This is the third in a series of articles exploring the critical policy challenges that the next governor and Legislature will face, as well as their positions on these issues.
The past isn't always prologue to the future, but when it comes to healthcare and the candidates for governor, it could prove prophetic -- at least as far as the next four years are concerned.
From funding to family planning centers to the proposed decriminalization of small amounts of marijuana, Gov. Chris Christie and Sen. Barbara Buono have followed distinctly divergent courses on implementing healthcare policy. And the two candidates' views on the Affordable Care Act have led to sharply contrasting ideas as to how the state should proceed.
Christie has taken a hands-off approach to the ACA’s health insurance marketplace, letting the federal government take the lead, while allowing Medicaid expansion to go forward.
Buono believes that the state should operate its own exchange, enabling it to reap a windfall in federal funding that will let it better inform the public about the law. She thinks the state should embrace the ACA in its totality to make sure it works for New Jerseyans.
The disputes reflect the candidates’ different priorities, with Christie both citing budgetary imperatives that have limited healthcare spending while at times reshaping the state’s approach to healthcare, such as pursuing a comprehensive Medicaid waiver that will shift the focus of long-term care for the elderly and the disabled from institutionalized settings to community-based care.
Christie has left his mark on healthcare policy in other ways, such as moving to merge most of the University of Medicine and Dentistry of New Jersey into Rutgers University.
And he has refused to give ground on criticism that his decisions have been driven by factors other than what is best for residents.
As chairwoman of the Senate Budget Committee from 2008 to 2010 and a current member of the Senate Health, Human Services and Senior Citizens Committee, Buono has also shaped healthcare policy. For one thing she sponsored a bill that requires insurers to cover mammograms for women under 40 with a family history of breast cancer. For another, she sponsored the bond that would have funded stem cell research in the state, which was defeated in a referendum.
Buono said she has been an outspoken advocate for expanding healthcare for low-income residents her entire life and would push to increase funding for women’s health and to expand the reach and lower the cost of health insurance if she’s elected.
The gulf separating Christie and Buono has been evident since the first budget the governor proposed in the spring of 2010, when Christie cut $7.45 million for, which contributed to the closing of six family-planning and women’s health centers. The governor first cited budget constraints and later emphasized that the services the centers provided were duplicative.
But Democrats -- including Buono -- and women’s groups believe he cut the funding to burnish his antiabortion credentials and improve his national standing (with an eye to making a bid for a 2016 run for president).
Buono joined with Planned Parenthood and others inhad a detrimental effect on the centers’ clients .
Christie transferred the funds to the state’s federally qualified health centers. He said the decisionChristie has emphasized his support for the FQHCs, as well as increasing funding during his term for the state’s hospitals, which he said has increased healthcare access for the state’s residents. “Healthcare is more available in New Jersey under this administration,” Christie said during one of the gubernatorial debates. . The Democrats countered by pointing out that the federally qualified health centers serve predominantly low-income clients, while the women’s centers serve everyone. Arguments over the issue have been played for every budget since.
Perhaps the area of disagreement that will have the longest-lasting effects on state healthcare policy are the candidates’ views on the ACA. Christie opposed the federal law and vetoed two bills that would have established a state-based health marketplace.
He opted instead for a federally operated marketplace,health insurance online, and learn whether they are eligible for federal tax credits to subsidize their policy.
“I don’t agree with the law, but we’ve complied with it, and that’s the job you have as governor. You don’t agree with every law you have to enforce, but I’ve enforced this one and I’m proud of our record on healthcare,” Christie said in the October 8 debate. “I think we’ve done a great job.”
Buono has been highly critical of the decision to let the federal government run the marketplace, noting that it deprived the state of tens of millions of dollars to advertise the exchange. The election will likely determine whether the state will operate its own marketplace over the next four years.
“This governor’s decision was based on appealing to that Tea Party element that has the grip of his party, and they have shut down government, and really put the American democracy in a vice for one reason, because they don’t have the votes to change the Affordable Care Act,” Buono said in the first debate.
But Christie hasn’t been as staunch in his opposition to the ACA as many of his fellow Republican governors. He said state officials would cooperate with the federal government on the marketplace. More importantly, he agreed to expand Medicaid eligibility. This provided insurance to residents with an annual income below 138 percent of the poverty line, which amounts to $15,856 for a single person instead of the current level of current level of $2,520.
In addition to adding more than 100,000 residents to the Medicaid rolls, Christie's decision deprived Buono of a potential line of attack in the campaign. However, she has claimed that she helped pressure him into the decision.
The introduction of prescription marijuana points to another point of disagreement between the two, in which philosophical differences about the potential dangers of the substance have led to differing proposals for treating both its medical and nonmedical uses.
Christie took office after the law establishing medical marijuana in the state was enacted, putting him in position to implement a measure that he had opposed. The state regulations his administration later issued to put the law into effect have been described as the most stringent of any state that has allowed prescription marijuana. They’ve also been criticized as having contributed to thethe alternative treatment centers that grow and dispense the substance.
The first alternative treatment center to open had supply problems and has largely remained shuttered, but two additional centers have progressed toward opening this fall.
The governor has been adamant that he will not allow the state to develop the permissive approach to marijuana that has characterized some states, while also upholding the law. He’s even expanded access to the prescription marijuana, agreeing to a bill that allows children to access edible forms of it while removing a restriction on the number of strains each alternative treatment center can grow.But to Buono, Christie’s approach has led to a situation in which there was no legal distribution of marijuana nearly four years after the law allowing it was enacted. She also was critical of his decision to veto the central provision of the new law affecting children, which would have reduced the number of doctors that children must see before they can receive a prescription.
More broadly, Buono proposes eliminating legal penalties on nonmedical possession of marijuana, including decriminalizing small amounts of it. Christie is opposed to any move to legalize or decriminalize marijuana for nonmedical purposes.
Christie pleased drug policy reform advocates when he signed a bill that provides legal protections for those who alert authorities about drug overdoses and administer a heroin overdose antidote, after having vetoed an earlier version of the bill.
If reelected Christie appears unlikely to give ground on the ACA marketplace, which has been hobbled by poor website performance since it was launched on October 1, and is generally more skeptical of the larger federal role in healthcare envisioned by the ACA. The pace of medical marijuana implementation appears set to increase, but is unlikely to assuage critics concerned about access. This reflects Christie’s approach to policymaking in other social issues, in which he has applied his conservative values in a way that has disarmed some Democrats. And the annual fights over family planning centers are likely to continue, reflecting both the governor’s resistance to revisiting the decision and some Democrat's focus on highlighting issues that rally core supporters.
If Buono is elected, the state would almost certainly have its own insurance marketplace, medical marijuana regulations would likely become more lenient and Planned Parenthood and other supporters of family planning and women’s health would see more funding. But even if she pursued policies that lead to more federal funding for healthcare in the state, she would be hard-pressed to launch healthcare initiatives that would prove expensive, considering that she would face some of the same fiscal limits that Christie has cited in making cuts.