Two weeks ago, Gov. Peter Shumlin inked a deal with the federal government that could transform the health care landscape in Vermont. But the election of Donald Trump on Tuesday could topple some of the reform initiatives that the Shumlin team has spent six years building.
Two weeks ago, on a swing through Florida, Republican Donald Trump won cheers from the crowd with one the more frequently repeated pledges of his campaign.
“Repealing Obamacare and stopping Hillary’s health care takeover is one of the single-most important reasons that we must win on Nov. 8,” Trump said.
The message played well in Florida. And North Carolina. And Michigan. And Wisconsin. And all the other states Trump won en route to his surprising victory in the presidential election. And for state officials on the front lines of the health care system in Vermont, the prospect of Trump following through on his pledge to repeal Obamacare is somewhat difficult to comprehend.
“You’re talking about losing all of the subsidies, you’re talking about losing the Medicaid expansion, you’re talking about tens of millions of Americans and tens of thousands of Vermonters losing the affordable coverage they’ve got today,” says Lawrence Miller, chief of health care reform for the Shumlin administration.
Vermont has embraced the federal Affordable Care Act more tightly than most states. Miller credits the law for bringing tens of millions of new federal dollars into Vermont. And he says it’s the reason Vermont now has the second-lowest rate of uninsured residents in the nation.
As goes Obamacare, according to Miller, so goes the federal money propping up private insurance subsidies, and a Medicaid expansion that has brought thousands of lower-income Vermonters onto the rolls.
“So if we were to try to retain that, the governor-elect and the Legislature would be facing some very, very significant challenges,” Miller says. “It’s very hard to imagine that that would be possible.”
There’s also the matter of the so-called all-payer contract that the Shumlin administration entered into last month with the U.S. Department of Health and Human Services. The contract allows Vermont to use federal Medicare dollars in ways that advance a payment-reform initiative that replaces the fee-for-service model with one that compensates providers based on patient outcomes.
The state or the feds have 180 days to pull out from the deal.
Miller says it’s true the contract is the product of a deal between a Democratic governor and a Democratic presidential administration.
“But I do think there’s a lot of compelling aspects of the model, regardless of where you are on the political spectrum,” Miller says.
Even if the model remains in place though, its success is in some ways predicated on the structural elements put in place by the ACA.
“The Center for Medicare and Medicaid Services basically oversees an innovation division that was created by the Affordable Care Act,” says Al Gobeille, chairman of the Green Mountain Care Board, a five-person panel that regulates the health care system in Vermont. "If the Affordable Care Act was repealed, you’d think they would go away.”
Gobeille, however, is optimistic that the fiery rhetoric Trump’s campaign might not be borne out in policy.
“And sometimes when folks actually become elected, they tend to see the big picture, and maybe are not as hasteful or as quick in their solutions when they actually have to practically apply them,” Gobeille says.
Miller agrees. Sure, the Republican-led Congress has already voted to repeal Obamacare – it was vetoed by Barack Obama. But, he says, “I have to believe that those people who vote that package when they knew it wouldn’t be signed have to think differently about voting that package when they know the collateral damage to their constituents.”
Governor-elect Phil Scott will oversee health care in Vermont under the administration of president-elect Trump. Scott says he’s taking a wait-and-see approach to what the coming months bring.
“But I look forward to working with the administration in any way we can to make sure Vermont is put up in the front,” Scott says.
Scott vowed on the gubernatorial campaign trail to disband Vermont Health Connect, and move to a regional or federal health insurance exchange. If Trump dismantles Obamacare, however, the exchange might not even exist.
Scott has also voiced skepticism about the all-payer model. He says he’ll make a determination about whether to proceed with that contract in the coming months – unless of course Trump makes his decision for him by nullifying the deal.
“Well first of all, we’re going to have to have a better understanding of what’s in there, what it means for Vermont,” Scott says.
Trump says the repeal of Obamacare will save money. Miller argues that taxpayers will end up footing the bill one way or another.
“People wind up from switching from showing up in primary care to showing up in the emergency room,” Miller says. “We can’t have that happen.”
Gobeille says some version payment reform in Vermont will proceed no matter what happens in Washington.