Anxiety grips county’s federal health care enrollees

Island healthcare leader sees relief ahead in Senate.

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

Consternation over the recent U.S. House of Representatives Affordable Care Act revamp, the American Healthcare Act, has resulted in a tide of nervous inquiries during Islander appointments at the county’s marketplace navigator, the Vineyard Health Care Access Program.

Islanders are concerned about premium hikes, benefit curtailment, and the dilution or elimination of protection for their preexisting conditions. While Vineyard Health Care Access Program director Sarah Kuh shares some of those concerns, she said alterations to the popular pre-existing-conditions portion of the Affordable Care Act, known also as Obamacare, aren’t likely to affect Bay Staters as adversely as they might the rest of the nation. In an Interview with The Times, Ms. Kuh said the commonwealth long ago prohibited insurance termination because of preexisting medical conditions.

In a subsequent interview, an office colleague of Ms. Kuh’s further emphasized this. “Before the Affordable Care Act, Massachusetts already had a law in place that insurance couldn’t discriminate based on pre-existing conditions,” Mary Leddy, assistant director of the Vineyard Health Care Access Program, said. “So it wasn’t a problem in this state. People could get insurance. So even if they repeal the Affordable Care Act and that’s no longer a protection, Massachusetts already has that in place.”

Because federal law can trump state law in unexpected ways, and because federal healthcare funding to the state may be radically altered, neither of the Island program officials ventured that Massachusetts law was foolproof against the erosion of pre-existing conditions integrity, though both expressed confidence about the vitality of the state’s provision. However, Ms. Kuh cautioned that the revised health care act in its current form is forecast to be a gigantic blow to the state’s healthcare capacity, with or without factoring in pre-existing conditions statutes.

“The governor said that we could take a hit of a billion dollars a year. That’s just not something that is easily absorbed,” she said.

The State House News Service reported that older incarnations of the bill were estimated by Governor Charlie Baker to cost double that amount.

Ms. Kuh said Island families and individuals who depend on Affordable Care Act benefits via the commonwealth are worried. “People feel very vulnerable,” she said.

Ms. Kuh is paying close attention to whether congressional legislation will ultimately focus on block grants and per capita caps for Medicaid: “Each of those has enormous implications for the state budget.”

According to Ms. Kuh, current Medicaid funding allows for open-ended enrollment, meaning that as many people on-Island or in-state who qualify can enroll for coverage. State-wide, she said, this enrollment feature has translated into big percentages.

“We have an enormous number of people [enrolled]. It’s actually amazing to me. Something close to one in four people in the state — remarkable benefits from the current Medicaid — MassHealth program. Even though I live and breathe this stuff, I still find that to be a huge number.”

But when set against the current House bill, Ms. Kuh sees the enrollment capacity Massachusetts enjoys in a potentially precarious spot. Likewise, the current tax-credit scheme that subsidizes plans and the low- or no-deductible coverage many Islanders enjoy appear jeopardized by the same bill. But Ms. Kuh cautioned against fretting over elements of inchoate legislation.

“First of all, I think a lot of people understand that that was just one vote and one terrible piece of legislation,” she said. “It is not going to be the same piece of legislation, even if it does pass the Senate. The Senate has different responsibilities [from the House]. For one thing, they have to look at the cost, and they have to have a CBO [Congressional Budget Office] analysis in order to form their policy.”

Ms. Kuh said that she and her colleagues, like so many Islanders with a stake in the outcome, are in vigil mode.

“We’re waiting. We don’t know,” she said. “We don’t expect anything quite as devastating as the House version to pass in the Senate.”

Whatever comes out of Washington, Ms. Kuh said she is confident that the commonwealth and its partners continue to formulate and game out different mechanisms in anticipation of new laws.

“I know there are people working pretty seriously on contingencies,” she said. “There’s such a strong commitment here: the governor’s office, the hospital association, the community health center association — a lot of brilliant analysts are working out different scenarios of how to maximize people’s coverage in the event of a big change.”

Vineyard Health Care Access Program was created in 1999 by the Dukes County Healthcare Council. According to Ms. Kuh, 75 percent of its funding comes from the six Island towns. Dukes County supports it administratively and furnishes it with its Oak Bluffs building. The remaining funding comes from grants, the Massachusetts Health Connector, from local groups and donors, and from the Blue Cross and Blue Shield of Massachusetts Foundation. “Believe it or not, they’ve [Blue Cross] funded us for 15 years consecutively. It’s a remarkable partnership. The foundation is a very strong advocacy organization for people who are uninsured and underinsured.”

The longtime director believes that the days of Vineyard Health Care Access Program past may hint at what’s potentially next.

“Back when I started doing this in the early 2000s, people had far fewer benefits, and certain benefits would come and go sort of like a Ping-Pong ball, depending on the budget. For example, sometimes MassHealth had dental coverage, sometimes they didn’t. Sometimes it included minimum services, other times the services were more,” she said. “There are ways to try to provide as much coverage as possible with less, but it won’t be the same.”

What more does she see in the tea leaves? “Fewer people will probably have benefits, and the benefits will probably be reduced, and they will probably be more expensive.”

That said, she doesn’t see worse prospects ahead: “I think it’s unlikely that this draconian law, as it came out of the House, is likely to become the law of the land. Even if there are changes to the Affordable Care Act, or if it’s replaced, Massachusetts has a super-strong commitment to providing as much coverage as possible to people. It is my sincerest hope that the Vineyard Health Care Access Program, as part of Dukes County, will remain to be able to help people with whatever system and policies and programs are in place after changes are made.”

In a recent statement to The Times, State Representative Dylan Fernandes described the U.S. House proposal as “an enormous step backward from the progress achieved under the Affordable Care Act.” Mr. Fernandes also said, “It is a giant tax cut for the rich masquerading as healthcare reform.”

In an email to The Times, Mr. Fernandes confirmed that Massachusetts forbids discrimination and payer increases based on pre-existing conditions but cautioned that Washington could undercut these safeguards.

Mr. Fernandes said Massachusetts is “not fully insulated from federal policy.” He added, “Should

the Senate choose to allow insurance sales across state lines, we could be at the mercy of other states with looser regulations.”