Meeting basic needs under Trump
Fed funds key for landlords, affordable tenants; Trump’s health secretary opposes Obamacare
As Donald Trump’s White House takes shape, local thinkers anticipate what the president-elect’s federal appointments might mean for a state that voted overwhelmingly for Hillary Clinton. While current practices of individual states and cities may buffer them against some of the impacts, the Trump administration is expected to usher in dramatically different federal policies affecting residents’ basic needs such as health care and housing.
While the Trump administration’s health care agenda has yet to emerge, the selection of Georgia congressman Tom Price for Health and Human Services Secretary provides a clue as to potential direction. In particular, many say his appointment could affect federal funding for MassHealth, or the state’s Medicaid, which provides health care coverage for many people with low-incomes.
Price is known, in part, for his calls to repeal and replace President Barack Obama’s Affordable Care Act. Meanwhile, the ACA has been largely embraced in Massachusetts.
Massachusetts is home to the health insurance reform laws developed during the administration of former Governor Mitt Romney, which were used as a model for the ACA. State leaders also took up optional provisions in the ACA to expand Medicaid coverage to more people and include more benefits. MassHealth provides for optional services such as dental care, speech therapy and psychologists, as well as eyeglasses and hearing aids, according to Ballotpedia.
Medicaid expansion in Massachusetts extended coverage to any non-elderly adult who earns up to 133 percent of the federal poverty level. In 2015, this included individuals earning up to $16,242 or families of four earning up to $33,465. As of September 2016, more than 300,000 state residents received their heath coverage under this expansion, according to Massachusetts Medicaid Policy Institute report. Price’s proposals include reversing the Medicaid expansion, which would push those individuals into the private market.
Price previously proposed replacing the ACA with a system of tax credits to motivate individuals to purchase health insurance policies for themselves or their families. The level of tax credits would be based on the person’s age, not their income. However, the proposed tax savings fall short of the premium and out-of-pocket costs incurred with standard health insurances plans in most of the U.S., according to The Fiscal Times. States would receive grants for subsidizing the purchase of insurance by individuals from high-risk populations, with tax credit limits placed on businesses that provide workers with health insurance.
Randall Ellis, a Boston University professor who specializes in health economics, said that proposals to encourage individuals to be more responsible for setting aside money in savings accounts for their health may help rein in costs on middle- and upper-income workers and those working at large companies. But such a policy poses a burden for low-income individuals, who have fewer funds available to save for future health costs. In part, this is because chronic poor health can make it difficult to hold a steady job, Ellis said. Another factor: Those with lower incomes also have less to invest in resources that promote positive health outcomes, such as gym memberships, health foods and preventive care.
“There’s a national trend toward making consumers more responsible for some of the costs of their health care,” Ellis told the Banner. “That doesn’t work as well for low-income workers, because they have a harder time saving toward their own health care and health care spending is higher among low income than high-income people, partially because being unhealthy is one reason you have trouble staying in the labor market.”
While the state has a history of promoting near-universal coverage, federal funding for health care could be at risk, limiting support for those with fewer personal resources, experts say. According to the Kaiser Family Foundation, a nonprofit focused on national health policy, in fiscal year 2015 roughly 56 percent of Massachusetts’s Medicaid spending was funded by the federal government. Ellis predicted that under Trump, the state will see less federal support for health care spending, which could prompt cutbacks on Medicaid expansions.
The federal government also fully funds income-based tax credits for individual who shop for health insurance on the private market, said Dr. Benjamin Sommers, Harvard assistant professor of health policy and management at the T.H. Chan School of Public Health.
“If the Congress and President Trump decide to pull that back, Massachusetts could try to keep up a lot of that coverage, but would be doing so with much less money to spend,” Sommers told the Banner.
If so, any local political will to continue the same level of health care support may be limited by the state of current political finances, Sommers predicted. “It is safe to assume Baker and the legislature would try to protect coverage as much as possible in the commonwealth … but the reality is the [state] budget is already under pressure from health care costs.”
Price also has advocated for reduced federal regulation of health care and health insurance providers. If his vision is enacted, insurers would no longer face limits on how much they may charge their oldest enrollees or be prevented from charging women more than men. The marketplace would determine any limits set.
Federal grants and funding also play a critical role in maintaining and providing affordable housing stock along with vouchers for securing affordable housing from private landlords.
Speaking last week, before Ben Carson’s Monday appointment as Secretary of Housing and Urban Development, Michael Kane, executive director of the National Alliance of HUD Tenants and Mass Alliance of HUD Tenants, said that little is known about Carson’s policies other than his declared opposition to the Fair Housing Act, which outlaws discriminatory housing policies.
More readily apparent: the impact of federal funding decisions on Boston, where much of the housing is directly or indirectly supported by public funds. The Boston Housing Authority houses approximately 9 percent of Bostonians, according to the organization’s website. In addition to facilitating low-income individuals’ access to comfortable, quality housing in locations accessible to their work and schools, affordable housing programs support a large economy, said Sandra Henriquez, former BHA administrator. Section 8 rentals can keep neighborhood rents from skyrocketing, thus maintaining affordability to middle-income renters. Section 8 vouchers also provide a government-guaranteed income to landlords. Voucher-holders’ rent is not at risk of interruption by life emergencies such as job loss or sudden illness that otherwise could interrupt a tenant’s ability to pay.
“The ripple effect of the voucher program is not just to house families affordably and well,” Henriquez told the Banner. “It also provides support for paying the mortgages of private owners, which translates to them paying property taxes, which translates to all sorts of things.”
Kane said one short-term impact of Republican control of both the federal executive and legislative branches is that there likely will be domestic spending cuts. One very real eventuality, he said, is that Congress may postpone passage of the federal appropriations bill, thus maintain current funding levels instead of raising them at least enough to match inflation. This would mean a de facto budget cut for HUD, which may be coupled with other reductions. Should funding levels stay static, Kane anticipated a freeze on rent payment to landlords and a limit on use of Section 8 vouchers as HUD’s funding runs low.
“They [the Republican Congress] are not going to pass the appropriation bills,” Kane told the Banner. “Instead they’ll extend current funding levels to as late as May. If they do that — continue current funding at current level without any inflation adjustments — there will start to be crunch in the HUD budget for rental housing around January or February.”