Lebanon
Such changes would put in place a new framework for health care policy in Vermont, where reform has been a long-standing priority for officials and activists, and in New Hampshire, where fiscal restraint generally sets the limits of debate.
But nobody seems to know yet just what that framework will look like.
Trump promised to “repeal and replace with something terrific” the 2010 Affordable Care Act, the reform legislation pushed by the Obama administration that sought to reduce the number of Americans without health insurance.
Daniel Bass, a 63-year-old school bus driver from Pittsfield, Vt., heard Trump on television after the election promise to replace Obamacare with “something better and less expensive.” Bass, who bought health insurance through Vermont Health Connect, the state’s website for shopping for individual policies, said he hopes Trump keeps his word. “I don’t know what people do without insurance.”
So far, Trump has not spelled out what new plan he supports to replace the ACA.
The health care reform plan posted on Trump’s campaign website promises “free market reforms.” It lists but only briefly elaborates on such measures as making it easier for health insurers based in one state to sell policies to consumers in another, allowing individual health insurance premiums to be deducted from income subject to federal taxes, expanding the availability of pre-tax health savings accounts, mandating “price transparency” by doctors and hospitals and allowing consumers to buy prescription drugs from overseas.
Which really isn’t enough to start a conversation, said James Weinstein, the chief executive of Dartmouth-Hitchcock: “Until we have specific details, it’s just words.”
In fact, said Corey Gustafson, a spokesman for Blue Cross Blue Shield of Vermont, so far there is nothing on the table but “a lot of speculation. There isn’t specificity to react to.” To comment now would only “fuel the speculation” that’s already out there, he added.
Recent events have sparked worries for some consumers. “People feel more uncertain than I’ve ever seen them,” said Sandy Singer, who has been a navigator helping Vermonters shop for individual insurance policies since the state launched Vermont Health Connect in 2014. Current emotions range from “anxiety to being outright scared,” she said.
Many women are worried, especially because repeal of the ACA, commonly referred to as Obamacare, could eliminate fully covered access to birth control and other preventive services, according to Victoria Bonney, communications director for the Planned Parenthood New Hampshire Action Fund.
“Since the election, we have seen an unprecedented surge in questions about access to health care and birth control, both online and in our health centers,” Bonney said. Nationally, Planned Parenthood has had “a significant increase in appointments scheduled online for birth control,” she added.
Closer to home, where Republicans replaced Democrats in each of the Twin State governorships, the outlook isn’t as blurry.
Neither Lt. Gov. Phil Scott, the governor-elect in Vermont, nor Executive Councilor Chris Sununu, his New Hampshire counterpart, has signaled an intention to dramatically reverse state health care policies.
Neither made health care a centerpiece issue in his campaign, and each presented himself as a critic prepared to improve the status quo rather than a crusader promising radical change.
Those who crave, or fear, dramatic change in health care policy need only look to Washington, D.C., where the party that sent Trump to the White House also controls both houses of Congress.
Chris Jacobs, a conservative health care policy blogger, said the electoral sweep had left Trump and the Republicans in a place similar “to the dog that finally caught the proverbial car.”
Republicans now face the need to implement their vision despite differences on some fundamental issues including whether the main aim of their Obamacare replacement should be to lower costs or expand coverage, Jacobs wrote.
Both Congress and Trump will have to sign off on any replacement. “Speaker (of the House Paul) Ryan and Mr. Trump thus face a potential squeeze between a Republican political base adamantly opposed to Obamacare, which wants the law repealed — in its entirety, immediately — and the ramifications of doing just that,” Jacobs wrote.
The biggest ramification, according to Jacobs, is the high political cost of taking away health insurance from the estimated 20 million people who have it as a result of ACA mandates, regulations and subsidies. Suspending those subsidies, Jacobs added, could get Trump “blamed for chaos as millions of people lose their plans overnight.”
Last week, Trump promised that he would not repeal the ACA until its replacement was teed up. He also expressed his desire to preserve the ACA’s requirement that insurance companies offer coverage, without premium penalties, to consumers with so-called pre-existing conditions. He also spoke in favor of a provision that allows parents to cover through their policies children up to 26 years old.
Moving beyond those broad policy statements toward a more detailed look at what might replace Obamacare is critical for health care providers and policymakers, said Jeffrey Tieman, president of Vermont Association of Hospitals and Health Systems. “It’s important that we understand precisely what they mean by ‘replace,’ ” he said.
After years of political deadlock that prevented any tinkering or compromises to reduce the complexity or correct flaws in the ACA, even some supporters of the law see some signs for hope on Trump’s list of ideas.
Dana Michalovic, executive director of the Good Neighbor Health Clinic in White River Junction, said the clinic, which was set up to provide care to patients without insurance, had also “tried hard to reach out to people who were deferring care” because of the high ACA premiums and the policies’ high deductibles.
Perhaps allowing sales of health insurance across state lines might not be such a bad idea, she said.
During Vermont’s recent election, the hot button health care issue was Vermont Health Connect, the star-crossed website that the state built for $200 million to allow consumers to shop for the health insurance policies the ACA required them to buy.
“We should have pulled the plug on Vermont Health Connect a couple of years ago,” Scott said during the campaign.
By then, the website had become a political albatross hanging around the neck of Vermont health care reform advocates and Democrats. Some observers pointed to website woes as a major part of the political calculus of Gov. Peter Shumlin’s decisions to abandon the quest for universal, publicly financed health insurance and not seek re-election.
Scott proposed during the campaign that Vermont send its residents in need of individual health insurance to shop elsewhere: either in the Marketplace, the federally operated online exchange that already serves consumers in New Hampshire and 38 other states, or in an online exchange operated by Connecticut or another state.
Daniel Bennett, the new chief executive at Gifford Medical Center in Randolph, said he expects the new governor to think through and weigh carefully any proposed changes. “I think the general statement is that Gov.-elect Scott is taking a look at everything,” Bennett said. “I don’t feel any sense of panic or anything (or that) the rug is going to be pulled out or whatnot.”
Scott campaigned as an advocate for health care reform and a supporter of the existing health care regulatory scheme under which the Green Mountain Care Board reviews insurance premiums and hospital budgets and investments.
That jibes with the position of the state hospital association, which also supports an ongoing role for the state’s main health care regulation panel.
“Phil Scott has expressed an openness to look at all the policy options,” said Tieman, the hospital association president. “We feel we can work with him on making health care better for Vermonters.”
One key issue, according to Tieman, is the all-payer waiver — a deal between the Shumlin and Obama administrations that promised better and cheaper health care by tying the payments to providers to the number of patients cared for and the quality of that care.
Last week, Scott told Vermont Public Radio that he wanted to see the all-player plan go forward. “I hope they don’t pull the plug on something that was worked on, apparently, for a couple of years, and has the support of many,” he said. “I look forward to the possibilities and just trying to make lemonade out of lemons.”
“I think Gov.-elect Scott is generally supportive of the all-payer model,” and the architecture and financial arrangements in the current deal, said Paul Harrington, executive director of the Vermont Medical Society.
But Harrington expressed concern that actions by the Trump administration might affect health care reform including the all-payer deal. That model depends on the continuation of premium subsidies under the ACA, Harrington said, noting that those subsidies had also helped make Vermont’s uninsured rate among the lowest in the country.
Tieman said the hospital association is “still optimistic” about the all-payer model and its prospects for moving forward under the new administrations in Washington and Montpelier.
D-H’s Weinstein, noting the project’s dependence on financial support from the federal government, was more cautious. “I’m hopeful but I’m not as optimistic,” he said. “There’s a lot of federal dollars there.”
Harrington pointed to one positive sign: candidate Trump’s expressions of support for state-led reform efforts, which could signal a willingness to let Vermont’s plan go forward. “It’s unclear what they will do,” Harrington said.
Sununu has yet to chart a clear path for New Hampshire health care policy. His campaign website called for repeal of the ACA but ranked health care fifth on a list of issues (behind the economy, taxes, the opioid epidemic and education).
“New Hampshire is among the healthiest states in the country, but also has some of the highest health care costs,” his campaign website said. “That’s unacceptable.”
The site offered only two policy prescriptions: more competition among hospitals and doctors and opposition to unspecified ACA regulations.
Colin Manning, a spokesman for Anthem Blue Cross Blue Shield of New Hampshire, the state’s largest health insurer, said the company would “remain committed to providing quality (offerings) to the marketplace and delivering value-added products and services to our customers.”
“We’ll work with the new governor like we did with the previous governor,” Manning added.
During the campaign, Sununu spoke out prominently on mental health issues. He criticized the decision of Gov. Maggie Hassan’s administration to award Dartmouth-Hitchcock a contract to provide psychiatric services at the state’s main mental hospital, then voted for the contract, and then called for its revocation and rebidding. Sununu also called for a comprehensive review of the state’s provisions for mental health care.
Weinstein said Sununu’s campaign swipes at D-H, operator of the state’s largest health system and only academic medical center, wouldn’t affect the ability of D-H leadership to work with the new governor. “My obligation is to the patients and their families no matter who sits in the corner office, so to speak,” Weinstein said. “We would never let any of our relationships distract us from that.”
Sununu went on record supporting repeal of the ACA. However, he said he was open to a two-year extension of the 2014 legislation that took advantage of the ACA to expand the eligibility for Medicaid. About 50,000 New Hampshire residents are covered by Medicaid as a result of those changes. Sununu did voice concerns about the future costs of the so-called Medicaid expansion.
Medicaid may be the canary in the coal mine for changes in health policy in the Twin States.
Large populations depend on Medicaid in this region: 174,000 in Vermont and 186,000 in New Hampshire, according to the Kaiser Family Foundation. Medicaid provides health insurance for low-income individuals and families and covers a major portion of the costs of care for nursing home residents and people with addictions or mental illness.
ACA backers have associated the growth in Medicaid coverage with successful efforts to reduce the number of people without any insurance.
But during the campaign, Scott lamented growing enrollment and administrative costs in Vermont’s Medicaid program and said that, by boosting economic growth, the state could “decrease usage in the Medicaid program.”
Medicaid remains important to the state’s hospital operators, said Tieman: “We’re always concerned about any threat to Medicaid.”
The most serious threats to Medicaid are looming in Washington, D.C., where both Trump and Republican leaders in Congress aim to end the federal government’s open-ended commitment to pay a portion of the costs of Medicaid plans administered by the states.
Timothy Jost, a retired law professor and health care blogger who supports the ACA, wrote after the election that replacing Medicaid matching funds with block grants “would shift much of the burden of Medicaid financing to the states.” If the block grant amounts do not rise with costs, he added, “millions of Americans could lose Medicaid coverage.”
But that, like much about health care policy, remains to be seen. All of which leaves Weinstein, as head of the largest and most influential local health care organization, proceeding just as he was before the election because, he said, “I have no other road map to follow right now.”
Contact Rick Jurgens at rjurgens@vnews.com or 603-727-3229.