Q&A: Health Access Exec. Dir. Amanda McAllister-Wallner

This year we’ve seen two major legislative actions that will have an outsized impact on healthcare access here in California. The first was H.R. 1 in Congress, President Donald Trump’s so-called Big Beautiful Bill, that makes pretty drastic cuts to Medicaid and other social safety net programs. The other was the California budget, which has its own significant impacts on Med-Cal.

We sat down with Amanda McAllister-Wallner, Executive Director of Health Access California, a consumer advocacy coalition that advocates for more accessible, equitable, affordable, quality health care for all Californians. The interview has been lightly edited for length and clarity.

CW: Let’s start with H.R. 1 first. How do you see this impacting Californians’ healthcare?
AMW:  It’s hard to overstate how devastating cuts in H.R. 1 will be to Medi-Cal. The public narrative around H.R. 1 throughout most of the country continues to be that this was an extension of the Trump tax cuts. But what we’ve really tried to emphasize to folks here in California, and I think Californians probably understand this better than many others, is that this was a health care bill. And this was essentially a repeal of the ACA by another name. It will undermine two of the huge achievements in the ACA, starting with the Covered California Marketplace, which has opened up affordable coverage to over a million people here in California, especially small businesses and the self-employed, who have had access for the first time to affordable healthcare that isn’t reliant on an employer. We’re going to see prices in the marketplace go up dramatically. The second part is that between the changes to provider taxes and the work reporting requirements that are in the bill, we can see potentially millions of Californians losing health care entirely. We’re going to see not quite a pre-ACA world again, but I think we’re going to unfortunately see a return to the time of double-digit uninsurance here in California, of people using the emergency room as their primary source of healthcare. It may take time for some of these things to take effect, but we will start feeling impacts immediately for others. So there are things that are going to hit right away, and there are things that will take time, but we will be feeling the effects of these healthcare cuts for a long time here in California.

CW: I mentioned the California budget, which will have its own impacts on Medicaid, particularly for undocumented immigrants. How is that going to impact our healthcare system?
AMW: The changes to Medi-Cal eligibility and enrollment for immigrants is not just for undocumented folks. It’s for people who have legal status here in the United States, for asylum seekers, for refugees, for victims of violent crimes who’ve been cooperating with law enforcement. There are thousands of Californians who have had access to Medi-Cal for decades, who have a legal status but are not citizens. And they are all also getting swept up in some of these changes, both in H.R. 1 and the changes to the state budget and to our Health for All program specifically. I think the state’s decision to balance the budget by making health care less affordable, more burdensome and less accessible for the most vulnerable people in our communities just really flies in the face of California values and of the commitments that we’ve made to our immigrant communities to remove barriers in health care. I think it’s really the wrong direction for us to be going and it’s going to just compound the changes that we’re seeing at the federal level.

CW: Voters endorsed Prop 35 last year, which ensures the MCO tax going to fund Medicaid reimbursements. How is that going to factor into all of this?
AMW: It appears from what we can tell right now that Prop 35 is not compliant with H.R. 1 and that California will not be able to use any revenues from Prop 35 to support its Medi-Cal program. DHCS put out information about that a couple weeks ago. I think the state is looking into whether we can get additional time to bring our MCO tax into compliance with H.R. 1 to continue to be able to have stable funding for our Medi-Cal program. But if the worst case scenario continues to persist, then we’ll be looking at a pretty big hole in our Medi-Cal budget here in California. Which just to be really clear is the intention of H.R. 1. That’s why they included it in the bill.

I think Californians probably understand this better than many others that this was a health care bill.

CW: Immigrant communities are not the only ones that will be impacted by these changes. The LGBTQ+ community, which often tends to be lower income, also stands to be very deeply impacted by all of this as well, correct?
AMW: Absolutely. We luckily saw the restriction on Medi-Cal funding for gender-affirming care piece was taken out of H.R 1. It failed due to the Byrd rule in the Senate. However, we know that Congress is looking at other avenues to restrict funding to gender-affirming care. We’ve seen the Trump administration put out a number of new and amended rules related to gender-affirming care. They’ve made really explicit threats to providers who offer that care and have set up “whistleblower” websites and forms and hotlines to report doctors and providers who are offering that care, really for no other purpose than to have a chilling effect. Not because anything they’re doing is illegal, not because anything that they’re doing does not conform with the best practices set out by the standards of care for treatment of gender dysphoria and treatment of folks who are transgender, but simply to have a chilling effect and to scare providers and families out of this care. And we’ve already seen the effects of that side in California with Children’s Hospital L.A closing their gender clinic. Kaiser has also closed a number of its gender clinics. We’ve seen just a huge number of dominoes starting to fall here in California that reduce access even without making some of those changes in the law. And it means it’s going to be harder and harder for people to continue to access care, which is very time sensitive in many cases. And it’s even further compounded by the effects of Planned Parenthood clinics closing, which are also an important provider of gender affirming care in many parts of California.

CW: We were already seeing some reduction in Medicaid enrollment even before this year, to some extent by design through eligibility losses and procedural disenrollments. Can you maybe explain that a little bit to me?
AMW: During the COVID pandemic the government had relaxed a lot of its re-enrollment and eligibility redetermination procedures to ensure that people had continuous access to care. That public health emergency unwinding has been taking place over the last few years, and as redeterminations have picked back up and become a little bit more stringent, many places throughout the country have seen dips in enrollment. Here in California we actually saw a little bit less of that than we expected. We actually have seen higher enrollment in Medi-Cal than some of the initial projections expected because California has taken a number of steps to make enrollment easier and to make the program more accessible and robust. But you’re right, we’ve started to see some of the effects of those changes. And I think that’s actually a good glimpse into our future. Because of H.R. 1, the redeterminations are going to happen every six months and work reporting requirements are expected to happen monthly. How we implement that in California can really have a huge impact on how many people lose coverage as a result of these new rules. We’ve got some really, really important questions that we’re going to have to grapple with as a state when it comes to how we implement H.R. 1 and how can we, to the best of our ability, preserve access to care and maintain our near universal coverage here in California.

CW: The decision by the Trump administration to share the personal private medical data of Medi-Cal recipients with Immigration and Customs Enforcement, or ICE, will obviously have a chilling effect on immigrant communities, but could it have a bigger impact across all of health care access?
AMW: I think this decision by the Trump administration almost more than anything else they’ve done hit a lot of health advocates and immigrant rights advocates incredibly hard. Over the course of the last decade, as California has opened up its Medi-Cal system, millions of people have asked is it safe for me to enroll in health care? What’s going to happen to me or my family if I do that? And time and again, we reassured them that there are strong protections to make sure that your information will only be used for the delivery of health care. And to violate that trust is devastating. And even for those who didn’t enroll in health care, if you went to the emergency room, or you got care at a FQHC, which receives Medi-Cal funding, your data is shared with ICE now. And that is absolutely devastating to think that people’s trust was violated in that way.

We’ve already seen the Trump administration go after birthright citizenship. We’ve seen them going after people who are here legally, people who are showing up to their immigration court hearings and doing things “the right way,” but they keep moving the goalpost. As advocates, we have historically been able to rely on the rule of law and on political norms as such an important part of the work that we do, on the expectation that nobody would share your data because there’s a rule saying they can’t. But we’ve seen time and again that there is not the same conformity to norms. There’s not a respect for norms. There’s not a respect for the law. They’ve proven that they’re willing to just ignore it. And we need to internalize that as advocates and internalize that into our risk assessment and how we’re thinking about how the worst case scenario is different now than it was a few years ago. What’s the worst that could happen? Well, if someone’s willing to break rules and is willing to completely rewrite what’s acceptable, then that looks different than what we’ve been used to incorporating into how we plan for things.

It does give me hope that people will continue to fight back and that we can continue to push back and against these cuts and avoid some of the worst impacts of H.R. 1.

CW: Right. We haven’t really talked about behavioral health, but one of the really big issues when it comes to behavioral health – and really across all of health care – is just having enough medical personnel to meet the needs, the general practitioners, the specialists, the technicians even. Are we making any progress in improving the pipeline to having enough health care providers to meet the access needs we have here in California?
AMW: On the behavioral health piece, I think we really do have a lot of work to do still. We’re especially at a time when there is a huge need. I know I would not be making it through the last few years of this administration and the last Trump administration without my therapist. We are facing multiple health and mental health crises, with so many traumas stacked up on top of one another, and I think we have a long way to go on that. In terms of our provider shortages more generally, I think H.R. 1, unfortunately, is going to make a lot of those issues tougher as well. Getting rid of or making drastic changes to financial aid and the public loan forgiveness programs, those types of things, are incredibly important to health care professionals. Whether you’re a doctor, a nurse, a mental health worker, we really used financial aid and incentives as a really important tool to address our provider shortages. And seeing just the instability in that, whether some of those things may be reversed in a few years or not, we’re going to see a long tail of some of these impacts of people not feeling confident to what’s going to be available, how to plan for your future, how to plan for whether the program that will allow, especially for a lot of our underserved communities to get into health care. And then just the instability in the job market as well. If you don’t know, if you’re constantly seeing rates change, hospitals and clinics closing, or just a general instability in the health care marketplace, this is one of the fastest growing employment sectors over the last few years. It’s been a hugely important part of our economy here in California and throughout the country. But people are going to have to make really different decisions and really different calculations because of some of these changes in H.R. 1.

CW: Is there anything positive that we can look to this year? Is there anything hopeful in any way, anything to be optimistic about on this front?
AMW: Yeah. I mean, when I’m looking for hope, I’m not looking toward anything the government’s doing, but I’m looking toward what the people are doing in response to that. We’ve seen a huge outpouring of support for Medi-Cal and across the country for Medicaid. A lot of people standing up and talking about the importance of Social Security and Medicare, which have been third rails in public policy for a very long time. And shifting the conversation to include Medicaid as one of those core programs is encouraging. It does give me hope that people will continue to fight back and that we can continue to push back and against these cuts and avoid some of the worst impacts of H.R. 1. But even despite that, we still saw every California Republican vote for this, despite giving lip service to the importance of Medi-Cal. And so I think we can’t look to those leaders to save us from the mess that they created. And we have to keep pushing back..