California, which has used the Affordable Care Act to extend health protections to millions of its residents and cut in half the number of people without health insurance, stands to lose more than any other state under the latest Republican plan to roll back the 2010 law.
The GOP plan, which Senate leaders want to bring to a vote this week, would slash more than $100 billion in federal funding for the state over the next decade and tens of billions more in the years that follow.
That would force unprecedented cutbacks to the state safety net, hobble hospitals and clinics across California and likely leave millions of Californians without access to regular medical care, government and health officials warn.
"For the first time, we've been able to create a path to ensuring everyone has basic health benefits here," said California Health and Human Services secretary Diana Dooley, who has worked in the state's healthcare system for more than two decades. "This would strip all that away … and leave us with a series of terrible choices about who we could afford to help."
Although prospects for the repeal bill took a hit last week when Sen. John McCain (R-Ariz.) announced he would oppose it, state officials remain deeply concerned that congressional Republicans are continuing to push ahead and could make more attempts to revive the legislation even if it doesn't advance this week.
The current Republican plan will hit California particularly hard because it shifts federal healthcare aid away from states that have expanded coverage and moves it to states — most of them Republican — that rejected the current law, such as Texas.
Those hit hardest in such a shift would likely be California's most vulnerable residents, many of whom have gained insurance in recent years. "To take away health security from these people is particularly cruel," California Medical Assn. chief executive Dustin Corcoran said.
Ken Rogers, a psychologist at a clinic in Sacramento that sees many patients who've been able to acquire insurance in recent years and now are getting treatment for addiction and pain, predicted many of those people would slip back into the shadows.
"People are going to go back to doing what they were doing before — using illegal opioids on the street," he said. "And we're going to end up paying for it one way or another."
Despite McCain's announcement Friday, GOP lawmakers and the Trump administration still were trying to round up votes over the weekend ahead of a Sept. 30 deadline, after which Senate Republicans no longer will be able to advance repeal legislation with only 50 votes.
Under Senate rules, the threshold then rises to 60 votes, although congressional Republicans could try other tactics afterward to try to fulfill their years-long campaign to roll back the healthcare law, often called Obamacare.
The GOP repeal effort has always represented a major threat to California, which has done as much as any state to take advantage of the current law's tools for expanding coverage and improving medical care.
Between 2013 and 2015, the share of working-age adults in California without coverage shrank from 23.7% to 11.1%, according to federal data. Only three states saw greater reductions over the same period.
California still faces challenges under Obamacare, including rising costs. Like consumers elsewhere, some Californians, particularly those who make too much money to qualify for government healthcare assistance, have seen substantial premium increases and narrowing networks of healthcare providers.
But the new coverage has dramatically improved many patients' access to medical care and reduced financial strains, research indicates.
More than three-fourths of newly insured Californians said their health needs are now being met, a survey by the nonprofit Kaiser Family Foundation found.
By contrast, less than half said they were getting needed care before they got coverage through the health law. At the same time, Californians who gained coverage reported fewer worries about paying not just for healthcare, but also housing, transportation, even food.
"People [who] actually need help are being served," said Dr. Ilan Shapiro, a senior physician at AltaMed, a large network of Southern California clinics that serve low-income patients.
The gains are no accident.
State leaders, including former Republican Gov. Arnold Schwarzenegger, decided soon after President Obama signed the Affordable Care Act in 2010 that California, which at the time had among the highest uninsured rates in the country, would aggressively implement it.
That meant expanding eligibility for the state's Medicaid program, known as Medi-Cal, and creating a robust insurance marketplace that would set high standards for health plans and actively negotiate to control prices.
Most states, instead, allowed the federal government to run their marketplaces. And 19 states, all with GOP governors or legislatures, still have not taken federal aid made available by the health law to expand Medicaid.
These states have much lower levels of insurance coverage, and patients there have worse access to medical care, studies show.
Even with Medicaid expansion in California, the state remains among the least reliant on federal assistance, ranking 43rd in a recent measure by the nonprofit Tax Foundation.
But under the latest GOP repeal plan — authored by Sens. Lindsey Graham (R-S.C.) and Bill Cassidy (R-La.) — California's large coverage expansion makes it the biggest target.
The centerpiece of the Graham-Cassidy bill is a new system of federal healthcare financing that both redistributes money made available through the 2010 law and puts new caps on Medicaid funding that the federal government has provided to states for more than half a century.
That threatens to further squeeze states like California, where some 13.5 million people rely on Medi-Cal, including more than 3.8 million who have gained coverage since the expansion.
Estimating the full impact of the Graham-Cassidy plan is difficult given its complexity and uncertainty about how it would be implemented, but analyses by the Kaiser Family Foundation, consulting firm Avalere Health and the state itself indicate California would lose at least $112 billion in federal aid by 2027.
In Kaiser's analysis, only six states lose a larger percentage of federal aid available through the current health law over the next decade: Connecticut, Minnesota, Montana, New York, Oregon and Vermont.
Even the Trump administration's own analysis, first reported by Axios, estimates that California will see a 45% cut in federal healthcare aid in 2026, as funding is reduced more than $20 billion.
State officials, who calculated that California would see $138.8 billion in federal cuts by 2027, called the Graham-Cassidy bill the worst of the three leading repeal plans congressional Republicans have tried to advance this year.
They also warned that not only would coverage likely be scaled back, numerous other initiatives to improve care would be jeopardized, including expanded home-based services for the disabled, which serves nearly 500,000 Californians, and family-planning services, which serve more than 600,000 low-income people in the state.
"The impacts … are serious and will be devastating to not only our Medi-Cal program, but the larger healthcare delivery system that all Californians rely on," state analysts concluded.
Times staff writers Soumya Karlamanga in Los Angeles and Sarah Wire in Washington contributed to this report.