FILE – In this Oct. 20, 2016 file photo, President Barack Obama speaks about the Affordable Care Act, at Miami Dade College in Miami. President Barack Obama is leaving the White House in just a few months, but his namesake health care law will still be generating headlines. With premiums rising significantly and some insurers bailing out, the 2017 sign-up season that starts Nov. 1, 2106, could get tricky. (AP Photo/Susan Walsh, File)
"… we’ll do what we need to do to make sure that we continue to be a national leader on this irrespective of whatever happens." — Charlie Baker
President-elect Donald Trump and congressional Republicans have pledged to "repeal and replace" the Affordable Care Act, President Barack Obama’s landmark health care overhaul. What would that mean for Massachusetts?
Health care experts say it is too early to tell what the implications are, because Trump and the Republicans have not laid out exactly what they plan to do. Massachusetts is better positioned to withstand changes than many other states because Massachusetts has had its own version of universal health care coverage since 2006. Then-Gov. Mitt Romney’s health care overhaul became the basis for Obama’s national law. However, Massachusetts has had to make significant changes to comply with the national law, and millions of dollars of federal funding is at stake if it is repealed.
"There’s going to be a lot of uncertainty," said Lora Pellegrini, president and CEO of the Massachusetts Association of Health Plans. "We do still have the state law on the books, but how is that going to be financed?"
Health care, in addition to being a budget-buster in Massachusetts, is one of the areas in which the state and federal governments are most closely intertwined.
Medicaid, health insurance for the poor, and Medicare, insurance for the elderly, are joint federal-state programs. MassHealth, the state Medicaid program, costs approximately $15 billion, of which around $9 billion is paid for by the federal government. In early November, state officials received a waiver from the federal government allowing Massachusetts to restructure MassHealth in a five-year, $52.4 billion deal.
State administration officials have said they assume that waiver will remain in effect, although there are no guarantees.
"We’re working off that waiver from this point forward," Gov. Charlie Baker said at a post-election press conference.
Trump, a Republican, has said since the election that he wants to keep some popular provisions of the Affordable Care Act, including prohibiting insurers from denying coverage based on pre-existing conditions and allowing young adults to remain on their parents’ health plans until age 26. Major provisions that could potentially be repealed include the individual mandate requiring that everyone buy health insurance, the mandate requiring employers to offer insurance, the federal subsidies that make insurance affordable for low-income families, the expansion of Medicaid to new groups of people and new taxes on individuals, employers and medical device companies.
There has been talk among Republicans about providing Medicaid funding as "block grants," where each state gets a sum of money to design its own program. Plans previously proposed by Republican leaders would use this strategy to cut Medicaid funding, so states would be faced with the choice of whether to cut eligibility or benefits or use more state money.
Top Massachusetts officials have said they are committed to keeping Massachusetts’ 2006 commitment to providing near-universal coverage.
"The commonwealth of Massachusetts was very far down the road on its own, implementing and supporting what for all intents and purposes was pretty close to universal coverage for everyone in the commonwealth before the ACA," Baker said. "My view on this is it’s a policy statement and policy totem that’s held in very high regard here in the commonwealth, and we’ll do what we need to do to make sure that we continue to be a national leader on this irrespective of whatever happens."
State Sen. Jim Welch, D-West Springfield, co-chair of the Legislature’s Joint Committee on Health Care Financing, said similarly, "My belief is that Massachusetts will continue on the path that we’re on, even if there are changes on the federal level."
Tim Gens, executive vice president and general counsel at the Massachusetts Health and Hospital Association, said all the groups involved in health care in Massachusetts are committed to expanding insurance coverage, providing quality care and addressing costs. "I can say there’s a broad commitment that we will fight to maintain the great programs and coverage that we have right now," Gens said.
Gens said it is too early to know what the federal landscape will look like, but his biggest concern is money. "The funding for coverage in Massachusetts is intertwined, the federal funding and the state funding. Some of it is embedded in ways that I think can be maintained, others may be open for questions," Gens said.
Although Massachusetts already had the basic systems in place before the ACA, such as a health insurance marketplace with subsidies and an individual mandate, significant changes were made to conform with the federal law. Under the ACA, Massachusetts residents earning 300 percent to 400 percent of the poverty level became eligible for federal subsidies to buy insurance. MassHealth was expanded to cover all poor people, not only those who are children, elderly or disabled. Preventative care became covered with no co-pays or deductibles.
Massachusetts also had a years-long struggle to develop a new health insurance exchange that conformed to the federal law.
If the ACA is repealed, "What we’ll have to understand is how do we go from the ACA version back to what was Romneycare before," said Ashley Allen, vice president of sales and marketing for the Springfield-based insurer Health New England. "Until we know exactly what those changes at a federal level are, we won’t understand how difficult it will be."
If federal funding is removed for things like subsidies or the Medicaid expansion, it will be up to state officials to decide whether to roll back those programs or to replace the federal dollars with state money.
"I certainly have real concerns about Medicaid and Medicaid funding coming into our state," said Attorney General Maura Healey, whose office tracks health care costs.
Healey said her office is committed to working with legislative leaders to monitor federal health care policy and be ready for Massachusetts to respond in a way that protects the state’s consumers and health care market.
Stuart Altman, chairman of Massachusetts’ Health Policy Commission, said his biggest concern is what congressional Republicans will push for. He said a budget plan proposed by Republican House Speaker Paul Ryan would have "serious negatives" for Massachusetts. "They’ll cut back on Medicare spending, they’ll cut back on Medicaid spending, and they’ll eliminate subsidies for people who buy insurance, which means our uninsured rate will go up," Altman said. But Altman said his sense is Trump has a more nuanced approach, so he is waiting to see what happens.
David Seltz, executive director of the Health Policy Commission, said the first major signal about the administration’s intentions will be who Trump appoints as Secretary of Health and Human Services.
Like other Massachusetts experts, Seltz said the biggest question will be how the state will maintain coverage for residents if federal funding dries up. "If the federal government is not a partner financially, that will require some difficult decisions at a state level in terms of finding a plan to finance the coverage and maintain that commitment," Seltz said.