I met Rena Salamacha last summer, when the worst of H.R. 1\u2019s cuts to federal Medicaid funding weren\u2019t yet finalized, only feared. Salamacha, CEO of Mee Memorial Healthcare System in Monterey County, knew then that the system\u2019s medical center in King City, serving rural and mostly low income patients, was already in trouble.<\/p>\n
\u201cWe don\u2019t have services to cut,\u201d the CEO said simply.<\/p>\n
More than a year later, that remains the reality. After all the shouting over Prop. 40, and the massive investment of time and money by California\u2019s billionaire class to defeat the tax<\/a>, the state\u2019s fragile health care ecosystem is in the same place it was last week: trying, as Salamacha tries every week<\/a>, to find ways to keep going.<\/p>\n That road is about to get rougher. The worst of the new federal Medi-Cal cuts and rules changes (including work requirements) will kick in beginning next year, and from the California vote totals available so far, there won\u2019t be Prop. 40 money<\/a> coming in to offset any of the reductions. The result: Increased strain on existing hospitals and clinics, fewer services available, and more people going uninsured.<\/p>\n As always, this long-term structural problem will land on the state\u2019s most vulnerable. California stands to lose an estimated $30 billion a year<\/a> in federal funding for Medi-Cal, the low-income program upon which roughly 14 million<\/a> residents \u2013 more than a third of our population, including 4.5 million kids \u2013 rely for their health care.<\/p>\n Congratulations, Xavier Becerra: This is your problem now.<\/p>\n Prop. 40 certainly wouldn\u2019t solve the health care crisis in California, nor was it designed to. It was as it appeared: a one-time 5% wealth tax on the richest 250 people in the state, billionaires all, which would generate up to $100 billion in revenue over about five years. Almost all of the money was to be used to offset federal funding cuts to health care.<\/p>\n Not every detail was ironed out, as was known. That included the question of how the state would go about valuing certain assets \u2013 art, wine, automobiles \u2013 that are part of many ultra-wealthy portfolios, as well as how the new tax revenue would be distributed among health care providers. Also known: The union that spearheaded the Prop. 40 drive represents health care workers whose jobs could be on the line if, as expected, California\u2019s care system contracts in the absence of funding.<\/p>\n Now state lawmakers and Becerra, the incoming governor, must search for ways to protect Medi-Cal for as many residents as possible, or else face a wave of uninsured patients who won\u2019t stop needing care just because they can\u2019t pay for services. As many as 1.3 million Californians<\/a> could lose health insurance as a result of H.R. 1, according to estimates.<\/p>\n First as a member of Congress and then as secretary of Health and Human Services under President Joe Biden, Becerra fought for decades to expand Medicaid at the federal level. More recently, he opposed Gov. Gavin Newsom\u2019s move to scale back coverage for undocumented adult immigrants in California, a cause Newsom had championed but retreated from due to budget issues.<\/p>\n California\u2019s budget cannot backfill the steep H.R. 1 funding cuts, so it\u2019s a matter of limiting the damage. Becerra, who says he wants the state to be \u201cthe backstop for health care,\u201d has a few options.<\/p>\n Institute a \u201cfair share\u201d tax. Becerra is a strong supporter<\/a> of state legislation that would levy fines on businesses that have a large number of employees on Medi-Cal \u2013 in other words, tax those companies for paying their workers so little that they qualify for the low-income health care program. The state Department of Finance is studying<\/a> what such a program would look like, with a presentation to state legislators expected next spring.<\/p>\n Reduce waste. As a candidate, Becerra said that California is \u201closing billions to fraudulent claims and misused benefits.\u201d<\/a> He said that as governor, he\u2019ll create a dedicated health care fraud task force to go after such activity. Becerra also pledged to modernize Medi-Cal\u2019s\u2019 system to include automatic state-generated renewals, which he said would reduce paperwork errors that lead to eligible patients being mistakenly dropped from coverage \u2013 an idea that will be sorely tested by H.R. 1 rules that now require twice-yearly requalifying.<\/p>\n Raise taxes on the wealthy. Becerra opposed the Prop. 40 wealth tax, but he has indicated he\u2019s open to increasing taxes on top income earners. Becerra told KCRA<\/a> in Sacramento that the idea is to go after that money \u201cif we can prove that you\u2019re not paying your fair share. And to me, that\u2019s pretty basic: If you\u2019re a billionaire and you\u2019re paying at a lower tax rate than a firefighter, a teacher or a nurse, you\u2019re not paying your fair share.\u201d There are no details on such a plan, nor a timetable for implementation.<\/p>\n