Officials overseeing Marin County’s health and social services programs are nervously awaiting possible changes under the coming Trump administration.
Marin County receives about $100 million a year from the federal government and millions more through state pass-throughs to fund such programs as Medi-Cal and CalFresh, the state’s food stamp program.
“Probably our biggest vulnerabilities are significant federal adjustments to health and human services,” said Marin County Executive Derek Johnson.
A staff report prepared for county supervisors in December 2017, about a year into Trump’s first presidential term, stated: “Federal threats to several board priorities remain with continued efforts to repeal or weaken the Affordable Care Act; to turn over Medicaid (Medi-Cal in California) to the states or to convert Medicare to a voucher system with less federal funding.”
During Trump’s first presidency, county supervisors focused their legislative lobbying efforts on supporting the Affordable Care Act; protecting the rights of immigrants and opposing mass deportations; protecting federal funding for public housing grants and Section 8 housing vouchers; and preserving and enhancing efforts to mitigate climate change.
Johnson is reluctant to speculate on what changes might be in the offing during the second Trump term.
“It’s tough to predict what will happen after the new administration takes over,” Johnson said. “What was said on the campaign trail and what actually materializes into policies and actions, I think, are two different things.”
“We need to stay vigilant and watchful and work with our partners at the state and regional and local levels, ensuring that we meet the needs of Marin County residents,” he said. “We can’t be driven by speculation, innuendo or rumor.”
Nevertheless, Johnson said his second biggest concern is whether Trump’s election will affect federal disaster response in communities that didn’t vote for him.
“We rely heavily on our state and federal partners in times of disaster,” Johnson said.
It has been widely reported that Trump initially contemplated declining federal aid to California following devastating wildfires in 2018, but he changed his mind after being reminded of the large number of registered Republican voters in Orange County.
“So I’m hoping that everyone continues to remember that we’re one country,” Johnson said.
He said the county is still waiting to be reimbursed by the Federal Emergency Management Agency for expenditures from past disasters as well as the COVID-19 pandemic.
The state’s Medi-Cal coverage has been expanded significantly over the last 10 years. Undocumented residents of all ages are now eligible.
Under a new program, California Advancing and Innovating Medi-Cal, known as CalAIM, the state has also broadened Medi-Cal’s mandate to include non-clinical services that recognize social determinants of health, such as access to housing and healthy food.
The state received a waiver from the federal Centers for Medicare and Medicaid Services (CMMS) to initiate the CalAIM program.
Talia Smith, the county’s legislative director, said, “We are concerned that under a Trump administration there may not be the same approvals by the CMMS board that we’ve seen in the last four years for certain Medi-Cal expansions.”
Even if Kamala Harris had won the election, the revenue stream for Medi-Cal was likely to suffer a significant setback because of the passage of Prop. 35 on Nov. 5. The proposition ensures that revenue generated by a state tax on managed care organizations is spent to increase the wages of Medi-Cal providers.
The federal government matches every dollar raised by the tax, which amounts to an estimated $7 billion to $8 billion annually.
Late last year, however, the Centers for Medicare and Medicaid Services gave notice that it intends to close a loophole that has allowed the state to collect most of the tax from Medi-Cal plans and only a tiny percentage from commercial insurers.
If the CMMS follows through on this threat, it means that the amount of tax on managed care organizations the state will be able to collect will be reduced by billions of dollars a year. That is because Prop. 35 caps the tax on commercial insurers at a very low rate.
Kathie Powell, interim chief executive officer of Marin Community Clinics, said she isn’t overly concerned regarding impacts to Marin’s largest federally-qualified health center, which serves the county’s uninsured and low-income residents. Marin Community Clinics receives a $3 million grant annually from the federal government.
“I’ve enjoyed good relationships with administrators regardless of which side of the aisle they’re on,” said Powell, who headed the Petaluma Health Center for over two decades before coming out of retirement in September to manage Marin Community Clinics until it hires a longer-term chief executive officer.
“Health centers received a significant amount of funding to grow during the first Trump administration,” Powell said.
She said federally-qualified health centers have enjoyed bipartisan support because they provide health care at a very low cost.
“We generally don’t prescribe really expensive medications,” Powell said, “and we don’t refer out to specialists unless it’s really necessary.”
Powell said what concerns her most is the chilling effect the Trump administration might have on some of Marin Community Clinics’ patients.
“There are patients, legal immigrants to this country, who may be afraid to come in the door because of potential raids,” Powell said.
Powell said that while immigration raids have happened at health centers in the past, they are rare occurrences. She said that during his first administration, Trump did not rescind a government policy that designated health care facilities as sensitive locations.
In February 2020, the Trump administration enacted a rule that denied green cards, permanent legal status, to immigrants who were judged likely to require public benefits such as Medicaid, housing vouchers or food stamps. The practice discouraged some immigrants from seeking public benefits, and the Biden administration ended the practice in 2021.
Janna Barkin, a Marin advocate for parents and families of transgender youths, said, “I am extremely concerned about what a Trump administration and its policies could mean, especially for transgender rights.”
“Eliminating the ability for people to access gender-affirming care is on the agenda,” said Barkin, who has a transgender son. “So a transgender man who needs testosterone might be eliminated from a program like Medicare.”
She said the transgender community is also concerned about possible changes in the law that would make altering the gender marker on birth certificates or drivers’ licenses more difficult. In California, changes can be made to both without a court order or medical certification.
In addition, Barkin said, “I’m hopeful that California is going to continue to be a sanctuary state. We’ll see.”
In 2022, Gov. Gavin Newsom made California the first state in the nation to create a sanctuary for transgender youths seeking medications to suppress puberty changes or surgery to alter their gender appearance.
Barkin said she recently spoke at a gender identity training conducted by the Novato Unified School District to instruct teachers in how to be allies.
“The Trump administration is threatening that if a school respects the needs of transgender students, by allowing them to use their correct gender marker or use the bathroom that corresponds to their gender identification, that they will be subject to losing federal funding,” Barkin said.
Nicola Pitchford, the president of Dominican University of California in San Rafael, said, “Our faculty and staff will continue to be offered ‘Safe Zone’ training as part of an initiative developed several years ago by our Office of Diversity, Equity, and Inclusion and the University’s Diversity Action Group.”
Pitchford said the “intensive” training prepares faculty and staff to serve as role models for inclusivity.
Sarah Nagle, a Trump supporter who lives in Novato, thinks much of the talk about what the president-elect will do amounts to fear mongering.
Nagle said Marin residents should be worrying instead about the dearth of physicians in the county.
“We live in an area where younger doctors don’t want to move to because they can’t buy a house here and pay off their medical school debt,” Nagle said. “So we’re facing a demographic winter in Marin with an aging population and a shrinking number of practicing physicians.”
As for Trump threatening Obamacare, Nagle said, “I don’t think Obamacare has been a success. OK, great, more people have insurance, but it’s almost impossible to find a doctor in network. This doesn’t really seem like an improvement if you have insurance, but you can’t actually get an appointment with a doctor for some basic issue.”
Francis Drouillard, a Marin Republican Party central committee member, said, “I don’t think Trump is going to make significant changes to Obamacare. He said he’s not going to. He said that he’s going to look at it and see if he can improve it.”
As for the possibility of Trump making Robert Kennedy Jr. his secretary of the Department of Health and Human Services, Drouillard said, “I’m all on board with Kennedy trying to clean up the Federal Drug Administration. I believe him when he says he’s not anti-vax; he’s anti-untested vax or inadequately tested vax. Yeah, let’s make America healthy again.”
