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We now know what to expect from our country’s new president, Donald J. Trump. Encouraged by campaign-staff-turned-presidential advisers like Steve Bannon and a cooperative Congress, Trump will continue to do his best to create chaos and disruption by tearing down existing legislation, agencies and regulations that protect and serve those with the least wealth, opportunity and power.
As a legislative first act, Trump and Republican congressional leaders, House Speaker Paul Ryan and Senate Majority Leader Mitch McConnell, immediately set to work on their promise to repeal the Affordable Care Act (ACA). Trump did his part through the issuance of a vague but potentially damaging executive order. The 200-day legislative strategy of Ryan and McConnell is to repeal and replace key portions of the ACA by spring, and then tackle tax reform before the August recess. They also have strongly indicated they want to restructure, reduce and cap federal funds for Medicaid and privatize Medicare.
Passage and implementation of the ACA marked a critical milestone in progress toward health justice. Altogether, 22 million of the 50 million Americans who were uninsured pre-ACA now have affordable coverage, either through state marketplaces or Medicaid expansion. Eleven of the 22 million are low-wage working adults enrolled in Medicaid. Medicaid covers 74 million people, or one in four Americans.
Privatization of Medicare – a GOP goal for many years – also figures into the plan. Joining the principal players in this assault is the narrowly-confirmed and ethics-challenged new Secretary of Health and Human Services, Tom Price, long on the record as determined to decimate our central safety net program for older adults. In a 2009 Politico op-ed he wrote, “Nothing has had a greater negative effect on the delivery of health care than the federal government’s intrusion into medicine through Medicare.”
House members and senators, however, fear political blowback from older and sicker Americans, and likely will postpone an outright attack on Medicare until after the 2018 election.
But Medicaid is in immediate danger. The ACA expanded Medicaid eligibility for adults up to 138 percent of the poverty line. In 32 states, the federal government is providing generous funding to cover Medicaid program expansions now enrolling over 11 million low income adults. This coverage will disappear with ACA repeal. However, Ryan and Price propose to further lower Medicaid spending to below pre-ACA levels by setting an absolute limit on federal spending through block grants or per capita spending caps. With a smaller, fixed pool of dollars, states will be forced to limit eligibility, cut back on covered benefits and/or require beneficiaries to pay more.
These changes will have devastating consequences for the millions enrolled in Medicaid and for state budgets. Sixty percent of Medicaid spending is on care for children and adults with disabilities and older adults over 65, many from middle-class families. One-half of Medicaid beneficiaries are children in poor families, and Medicaid pays for nearly one-half of births.
GOP lawmakers will be emboldened if they succeed with gutting the ACA and slashing Medicaid funding. Despite Trump’s campaign promises to never change Medicare “like all those other Republicans,” he probably would sign privatizing legislation if he buys the wholly invented narrative that his action will “save Medicare” from fiscal insolvency.
So how will ordinary families afford unregulated increases in health care costs when they can no longer rely on Medicaid, on the subsidies, new insurance benefits and free care obligations of hospitals created by the ACA, or on Medicare-guaranteed insurance coverage when they turn 65?
The fight to establish a right to health care is part of a long-term struggle for racial, social and economic justice in the U.S. It will have ramifications on all the other issues queued up by this administration to eat away at decades of progress toward greater civil and economic rights for all. It is morally and strategically critical to fund the ongoing struggle for health care rights at a time when the federal government’s role in assuring such a wide range of rights is under attack.
Foundations and wealthy donors can play critical roles in responding and staying the course to insure that groups in the broad ecosystem making up the resistance to the Trump and Republican health care agenda have the resources to win. This will require a variety of strategies working in concert: organizing affected constituencies and channeling them to effective action, pushing health sector stakeholders to speak out on behalf of their patients, battling in the courts, engaging the broader public through media, and coalescing with organizations waging economic security and racial justice campaigns.
Foundations and philanthropists can learn many lessons from the epic efforts to pass and implement the ACA. Among them:
A robust infrastructure of both national and state organizations is going all out to deploy as many resources as possible to take advantage of the current charged political moment. They need resources to coordinate their actions. Under the banner of “no repeal without replacement,” they are mobilizing public awareness right now, putting pressure on members of Congress and assisting local groups to put political pressure on their state and federal elected officials and to organize public protests and rallies in nearly every state.
To date, this has delayed the Republican timeline. Some GOP Senators have filed competing ACA “replacement” proposals, none of which would solve the problem of taking insurance away from millions and raising premiums for millions more. Meanwhile, grassroots opposition continues to gather steam, and public opinion has shifted still further toward “fixing” rather than repealing the ACA and re-enacting a substitute.
Because some form of repeal of the ACA is likely to prevail, funders need to support advocacy and organizing for the longer term as well as immediately. The good news is that state and national groups are already preparing for the long haul – to restore losses, regroup and move on. Fighting back will probably not totally prevent, but will at least mitigate, the damage.
With 74 million Medicaid enrollees, organizations representing diverse constituencies of low-wage workers, vulnerable older Americans, families of children with disabilities and families in poor communities must make common cause to preserve a robust federal role in Medicaid. There is a major opportunity for foundations and donors to infuse sufficient resources to bring this varied spectrum stakeholders together to develop long-term organizational strategies and roles, effective messaging and coordination of their work.
This convergence of organizations and mobilized constituencies is needed and already developing at the state level. A key factor in the ACA passage was the emergence of a new health care justice voice from the states in influencing the national debate. State-based organizations already successful in advancing progressive health policy at the state level were able to pivot and bring united, informed advocacy to the federal fight.
Health justice infrastructure groups now exist in over 40 states. They convene and mobilize large coalitions, including organizations with grassroots members. They vary in their communication, mobilizing and policy capacities. If funded, they are well positioned to make preserving health care affordability and coverage an issue that candidates for state and national office in 2018 and beyond cannot avoid.
Notwithstanding the unfolding federal fight and in the wake of federal retreat, both governors and legislatures will feel pressure to preserve some of the ACA’s insurance and financial assistance provisions. Success in ratcheting up constituency pressure will be critically important to counteract immediate conservative pushback and to demonstrate the political saliency of enacting policies that will inform the next generation of progressive federal health care policy.
Pennsylvania health advocates played a key role in organizing a recent 5,000-person protest when GOP congressional lawmakers met in Philadelphia to plan their health care agenda. Just a few days before, signs carried by millions of women (and men) marching in large and small cities across the country demonstrated strong resistance against the rollback of health care rights.
These and other events hint at a ripe opportunity to resource existing state- and community-based groups as well as those new to the fight, to develop new levels of health care organizing capacity. State health infrastructure organizations already have health policy and political expertise, but they and community-based partner organizations need capacity to expand community education, constituent leadership development, systematic base-building, and ties with organizations leading other economic and social justice movements. Likewise, social movement organizations unfamiliar with health issues and politics need support to fully engage and collaborate with groups advancing health equity campaigns.
People of color and poor communities are benefitting disproportionately from the new health care law and Medicaid. Millions gained coverage due to the ACA, but many were not voters. The lesson is that simply providing people with a new public benefit doesn’t motive them to vote, as Democrats had hoped and Republicans feared would happen through passage of the ACA.
The work of health advocates needs to be coupled with vigorous efforts by civic organizations of all stripes to engage beneficiaries of the ACA, Medicaid and Medicare and enable lots of angry people to engage in the political process in future elections.
There has not been a moment in recent American history when the impact of philanthropy can make a more critical and essential contribution, not just in defending crucial and people-affirming programs, but also buttressing the robustness of our democratic institutions to respond when those among us with the least power to defend themselves are being systematically put at risk on so many fronts at once.
Kate Villers is a NCRP board member and president of Community Catalyst, a national advocacy organization that believes that affordable quality health care should be accessible to everyone. Community Catalyst has moved $5 million into resistance campaigns led by state organizations to influence decisions about repealing the ACA and restructuring Medicaid and Medicare.
 Harris Meyer, “President Trump’s healthcare plate is full, and it won’t go down easy,” Modern Healthcare, January 20, 2017, http://www.modernhealthcare.com/article/20170120/MAGAZINE/301219967.
 Tom Price, “How the GOP wants to fix health care,” Politico, July 30, 2009, http://www.politico.com/story/2009/07/how-the-gop-wants-to-fix-health-care-025581?paginate=false.
 The Common Wealth Fund, “What would block grants or limits on per capita spending mean for Medicaid?” November 2016, http://www.commonwealthfund.org/publications/issue-briefs/2016/nov/medicaid-block-grants.
 See Richard Kirsch, “The time is now: How grantmakers can help preserve health access for millions of Americans,” Keeping a close eye on philanthropy, February 1, 2017, https://www.ncrp.org/2017/02/time-now-grantmakers-can-help-preserve-health-access-millions-americans.html.
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