President-elect Donald Trump has vowed that he will repeal and replace Obamacare. Specifics are scarce, but one plan Trump has outlined would change how the federal government funds Medicaid, health coverage for low-income people.

Twenty-million Americans now have health coverage because of Obamacare. A full quarter of them are in California. And most of them are covered by Medi-Cal, California’s version of Medicaid.

“Winding back the clock would create all kinds of turbulence and disruption,” says Larry Levitt, senior vice president for special initiatives at the Kaiser Family Foundation.

Right now, the federal government shares the cost of Medicaid with the states, no matter how many people are enrolled. But Trump wants to put a limit on that funding and give states a fixed pot of money called a block grant.

“A block grant would give California greater flexibility in running the Medi-Cal program, but it would also give the state less money,” Levitt says.

California would feel the pain more than other states. “The effect is magnified in California in part because the state has been so successful in getting people signed up for coverage,” Levitt says.

And in California, 62 percent of Medi-Cal enrollees who have signed up since Obamacare allowed states to expand Medicaid are Latino, African-American, or Asian-American.

To save money, some states could pay doctors and hospitals less. But in California, payment rates are already the second lowest in the country.

“California can’t really pay much less than it does to providers,” says Gerald Kominski, a professor of health at the University of California, Los Angeles.

In the face of severe budget cuts, Kominski says, the only choice California really would have is to reduce services or reduce the number of people who get Medi-Cal.

“That would have a devastating consequence on the Medicaid expansion population in California, and would basically put everyone who’s been newly enrolled in the program back off the program,” he says.

It’s unclear how soon a Trump administration would change Medicaid funding, so health advocates are encouraging people to continue signing up for Medicaid and other coverage during the current Obamacare open enrollment season.

“California is not an island,” says Anthony Wright, executive director of Health Access, an advocacy group, adding that the state “must engage fully in the coming national debate on the future of health reform — especially as an example of what has been achieved, and what we can’t give up.”

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News, which is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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The number of cigarette smokers in the United States has dropped by 8.6 million since 2005 — and that fall could be accelerated by a tobacco tax just passed in California.

The Centers for Disease Control and Prevention says smoking rates have fallen from 21 percent of the adult population in 2005 to 15 percent in 2015, when the agency conducted its latest survey. The smoking rate fell by 1.7 percentage points between 2014 and 2015 alone — a substantial decline, according to a report Thursday in Morbidity and Mortality Weekly Report.

The proportion of cigarette smokers in the U.S. population, broken down by age, in 2005 and 2015. CDC hide caption

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CDC

Smokers light up less when cigarettes are more expensive. So, more smokers may have been nudged to quit after the federal government increased tobacco taxes by 62 cents a pack in 2009. California voters approved a $2 a pack tax on Election Day, so rates there are likely to fall further.

“Raising the tobacco tax is probably the single most effective way to reduce smoking, especially among kids,” says Vincent Willmore, vice president for communication at the Center for Tobacco Free Kids. That organization and other public health advocates pressed for passage of the California tobacco tax. “The California vote was a huge victory for kids and health,” he says.

The tax will not only discourage people from purchasing cigarettes, it will also fund a renewed anti-smoking effort in the state, Willmore says.

While that initiative won, tobacco control advocates lost similar efforts in Colorado and North Dakota.

The story was topsy-turvy in Missouri, where the tobacco industry actually supported a 17-cent-per-pack tax, while advocates opposed it as too little to discourage smoking. Voters in Missouri rejected that tax.

Tobacco is the leading preventable cause of death in the United States. The CDC says it’s linked to 40 percent of all cancer cases, and 30 percent of cancer deaths. The government is striving to reduce smoking rates to 12 percent of the adult population by the year 2020, and is making progress toward that goal.

The latest drop in smoking rates was documented in the National Health Interview Study, which relies on people meeting face-to-face with survey-takers and reporting their habits. The 1.7 percentage-point drop between 2014 and 2015 is especially sharp, but it follows a recent downward trend.

In addition to the higher federal cigarette tax, there have been several national stop-smoking campaigns, such as The Truth. The Affordable Care Act has also increased access to smoking-cessation programs.

Progress nationally is uneven. The CDC’s new report notes that smoking rates are lowest in the West, even though taxes are higher elsewhere. They are highest in the Midwest.

Smoking is more common among men, and among American Indian/Native Alaskans. Smoking rates are low among Asians and people with college degrees.

Another trend has paralleled the recent decrease in cigarette smoking: Vaping has taken off in the United States. That has led some researchers to wonder whether some of the decline in cigarette use is a result of people switching to these vaping devices. At this point, there’s no data to show how much vaping is contributing to the downward trend in smoking.

E-cigarettes certainly aren’t a panacea. About 60 percent of adult people who use them also smoke cigarettes. Vaping also provides users with addictive nicotine doses. And public health officials are concerned that some youngsters who start vaping will then become smokers.

You can contact Richard Harris with comments: rharris@npr.org.

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