Weathering the Trump healthcare change-storm

Courtesy of Dreamstime.com Local health care experts say they're bracing for major changes in federal health care policy under the Trump Administration and a Republican-controlled Congress.

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By Laura Finaldi

A Donald Trump presidency and Republican control of Congress will likely mean sweeping changes in healthcare policy across the U.S., but in Massachusetts, state laws that pre-date federal healthcare reform could help prevent major disruptions.

“Until you have an actual proposal, it’s difficult to talk about specific elements,” said Eric Linzer, vice president of public affairs and operations at the Massachusetts Association of Health Plans.

President-elect Trump spent a lot of time on the campaign trail railing against the Affordable Care Act, which was spearheaded and signed into law by President Barack Obama in 2010. The law extended health insurance coverage to millions of Americans, pushed hospitals and doctors towards value-based payment systems, and prevented insurance companies from denying coverage to people based on pre-existing conditions, among other things.

Massachusetts healthcare reform served as a model for what eventually became known as Obamacare. In 2006, the state pushed through comprehensive healthcare legislation that requires most adults 18 years of age and older to purchase health care. In 2015, Massachusetts had a 3.6 percent uninsured rate – the lowest in the country.

Through the Affordable Care Act, the number of people on subsidized plans through the state Health Connector grew from about 124,000 to 181,000. An additional 9,000 people are receiving federal tax credits to pay for their insurance.

Several in the Central Massachusetts healthcare community said the existing state law will shield it from a major upheaval – at least in comparison to other states.

“In Massachusetts, we’ve had nearly universal insurance coverage from our own health reform on which the federal reform was based,” Carrie Wattu, a spokeswoman for Worcester insurer Fallon Health, said in a statement. “Whatever happens at the federal level, we are confident that many key elements of reform will stay in place in Massachusetts.”

Trump backpedals?

Over the course of the presidential campaign, Trump repeatedly called for a repeal of the Affordable Care Act, calling it a “total disaster.” Since his election night victory, however, he has indicated he wants to keep parts of the law, including the pre-existing conditions provision and another that allows young adults to stay on their parents’ health insurance until age 26. But both his campaign and transition website still call for a full repeal.

“There seems to be a lot more clarity around the coverage piece – coverage for pre-existing conditions, coverage for people remaining on their family’s plans on the age of 26,” said Christopher Philbin, vice president for government and community relations at Worcester-based UMass Memorial Health Care. “The president-elect has spoken about those two specific provisions.”

At UMass Memorial, the biggest concern is what Trump and a Republican Congress might do in terms of Medicare and Medicaid reform, Philbin said. More than 60 percent of UMass Memorial’s patients are on either Medicare or Medicaid, he said, so any major changes to either could mean big changes for UMass Memorial, the largest healthcare network in Central Massachusetts. The president-elect’s transition website says he will “modernize” Medicare and “maximize flexibility for states in administering Medicaid,” but offers few specifics.

UMass Memorial braces for ‘dramatic changes’

More specific is a proposal put forth by U.S. Speaker of the House of Representatives Paul Ryan. In his plan, Speaker Ryan proposes per capita allotments of Medicaid funds to the states, with the option of electing block grants. The allotment rate would grow at a slower rate than the one set by current law. Ryan also suggests turning Medicare into a premium support model starting in 2024.

If enacted, this plan could mean big changes for UMass Memorial, Philbin said. A fixed allotment of money to the state is a sharp contrast to the accountable care model that UMass Memorial and others in the region have been moving towards.

“We’ve been preparing for accountable care, so there could be a fair amount of disruption across our entire system,” Philbin said. He said the healthcare network doesn’t expect much change towards accountable care, lowering the cost of care or care coordination in the short term.

Worcester-based Reliant Medical Group, which is also based on accountable care, said it’s too soon to speculate on what a Trump Administration might mean.

Even though there’s no guarantee that the president-elect will go with Ryan’s plan, UMass Memorial is watching closely to see what will happen in Congress’ current lame duck session, and in the first 100 days of a Trump administration, said Philbin.

“We’re certainly bracing ourselves and anticipating there will be dramatic changes to the ACA,” he said.

Uncertainty also surrounds the fate of a Medicaid waiver announced by the state earlier this month. The five-year, $52.4-billion Medicaid waiver moves MassHealth towards accountable care. The waiver, which Gov. Charlie Baker said is the first major overhaul of the MassHealth program in over 20 years, will help maintain the state’s high level of health coverage.

According to the State House News Service, Baker said he expects the waiver will remain intact.

Existing protections

One of the most groundbreaking pieces of Speaker Ryan’s plan calls for the elimination of the individual mandate, which requires people to buy health insurance. While the mandate’s repeal wouldn’t have a huge affect on MassHealth enrollment, it would affect some healthcare providers who, under the ACA, agreed to $155 billion in funding cuts largely because they were promised more patients would have coverage, Philbin said.

Still, the Massachusetts individual mandate will keep enrollment high, Linzer said.

“Massachusetts is probably better positioned than a lot of other states, given that our state’s reform law was the model used for the Affordable Care Act. Many important provisions in the Affordable Care Act, we’ve had those in place in Massachusetts for over a decade,” he said. “We’ve had an individual mandate since 2006, and some of the other provisions have been in state law even longer, even prior to health reform.”

Because of that, healthcare reform in Massachusetts should focus less on coverage, and more on making medical services – surgeries, doctors appointments, and prescription drugs – more affordable, Linzer said.

“In order to make sure that we maintain the significant gains that the state has made around access, the focus needs to be on making health care more affordable for employers and consumers,” he said.