Island health care leaders contemplate a post–Affordable Care Act world

The consensus: Nothing will happen this year, because health care contracts are all in place.

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Sarah Kuh, director of Vineyard Health Care Access, is keeping an eye on possible federal changes to the Affordable Care Act, but does not believe the public will feel the effects this year. — Stacey Rupolo

The Times recently talked to three Island health care leaders — Julie Fay, executive director of Martha’s Vineyard Community Services (MVCS); Sarah Kuh, director of Vineyard Health Care Access; and Joe Woodin, CEO of Martha’s Vineyard Hospital — about what health care on the Island might look like should the Affordable Care Act (ACA) be repealed.

“The bottom line is that it’s going to be really chaotic,” Julie Fay said about the potential effect on her agency and mental health services on Martha’s Vineyard. “When there is chaos in reimbursement, that’s a budget hit for us.”

Ms. Fay said that there are many “tripwires” with coverage of mental or behavioral health. “In the 1990s, it was first carved out of Medicaid,” she said. “It’s not administrated by the state, but subcontracted with an insurance company. Massachusetts Medicaid redoes the carve-out every couple of years.” MVCS clinicians who serve Medicaid clients are kept busy with a credentialing process. “There are a lot of hoops to jump through,” she said.

ACA, popularly known as Obamacare, was accompanied by expansion of Medicaid coverage. According to reporting by the New York Times, as of January 2016, 32 states, including Massachusetts, had expanded Medicaid coverage or were considering it. The result has been lower premiums for those with health care exchange (Obamacare) policies in those states.

Ms. Fay described Community Services as “thinly funded,” and with very little room for fluctuations in reimbursement: “We are really reliant on Sarah Kuh [of Vineyard Health Care Access], who is always working on insurance issues and on getting people signed up.”

Ms. Kuh is keeping her eye on federal elected officials who are promising to dismantle the ACA. “It’s an amazingly complex system,” she said of health care. “We’re unlikely to see anything dramatic happen in 2017.” She explained that the contracts among the companies that provide health care are already in place for the year, and nothing that happens in Washington will change the terms of those contracts.

“Massachusetts has been a standard-bearer for affordable care,” she said, “and we expect that to continue, but the devil is in the details.” Ms. Kuh said that the legislature and the executive branch of the commonwealth are both committed to continuing affordable care, but since 2008 Massachusetts has relied on cooperation with the federal government to make the state system work smoothly. She said she does not expect that in the wake of a dismantling of the ACA.

Chapter 58 of the Acts of 2006, an addition to the General Laws of the commonwealth in that year, served as a model for ACA. After ACA was nicknamed Obamacare, the Massachusetts plan became known as Romneycare, in honor of Massachusetts Governor Mitt Romney, who was one of its biggest supporters. “It was for people who didn’t have access to an employer plan,” said Ms. Kuh. “It’s important on the Island, where there are a lot of small businesses. It helped hugely.”

ACA allows people with moderate incomes to receive a tax credit to offset the premiums for health insurance. “What I fear,” Ms. Kuh said, “is that this is likely to go away.”

She was also worried that the demise of ACA would lead to issues with controlling the cost of premiums. “They have been fairly steady for a long time,” she said, “changing 5 to 10 percent per year, although this year they did jump.”

Increased cost-sharing might be another post-ACA change, Ms. Kuh said: “People will be expected to pay more out of pocket, even with higher premiums.”

The director of Vineyard Health Care Access keeps abreast of changing in her field by following several blogs, including Health Stew (healthstew.com) by John McDonough, professor of public health practice in the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health in Boston, and director of the school’s Center for Executive and Continuing Professional Education. Mr. McDonough is also a former Massachusetts legislator, and one of the crafters of the state health care reform enacted in 2006.

She pulled some numbers from Mr. McDonough’s site: “This is a worst-case scenario,” she said. “He estimates that 370,000 Massachusetts residents would lose coverage [if ACA is eliminated], and the state would lose $1.4 billion in Medicaid.”

Ms. Kuh also keeps tabs on Health Care for All for Massachusetts (hcfama.org), which she described as a policy tracker focused on the federal effect on Massachusetts, and Community Catalyst (communitycatalyst.org), a Boston-based nonprofit with a national focus on achieving affordable health care for all Americans.

One of the changes to health care, Ms. Kuh said, was that hospitals were induced to accept lower rates of reimbursement for patients receiving Medicaid because broader coverage would result in them having more patients.

The Martha’s Vineyard Hospital (MVH) is a critical-access facility. This designation was created by Congress in 1997 after a string of hospital closures in rural areas in the late 1980s and early 1990s. Critical-access hospitals (CAHs) are reimbursed by Medicare for the cost of the health care provided plus 1 percent; most hospitals receive a portion of the actual cost. But they have the same relationship with Medicaid as other hospitals.

“If they cut back,” said MVH CEO Joe Woodin by phone, “some people will stop getting services, and that’s dangerous to the public, and it will correspond to a drop in revenue. We’re not insulated by our critical-access status.”

Mr. Woodin did think, however, that Congress would not cut back on the CAH program itself. “It is entrenched in rural America,” he said, “so there is a lot of Republican support for it.”

The hospital CEO said that he does not take a lot of time to worry about what is happening with ACA. “I try to worry about the amount of time that I worry about the Congress and the new president,” he said. Echoing Ms. Kuh’s statement, Mr. Woodin predicted that it would take a long time for changes to health care to “grind through the system.”

“Health care is embedded in the political process,” Mr. Woodin said. “It will be given thoughtful consideration because it’s health care. [Congress] will posture and seem to say they will change it, but they won’t.”