Xavier Becerra left Washington with the US health insurance rate near a record high. Years spent passing, defending and expanding the Affordable Care Act formed a large part of his healthcare record.
Now the former congressman and US Health and Human Services secretary is running for California governor against Republican Steve Hilton, a former Fox News commentator. Becerra regularly points to the expansion of insurance coverage during his time in federal office.
The next California governor faces a much different insurance market. Recent federal and state policy changes are projected to reverse a sizable share of the coverage gains made since the ACA took effect.
Polling in July placed Becerra ahead of Hilton in the November race. If Becerra wins, the healthcare system he inherits will be dealing with a rapid increase in uninsured residents, rising pressure on Medi-Cal and tougher finances across hospitals and health plans.
California had about 2.4 mn uninsured residents under age 65 before the latest policy changes. By 2030, the figure is projected to reach 4.6 mn, according to a May analysis from the University of California, Berkeley Labor Center.
That represents another 2.2 mn people without insurance. The state’s uninsured rate would rise to 14.7%, nearly twice its previous level.
Federal Medicaid reductions and changes affecting ACA marketplace coverage account for much of the projected increase. California has also adopted state-level restrictions as budget pressure grows.
The financial effects stretch beyond households losing coverage. Hospitals face more uncompensated care when uninsured patients receive treatment without enough money to pay their bills. Health insurers face a different problem as healthier customers leave the market and the remaining membership becomes more expensive to cover.
Hospital executives have already reported growth in unpaid medical bills. Insurers, meanwhile, are preparing for higher claims costs as enrollment changes alter their risk pools.
Covered California is the country’s largest state-operated ACA insurance marketplace. Its position gives California unusual exposure to changes in federal marketplace subsidies, enrollment requirements and insurance rules.
The state also entered this period after recording one of America’s largest declines in its uninsured population following passage of the ACA. California expanded Medicaid through Medi-Cal and invested heavily in marketplace enrollment.
Those gains are now moving in the opposite direction.
If elected, Becerra would have to address how millions of newly uninsured Californians obtain medical treatment and how providers get paid for it. The federal government, meanwhile, is reducing parts of the safety net he previously managed as HHS secretary.
As California attorney general, he defended major provisions of the law in court. His legal work included cases involving access to birth control and other ACA requirements challenged during the first Trump administration.
His relationship with the law goes back further. In 2010, Becerra belonged to House Speaker Nancy Pelosi’s leadership team and helped secure votes for the ACA. He also participated in developing parts of the legislation.
One proposal he supported didn’t survive. Becerra pushed for a government-backed public insurance option, but Congress passed the final ACA without it.
A decade later, during confirmation proceedings for the top federal healthcare position, Becerra described expanding access and reducing consumer costs under President Joe Biden’s ACA policies as a main priority.
Before passage of the law, about 50 mn Americans lacked health insurance, roughly one person in six. Medicaid expansion and federal assistance for lower-income ACA marketplace customers helped cut the uninsured rate by nearly half within the following years.
The federal government temporarily stopped Medicaid disenrollments, allowing beneficiaries to retain coverage without the usual eligibility reviews. Expanded premium tax credits also reduced ACA marketplace costs for households earning too much to qualify for earlier levels of assistance.
Republicans have challenged the idea that rising enrollment alone demonstrates the success of federal insurance policy.
By 2024, 92% of Americans had health insurance. Census figures put the insured population at roughly 310 mn people, a historic high.
Conservative policy researchers argued that Biden-era enrollment rules and subsidies created opportunities for improper sign-ups, unnecessary federal spending and fraud. Edmund Haislmaier, a senior research fellow at the Heritage Foundation, has argued that enrollment totals aren’t an adequate measure of program performance.
The second Trump administration moved policy in another direction. Federal officials shortened enrollment periods and imposed stricter income-reporting requirements for ACA customers.
