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There’s nearly $2 billion in federal funds at stake if the Republican Congress and President Donald Trump move forward with some of the health care changes they’re contemplating as replacements for Obamacare.

There are more than 765,000 Connecticut residents receiving Medicaid and more than 111,524 residents who have purchased insurance from one of two private health insurance companies on the exchange. At least 60 percent of those exchange customers receive federal subsidies to lower their monthly premiums.

“Our concern is about all of it,” Lt. Gov. Nancy Wyman, who co-chairs the Access Health CT board of directors, said last week.

She said block granting Medicaid, and eliminating the federal dollars for experimenting with payment methods and care delivery structures would cost Connecticut billions.

“I think people are so scared of not knowing what’s going on,” Wyman said.

Dr. Tom Price, the Republican Georgia congressman, was confirmed Friday as head of the U.S. Department of Health and Human Services.

Dr. Price, back in September 2016 before becoming Trump’s nominee, said the Centers for Medicaid and Medicare Innovation should “stop experimenting with Americans’ health, and cease all current and future planned mandatory initiatives.”

The Center for Medicare and Medicaid Innovation has given Connecticut more than $45 million to examine value-based payment models. Dr. Price believes those models “could potentially harm patients and providers.”

That statement puts Dr. Price in the same corner as a group of advocates and Connecticut’s Department of Social Services, who have been saying similar things to the Connecticut Healthcare Cabinet.

The Healthcare Cabinet, led by Wyman, debated value-based payment models and cost containment measures and finalized a set of draft recommendations in December.

The cabinet voted 11-8 in favor of a proposal that will transition Connecticut residents, including state employees and Medicaid recipients, to plans that require doctors to take on greater risk for their patients health outcomes.

“While the vote got better and in the end it was close, the final Cabinet decision is out of step with the rest of Connecticut and the rest of the country,” said Ellen Andrews, executive director of the CT Health Policy Project and a member of the cabinet who voted against the proposal.

The proposal, which received a lot of opposition but was ultimately approved, would move Connecticut residents into a downside risk model of healthcare by January 2019.

Downside risk is a payment method that requires doctors to assume the financial risk and lose money if they don’t save enough money on their patients. Advocates worry it would cause doctors to reduce care to certain patients who require a lot of care and would be viewed as hurting their bottom line. There’s also a fear that fewer doctors would participate in the Medicaid program where already they are being reimbursed less than what they are paid by private insurance carriers.

The proposal was opposed by the state employees union, two Medicaid oversight groups, and three state agencies.

“I think that it’s premature to say that we are definitively going to risk sharing and it’s premature to set a timeline,” Frances Padilla, president of the Universal Healthcare Foundation of Connecticut, said before the vote in December.

Pat Baker, president and CEO of the Connecticut Health Foundation, said part of what the system fails to focus on is outcomes.

“We focus so much on the shared risk model, but we have not talked about the importance … of how it pushes to improve health outcomes,” Baker said.

Lt. Gov. Nancy Wyman (ctnewsjunkie)

Others disagree with that assessment.

“While the proponents claim that downside risk means ‘paying for outcomes’, something everyone would like to see, it does nothing of the sort,” Sheldon Toubman, an attorney with New Haven Legal Assistance, said. “Rather, under this untested proposal, we are paying for cost savings, period.”

Megan Burns, a consultant who put forward the recommendation to move to a shared risk model, said the program is “voluntary.” She said “if a provider doesn’t wish to join, a provider doesn’t have to join.”

She said the proposal was structured to make it more attractive to join than not to join.

But Connecticut health advocates who have been following the state’s Medicaid program for years are concerned that providers simply won’t participate because they will lose money if their patients, who are some of Connecticut’s poorest residents, don’t have good health outcomes.

Health care spending, according to the report, is nearly 20 percent of Connecticut’s state budget. The report found that compared to the national average, Connecticut spends a greater percentage of its own revenue on Medicaid even though the federal government had been picking up a bigger piece of the tab since the Affordable Care Act expansion in 2010.

The Healthcare Cabinet spent 11 months developing a set of “cost containment strategies” to help constrain the growth in healthcare costs for all Connecticut residents.

The legislature must now decide whether to introduce legislation to implement these recommendations.

Gov. Dannel P. Malloy’s budget proposal asks lawmakers to create a new Office of Health Strategy to coordinate efforts to react to potential health care reform changes at the federal level. The new agency would starts its work in July 2018 and would be under the Department of Public Health for administrative purposes. The executive director of the new agency would be responsible for “developing a comprehensive and cohesive health care vision for the state, including a coordinated state cost containment strategy.”

The new agency would be created through the consolidation of staff and resources from the Office of Health Care Access.

“Transferring the responsibilities of OHCA to OHS will ensure that the overall health system planning functions are aligned with the technological and health care reform initiatives being implemented in the state,” the budget book states.

Malloy’s budget doesn’t include any adjustments related to the potential repeal of the Affordable Care Act and it does not include any adjustments to reflect potential federal changes to the Medicaid program.