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Evan Horowitz | Quick Study

Massachusetts immune to Trump health care changes? Think again.

President-elect Donald Trump.
President-elect Donald Trump.(Evan Vucci/Associated Press)

Maybe you think the whole kerfuffle about repealing the Affordable Care Act doesn’t matter here in Massachusetts. Even if Congress decides to dismantle the program, we in Massachusetts can simply revert to the old home-grown approach introduced under Governor Mitt Romney. Right?

Maybe not. That Romney-era system was actually powered by federal dollars. And with congressional Republicans looking to reduce government spending on health care, it could be tough for Massachusetts to secure the same kind of support.

So while we might have a workable health care plan just sitting on the shelf, it’s not clear we could afford it on our own. That could mean big cracks in the state health care system and more uninsured residents.

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Romney’s plan: Made in Mass., funded in D.C.

It’s just not true that the Affordable Care Act is a national version of the universal health insurance plan pioneered in Massachusetts.

Yes, the Obama folks adopted the same three-part structure as Romney’s team: require people to buy insurance, reform the private insurance market to make this easier, and subsidize those who can’t afford it. And sure, many of the key architects of Romney’s plan went to D.C. to set up the national program.

But there is one enormous difference. Obama paid for his plan by raising taxes, particularly on high earners.

Romney didn’t do that. While there were some penalties for people who refused to buy insurance — and also companies that didn’t offer it — the Romney plan relied heavily on federal aid.

Going back to the late 1990s, Massachusetts has been getting a special bundle of extra federal dollars to use for health care. In fact, one of the big reasons Romney chose to pursue health care reform in 2005-2006 was because the feds threatened to close this spigot — unless Massachusetts tried something genuinely innovative.

We did, and the additional federal dollars kept flowing. The state got a total of more than $1 billion in the first three years, which was vital for making our fledgling insurance program work.

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A return ticket to Romney’s plan would be expensive

If Massachusetts wants to reinstate something like the Romney-era program, we’re going to need a source of substantial, sustainable funding. And there aren’t a lot of options.

Perhaps the best news is that the special spigot of federal dollars is still hooked up. In fact, Massachusetts recently secured another five years of extra funding.

But even this might not be enough. The agency that offers these waivers has been threatening to revoke ours for years — and someday it surely will. Not to mention that a good portion of this money is now meant for a different purpose: to help move Medicaid recipients into managed care plans. We might not be able to use it to resuscitate Romney’s plan — or to provide the subsidies essential to low-income residents.

What’s more, even the more conventional types of federal aid might be drying up. US House Speaker Paul Ryan has been pushing a proposal to stop reimbursing states based on actual costs and instead give them a predetermined lump sum. It sounds like a technical change, but over time it would almost certainly wind up reducing federal aid.

And finally, there’s the cramped state budget, which has been mired in deficit ever since the 2008-2009 recession.

Statehouse cupboards are bare, with no spare money to make a Romney-type health insurance scheme work again. And for now, there’s little appetite for raising taxes.

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What’s going to happen?

At this point, it’s impossible to say how this will all play out.

While President-elect Donald Trump and his Republican partners in Congress will undoubtedly take steps to make good on their promise to repeal and replace the Affordable Care Act, the exact steps and timetable remain a mystery.

Whatever the outcome, Massachusetts has some cause for optimism. We have proved ourselves a national leader on health care issues, and that spirit of ingenuity isn’t likely to disappear, whatever happens in Washington.

But there’s little room for complacency. Even if Massachusetts residents have the ingenuity to solve complicated issues in health care, that doesn’t mean the solutions will be easy — or cheap.

If the Affordable Care Act is repealed, Massachusetts might find itself unable to afford the old, efficient, Washington-funded system we once had.


Evan Horowitz digs through data to find information that illuminates the policy issues facing Massachusetts and the United States. He can be reached at evan.horowitz@globe.com. Follow him on Twitter @GlobeHorowitz.