This year, BARHII will provide periodic federal policy updates summarizing important federal level decisions and analyzing their predicted cumulative effect on the social determinants of health in our region.  We welcome your feedback on these policy updates.    

Issue (Update): The Affordable Care Act/Prevention Fund:  Following up on January’s Executive Order which allowed the administration to  change, delay or waive parts of the ACA, a proposal (The American Health Care Act, or AHCA) was introduced to replace the ACA, with a vote scheduled for Thursday 3/22.

This plan would cut the Prevention and Public Health Fund—the only dedicated source of federal funding for prevention and a key piece of local public health department budgets. Eliminating the Prevention and Public Health Fund could cost California health agencies over $300 million over the next 5 years and impact key programs such as REACH and the Million Hearts Initiative. See the BARHII’s Prevention and Public Health Fund webpage for a full list of programs affected.

The bill ( as amended Monday, 3/20)  retains some of the provisions of the ACA, such as dependent coverage, a pre-existing conditions policy, essential health benefits and a prohibition on lifetime limits.  However, it would institute sweeping changes, such as repealing mandated coverage; allocating subsidies by age rather than income;  cutting back Medicaid expansion and allowing states to institute work requirements; raising allowed rates for older Americans, and  limiting reproductive health access. The  Congressional Budget Office has estimated that approximately 24 million people would lose coverage under the initial plan by 2026, and 14 million next year alone. The Kaiser Family Foundation has also done some excellent analysis of the plan,  showing growing cost inequities by age, geography and income.

Health Equity Concerns:  The replacement plan currently under consideration would cut $300 million from California health agency prevention budgets, making it far more difficult to sustain critical health department positions dedicated to Policy, Systems and Environmental change.  It would also cause 24 million people (concentrated in older, low-income households) to lose health coverage. 

BARHII Action:  BARHII is tracking the potential funding implications if the Prevention and Public Health fund were repealed. See this page for a list of potentially affected programs.    

Issue (Update): Nullify Housing Discrimination Rule:  As we reported previously, a pair of bills have also been introduced ( S.103,  H.R. 482) to dismantle federal anti-discrimination regulations (the Affirmatively Furthering Fair Housing regulation), and eliminate federal funding for data collection and analysis related to racial disparities in health, education, and other areas. Partially in response, S.B. 686 has been introduced in California to establish a foundation for statewide efforts to end discriminatory housing policy. See BARHII’s Fair Housing General Meeting Panel Videos for more information on this topic.  

Health Equity Concerns: If passed ( S.103,  H.R. 482) would make it more difficult for local governments to address housing discrimination, exacerbating already stark inequities in health conditions and life expectancy. Ending federal support for racially disaggregated data would also make it more difficult for public health departments to identify health inequities, as well as inequities in the social determinants of health—making it harder to target effective interventions and evaluate progress. By contrast, California’s S.B. 686 would provide communities and agencies with tools to counter housing discrimination and its accompanying health impacts. 

BARHII Action: This past Friday, BARHII hosted a meeting and webinar featuring national experts on this topic. See the recordings here ( Framing by Will Dominie; Sarita Turner of PolicyLink; Renee Williams of the National Housing Law Project).  The BARHII Policy Committee is tracking these bills and considering them for our 2017 legislative priorities. For more information, or to participate in BARHII’s Policy Committee, contact [email protected].

Issue: Preliminary Budget Zeros Out Housing Programs: Leaked budget documents consider over $6 billion in cuts to key housing and community development programs at the Department of Housing and Urban Development (HUD). While these cuts are unlikely to survive congressional budget negotiations, they are nonetheless an indicator of potential reductions ahead. Proposed cuts include $2 billion from Public Housing, $4 billion in community planning and redevelopment grants (including the Community Development Block Grant program, a key tool used by local government to upgrade neighborhoods and housing conditions), and over $300 million in Section 8 and other rental assistance programs. 

Health Equity Concerns:  Affordable, stable, quality housing and neighborhoods are essential for good health. If passed, cuts to these programs would undermine efforts to improve housing and community conditions, forcing residents to make unhealthy trade-offs to pay for housing, accept unhealthy conditions, or face displacement and/or homelessness. 

BARHII Action: The BARHII Policy Committee and Staff is tracking the development of the 2017 budget and will provide updates as they occur. For more information, or to participate in BARHII’s Policy Committee, contact  [email protected]. 

Issue: Voting Rights:  The Federal Department of Justice (DOJ) has reversed its support for a closely watched legal case challenging Texas’ alleged voter suppression. The DOJ had previously contended that Texas’ voter identification law was intended to discriminate against African Americans’ votes. By removing their legal support, the federal government weakens the case, increasing the chance that the Texas law will set precedent for other laws that suppress voter turnout in communities of color. 

Health Equity Concerns: Evidence shows that voter ID laws disproportionately impact Black and Latino voters, limiting their voices in government decisions that shape, investments, policies, healthcare, housing, economic opportunity and other social determinants of health, and perpetuating long-standing inequities in power and health. 

Issue: Police Oversight:  The Department of Justice has also signaled that it will back away from monitoring police agencies with civil rights abuses. The DOJ has historically used monitoring—coupled with enforced reforms—to challenge civil rights abuses and, discriminatory policing and excessive use of force. The DOJ has investigated California departments from Oakland to Orange County. 

Health Equity Concerns:  Over 1,000 deaths and 100,000 law enforcement related hospitalizations are reported annually, with impacts concentrated in communities of color, low-income communities, people with disabilities and LGBTQ people. These populations also face disproportionate rates of incarceration. Removal of Federal oversight could exacerbate these numbers.  

BARHII Actions:  BARHII’s Social Determinants of Health/Structural Racism committee has completed its course of study on the Movement for Black Lives Policy Platform and integrated community safety and policing into the updated BARHII policy platform.  In the Spring, BARHII will be hosting a general meeting on community safety, trauma, and public health and beginning the development of a brief on the issue. Please contact [email protected] for more information. 

Issue: Legal Protections for Transgender Students:  The administration has withdrawn an Obama-era rule that required schools to allow transgender students to use the bathroom of their choice. Schools must still protect transgender students from bullying, but may pass policies to limit transgender bathroom access.  So far this year, 15 states have considered so-called “bathroom bills” to prohibit transgender people from using the bathroom of their choice. 

Health Equity Concerns:  School policies that force transgender people to use bathrooms that do not correspond to their gender reinforce transphobia and its corresponding health impacts. The National Transgender Discrimination Survey found that 78% of transgender K-12 students have faced harassment, 35% have been physically assaulted, and 12% experienced sexual violence.    

Issue (Update): Deportation, Fear, and Confusion:  As of March 15th, federal judges in Hawaii and Maryland have once again blocked key pieces of the administration’s revised, narrower executive order to prohibit immigration from predominantly Muslim countries. The administration is extremely likely to challenge this ruling, and conditions remain uncertain for many immigrants and refugees. 

Health Equity Concerns:  This order, and the three that preceded it, sparked fear and confusion for refugees and immigrants, which past studies have linked to  post-traumatic stress syndrome in children,  low birth weights and other health conditions.

BARHII Action:  The BARHII Policy Committee and Staff are tracking a number of bills to protect California immigrants and refugees in Sacramento and will be identifying bills to support in the next month. For more information, or to participate in BARHII’s Policy Committee, contact [email protected]. Additionally, the Internal Capacity Committee is assisting the ACLU in developing an immigration handbook for clinics, and the Social Determinants of Health/Structural Racism Committee is sharing lessons about rapid response network. For more information, or to participate, contact [email protected].

Issue (Update): Program Utilization:  We have continued to hear from member health departments about clients dropping out or not enrolling in Women and Infants with Children (WIC), CalFresh, and other programs that help ensure adequate health and nutrition.  There appears be a chilling effect of accessing services due to proposed immigration policies and feared repercussions. 

Health Equity Concerns:  Fear of deportation  inhibits critical, health supportive behaviors like attending medical appointments or enrolling in public services. 

BARHII Action: The BARHII Data Committee, in collaboration with the Public Health Alliance of Southern California and Dr. Neil Maizlish, are working to quantify a post-election trend from utilization data, as well as surveying health care and service providers to assess qualitative trends. If you are interested in learning more, please contact [email protected]. 

Issue (Update): Repercussions for Welcoming Places and/or Sanctuary Cities:  Despite the January executive order threatening funding to sanctuary cities, governments have continued to enact a wide range of protections for immigrant populations. The list of sanctuary cities continue to grow ( including Freemont last week) and the State Senate is considering an initiative (SB 54) which would move the entire state towards sanctuary status. Other local jurisdictions, like San Mateo County and Napa County have not become sanctuaries, but have passed or are considering resolutions to clarify their acceptance of immigrants. While the fear of pulled funding remains, analyses for California continue to hold that the Federal government cannot legally withhold health funding or funding for other non-law enforcement programs, and local governments and have filed suit to block the Executive Order’s implementation .

Health Equity Concerns:  Complying with this executive order could  inhibit critical, health supportive behaviors like attending medical appointments or enrolling in public services. For jurisdictions that do not comply, the federal government could try to withhold part of the $8 billion a year in federal funds that flow to California local governments. Cuts to these funds could jeopardize public services, public health prevention and healthcare.   

BARHII Action:  The BARHII Policy Committee is sharing analysis of these threats—as well as the broader range of federal and state policies related to immigration including California’s sanctuary legislation (SB 54). Three BARHII jurisdictions have also filed legal challenges to this proposed threat to funding. For more information, or to participate in BARHII’s Policy Committee, contact [email protected].  
 

Issue: National Budget Cuts for Health, Environmental Protection, Transportation, Housing, Food, and Other Essential Functions: The executive branch released its draft 2018 budget outline on March 16th, proposing a $54 billion increase in defense spending (including a $4 billion border wall), and a corresponding $54 billion decrease in other programs.  It should be noted that this budget represents a policy outline and the beginning of a bargaining process. Congress is responsible for setting budget levels.
Among the proposed cuts are an 18% reduction of Health and Human Services’ budget. Although it provides little detail, the budget does propose restructuring the CDC budget to move responsibility and funding from federal to state programs and the elimination of $403 million in health professional training. The budget does not address Medicaid, Medicare, or other entitlement programs.  The budget also cuts many programs related to the social determinants of health, abolishing 19 agencies and including a 31% cut to the EPA (including climate change programs, the Clean Power Plan, environmental justice and pollution enforcement), a 21% cut to the Department of Agriculture, and a 13% cut to the Department of Transportation (including transit capital programs). See here for a more detailed breakdown by agency, and for more details on potential cuts to housing programs, see the housing section above. 

Health Equity Concerns:  If adopted, these proposed cuts would impact health equity most directly by eliminating federal support for essential health and public health programs. Cuts to environmental programs could accelerate the health impacts of climate change, remove support for environmental justice communities, and in the words of Judith Enck, former regional EPA administrator, “it will literally make people sick” by allowing polluted air and water. Cuts to other programs related to the social determinants of health would also have far-reaching health equity implications. Overall, the proposed budget is likely to make it much more difficult for government institutions to provide effective care, services, and protections—with impacts disproportionally concentrated in low-income communities and communities of color. 

BARHII Action: BARHII Staff will be monitoring this issue closely and providing updates as they occur. For more information, contact [email protected].   

Issue: Health and Safety Regulations:  The Senate Homeland Security and Government Affairs Committee are considering a trio of bills designed to dismantle federal regulations including those related to public health and safety. The Regulations From The Executive In Need of Scrutiny Act (REINS Act) would require Congress to approve all future Federal regulations, including those related to food safety and pollution. The  Midnight Rules Relief Act would make it easier for Congress to dismantle regulations passed during the last administration, including pollution standards for heavy trucks. The Regulatory Accountability Act makes it far more difficult to pass new regulations, and forces agencies to make rules based on costs to industry rather than potential threats to public health and safety. These bills have passed the House and are awaiting consideration in the Senate. 

Health Equity Concerns: These bills would make it difficult for federal agencies to pass and update regulations, including those that are designed to protect public health, safety, and environmental quality. 

The Bottom-line for Health Equity: Taken together, the policies above comprise an evolving threat to this charge. Reductions to healthcare coverage, health and public health funding, and program utilization will make it more difficult to advance prevention and keep people healthy. Other critical government functions may see significant challenges, potentially operating with diminished budgets and power to enforce health protective regulations. Finally, immigrants, refugees, people of color, LGBTQ people and others face increased fear, discrimination and loss of political power and agency. While these impacts will make it more difficult, California’s local health departments will continue to fulfill their mission to protect the health of all residents—particularly those facing health inequities.