision that allows young adults up to 26 years old to remain on their parents’ health plan. However, if Trump intends to repeal other parts of the healthcare law, such as the individual mandate, which has historically been unpopular with Republicans, it is very possible that the entire system will unravel. The healthcare mandate is what incentivizes healthy and young people to participate in the insurance market, who otherwise may not have bought coverage. The participation of healthy people in an insurance market is vital for its success, as it balances the financial risk of all the unhealthy and older people who have chronic, and often expensive, conditions.

Not only does a partial revocation of the ACA threaten the system itself, but it will also likely cause premiums to skyrocket. An existing criticism of Obamacare is the high prices, due to lower than expected participation of healthy people, so eliminating the individual mandate will only lower the participation further. The sicker the average patient in a risk pool is, the more expensive the premium will be. Trump therefore has to decide whether he wants millions of Americans to lose coverage, prices to soar, or to go back on his word to repeal Obamacare.

According to the GOP website’s healthcare plan, they may intend to leave the majority of the administrating and managing of healthcare programs up to individual states, including the low-income program, Medicaid. Even under Obamacare, 19 — mostly red — states failed to expand Medicaid to reach more patients, mainly low-income adults. More state autonomy with regard to healthcare could result in less funding for Medicaid in Republican states, where at least 3 million people that qualify for the program under federal standards already lack insurance. Since subsidies are largely unpopular with the Republican party, they too could be in danger, and threaten to further decrease the number of insured Americans. Other GOP proposals include allowing health insurers to sell insurance in different states, with the hope that interstate competition may reduce costs, and making insurance premiums tax deductible.

If Trump and the GOP decide to completely repeal Obamacare, California could be one of the states most affected, largely because it enrolled more people than any other state. 1 in 3 Californians are now covered by Medi-Cal, California’s program for low-income patients, which was greatly expanded under the ACA. California has also not faced the rise in insurance premium prices that other states have seen and the exchange Covered California has been able to offer residents a variety of insurance plan options. As Sabrina Corlette, from Georgetown University said, “The ACA has not been perfect, there have been challenges. [But] if there was one state where it was really working well … it was California”.

With the repeal of the ACA and without federal funding of the exchanges and Medi-Cal, California could lose $20 billion for these programs. And although California leads the way on many social issues, it will likely be hard to do so without the federal funding and structures to provide health insurance to the millions of Californians who so desperately need it. However, if Trump only partially repeals the ACA and gives states autonomy through a block grant, which is more likely, the state will still be able to offer insurance, though will have much less funding to do so. With a much smaller budget, there are legitimate worries of reduced services or reduced number of insured patients, which could have detrimental effects for many families.

With much at stake in both California and across the nation, it is imperative that we remain as politically active as possible, to demonstrate both the value of the ACA, and its federal funding, in the goal of ensuring every American has access to quality healthcare.

Leaving Us Behind

One public health issue that has garnered less public attention than the call to repeal Obamacare, but may still have important implications for millions of Americans in the labor force, is that of paid parental leave. Currently, the United States is one of the three countries in the world that does not have a national law mandating paid maternity or paternity leave, the other two being Papua New Guinea and Suriname. The 1993 federal Family and Medical Leave Act and the California Family Rights Act provide for up to twelve weeks of unpaid leave per year to take care of a newly born, adopted, or fostered child, or for an immediate family member or themselves because of a serious health condition. But because of stringent eligibility requirements only about 60 percent of the American workforce is covered.

On the statewide level, Rhode Island, New Jersey, and California are the only states to provide paid parental leave, with California’s Paid Family Leave (PFL) program allowing workers to receive weekly cash benefits for six weeks of out of a year at approximately 55 percent of earnings up to a maximum of $1,129. In the past year, San Francisco also passed a bill mandating fully paid parental leave for new parents, including same-sex couples, who bear or adopt a child, with the 45 percent difference paid by employers.

Trump is the first Republican presidential candidate to address the growing need for a national paid family leave policy. His plan, outlined on his website, provides for six weeks of maternity leave to new mothers, at an average of $300 in weekly benefits. Even though providing paid maternity leave seems like a much-needed step forward for national policy, there are significant shortcomings in Trump’s plan.

First of all, the financing of paid leave would amount to billions of dollars, which Trump has proposed paying for by eliminating unemployment fraud. Using the average $300 per week benefit, Trump’s proposed plan is estimated to cost $2.5 billion annually. Yet this means that female workers on average would receive about 38.7 percent of their usual pay when on maternity leave. If the government opts to increase the wage replacement rate for mothers on leave and employers don’t provide paid leave, then the costs increase to $10.2 billion in the first year and $122.0 billion over ten years to provide this benefit. Unemployment fraud in the United States is estimated to cost only $3.3 billion a year.

Maternal leave following the birth of a child is crucial for the health of newborns and mothers. Studies show that infant mortality rates fall and cognitive development improves when a newborn is cared for by their parent full-time. Bonding and trust are established between parent and child during this critical time, and the physical and psychological tolls of pregnancy also mean that those who give birth need more than just four or six weeks to recover from pregnancy and labor. A six-week-old baby is just barely able to lift its head, which is why 86 percent of countries that offer maternal leave provide more than 12 weeks.

Donald Trump’s daughter, Ivanka Trump, has said that the policy would be meant to benefit a married mother who gives birth to a child. Yet providing paid leave only for new mothers also overlooks much of the complexities of work and parenting in the United States today. Same-sex couples, single fathers, adoptive parents, and foster parents won’t receive any of the benefits of the proposed maternity leave plan. Women would be incentivized to take time off work at a higher rate than men, likely placing them in the “mommy track” in the eyes of employers, which can lead to fewer promotions and raises, further widening the gender gap. Not providing paternity leave as well enforces the discriminatory myth that women should be the primary caretakers of children, discouraging men from sharing the work of childcare and housework and investing time and energies in parenting, especially in the crucial early months of life. Two-thirds of men say they also want an equal role in parenting, and this policy would not make it easy to do so.

While establishing a national plan for six weeks of paid maternity leave would be a step towards the right direction, doing so without clear plans for funding, a length of leave fully benefiting a child’s growth and development, or establishing equal leave for fathers, same-sex couples and couples would shortchange women, children, and families. Establishing paid parental leave on par with other high-income nations of the world would help ensure that the United States is not left behind in terms of health and wealth, achieving equality and well-being for all.

This article was originally published in the Fall 2016 print issue.