The last time Donald Trump was president, his health care policies chipped away at the Affordable Care Act and helped eliminate federal abortion rights, leaving states to fill the gaps. In his second term, experts predict Trump’s agenda to be similar and warn that health care will get more expensive and harder to access for millions of people.

Congressional Republicans, newly empowered by Trump’s victory and the Senate moving to GOP control, have made it clear that they intend to try to implement long-standing conservative goals that include decreasing government spending on health care and further dismantling abortion rights, which are currently protected in about half of the country, including California.

Newly nominated Health Secretary Robert F. Kennedy Jr. has also pushed erroneous claims about vaccine hazards and exaggerated the risks of water fluoridation that could have ripple effects across state public health efforts.

The Democratic supermajority in the California Capitol, however, has spent the past several years passing laws to stymie future conservative administrations on health care, said Mia Bonta, chairperson of the Assembly health committee and a Democrat from Oakland.

Legislators have protected insurance coverage of abortion and transgender care. They have expanded health insurance programs to low-income undocumented immigrants and paid for it with state funds. They have taken pieces of the Affordable Care Act and written it into state law, expanding the enrollment period and banning lifetime limits on coverage. And they’ve invested millions of dollars into public health after the system languished for a decade.

“We were able to be very deliberate in the past several years to Trump-proof our health system moving forward,” Bonta said.

Not all state lawmakers have been happy with California’s health care expansions. Senate Republican Minority Leader Brian Jones, for instance, said public insurance for undocumented immigrants, which as of this year is available to all income-eligible immigrants, is too expensive and should be “delayed or repealed entirely.”

But Democratic lawmakers and health care advocates say they are better prepared than the first time Trump took office — though they expect the new administration to put California’s new laws to the test.

“We have their playbook from 2017, and almost everything they tried to do, California helped stop through our advocacy … or through court cases,” said Rachel Linn Gish, communications director for Health Access California. “In that way we are in a much stronger position than before.”

Affordable health care at risk

During his first term, Trump tried and failed to repeal the Affordable Care Act. He has said for his second term that he has “concepts of a plan” for the program that insures more than 21 million Americans.

Republican lawmakers in general have shifted away from talking about eliminating the program entirely, but some leaders, including Vice President-elect J.D. Vance have suggested changes that would make insurance more expensive. Vance during the campaign said he wanted to increase choices for consumers and “make the health insurance marketplace function a little bit better.”

Eliminating the health insurance marketplace, which is also known as Obamacare, has grown deeply politically unpopular even among Republican constituents. Since Trump’s first term, the number of people enrolled has grown by more than 9 million nationally. That political leverage is something that California advocates believe will help protect the program.

“More people are enrolled in (Affordable Care Act) marketplaces than ever before,” Linn Gish said.

But in many ways the state’s Achilles heel is federal funding. Federal spending on California health care programs is more than three times greater than the state’s share. That’s more than $117 billion from the federal government to support Medi-Cal and the Affordable Care Act compared to $35 billion from California’s general fund for all state health spending, which includes public health, state hospitals and social services.

And much of California’s policies can only be fully realized with sufficient money in the bank.

With the state grappling with a third consecutive deficit next year, the most immediate and likely federal health care cut will be difficult to prevent: financial assistance for middle-class families.

Outgoing President Joe Biden approved two rounds of Affordable Care Act subsidies during his presidency, making assistance available to middle-class families for the first time. Those subsidies will expire at the end of 2025, and Trump and congressional Republicans have signaled that they don’t want to renew them.

Without them, premiums will increase by an average of $1,000 annually for residents with insurance through Covered California, the state’s Affordable Care Act program. Premiums are already set to increase by about 8% next year, and without federal assistance other out-of-pocket costs such as deductibles and copays will most likely spike as well.

Prior to Biden’s push to lower health care premiums, many Californians paid upwards of 18% of their income on health insurance, according to Covered California data. Federal assistance capped that expense at 8.5%.

“You’re talking about a world where we’re doubling how much people pay,” Linn Gish said.

In 2023, California lawmakers established a backstop of state funding to help more people afford health insurance, but those reserves can’t make up the gap if federal funding stops.

Health care for immigrants

Medi-Cal, the state Medicaid program, offers expansive benefits to all low-income individuals regardless of immigration status. The program could face uncomfortable cuts with a less-than-friendly federal administration.

Federal dollars cover about 70% of Medi-Cal’s program costs, while the state invests approximately $30 billion in general fund spending.

“The largest concern many of us have who have worked with our state budget is the resources we will be receiving from the federal government this upcoming year,” said Assemblymember Joaquin Arambula, a Democrat from Fresno who has focused on expansions for undocumented workers. “There are many who are struggling who need their government to help.”

About 7 million more Californians qualified for Medi-Cal after Affordable Care Act rules allowed the state to bump up income limits in 2014, and about 1.8 million undocumented immigrants have gotten Medi-Cal coverage after the state began expanding eligibility for them in 2015.

Some California Republicans have strayed from the party platform when it comes to health care for undocumented immigrants. The Central Valley relies heavily on immigrant labor, and a handful of state Republicans from those communities supported expanded access to health insurance for undocumented residents.

The state GOP, however, still officially opposes coverage for undocumented immigrants and several Republican lawmakers want the state to undo that health care expansion.

Gov. Gavin “Newsom and Democrat lawmakers insist on expanding free health care for illegal immigrants to the tune of $5 billion per year. In the midst of a multi-billion dollar budget deficit, hospitals and maternity wards shutting down, and a massive influx of migrants illegally crossing our open border, we should not be expanding this costly government program,” Jones, a Republican from San Diego said.

Immigrants who came to the United States in their youth and who are protected by the Obama-era program known as Deferred Action for Childhood Arrivals (DACA) for the first time can enroll in Covered California thanks to expanded eligibility under the Biden administration.

Liberal lawmakers and policy advocates hailed the expansions as a long-sought-after victory, but they remain controversial among California Republicans. Many lawmakers and advocates expect these expansions to be challenged over the next four years.

“Anything that has Biden’s fingerprints on it is going to be the first touched. The DACA expansion is going to be high on the list,” Linn Gish said.

This year a bill expanding Covered California to all undocumented immigrants, not just those who came to the U.S. as children, stalled in committee. That measure would have allowed immigrants who make too much money to qualify for Medi-Cal to purchase insurance.

Arambula, who authored the bill, said those populations are “unjustly excluded” from buying insurance at full price even if they want to. He plans on reintroducing the measure, which could be implemented without federal approval.

Family planning and abortion cuts

On the campaign trail Trump took credit for appointing the Supreme Court justices who ended the national right to abortion by overturning Roe vs. Wade, but he said he would not support a national law banning abortion.

Still, California Democrats aren’t taking any chances on abortion rights. They passed more than two dozen laws to protect access to abortion, contraceptives and gender-affirming services in the last three years.

In 2022, voters also protected abortion as a right in the state constitution.

Democratic lawmakers say they have more work to do.

Bonta said she plans on introducing bills to further protect reproductive rights on the first day of the legislative session. Those bills would require hospitals to provide emergency abortions, protect birth control for Medi-Cal recipients and ease the regulation of birth centers. Bonta said lawmakers are working quickly and she expects many of the bills introduced in December to have urgency clauses that allow immediate implementation.

“It’s going to be a huge change within the health care space,” she said.

The first time Trump was president, he also dismantled Title X regulations that fund the federal family planning network by instituting a “gag rule” prohibiting clinics from performing or referring for abortions. The clinics funded have historically provided contraceptives, abortion care, sexually transmitted infection testing and treatment, gynecology services and postpartum care. After the rule change, the number of people served by Title X clinics dropped 60% nationally as a result of clinics exiting the program, according to the Kaiser Family Foundation, an independent health policy research center..

In California the number of people served dropped from 1 million to fewer than 200,000, said Amy Moy, co-CEO of Essential Access Health, which administers the state’s Title X money.

California dedicated $10 million to bridge the gap, but Moy said if there is another federal cut, clinics say to expect longer wait times and fewer providers.

“We will be having to test the bounds of our guardrails and see what we can do here, but we are committed to working with partners and state leaders to do everything possible,” Moy said.

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Supported by the California Health Care Foundation (CHCF), which works to ensure that people have access to the care they need, when they need it, at a price they can afford. Visit www.chcf.org to learn more.

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