Today is my last day at Rhode Island Public Radio. So I’d like to leave you with some thoughts about health care in the state and my time here. I hope you’ll indulge me.

Rhode Island’s health care landscape is in flux now. It’s full of promise. And it’s full of challenges as the federal government sorts out what comes next with the Affordable Care Act. Meanwhile, health care workers, patients, and others on the front lines of health care in our state soldier on. It’s to you I’d like to pay tribute now, and with you I’d like to share some thoughts about what I believe is on the horizon – or should be – when it comes to conversations about health care.

First: It’s been a privilege to cover health in Rhode Island for nearly five years. I am grateful to everyone who has shared their story with me. I have learned so much from you – from the hospital leader uncertain about his institution’s future, to the patient trying to manage diabetes, from the cop who must diffuse mental health crises on the job, to the new mother recovering from opioid addiction.

Next: here are the issues I hope will stay on the radars of reporters and citizens alike.

Brace for uncertainty in the health insurance marketplace

At this moment, no one knows what Congress or the Trump administration will do with the Affordable Care Act. Rhode Island has benefited in many ways from Obamacare, from the expansion of Medicaid to cover poor, single adults, to the millions of dollars in grants to hospitals to innovate the way they deliver care. We established our own health insurance exchange – HealthSource RI – through which tens of thousands of Rhode Islanders now receive federally subsidized health insurance. That’s in addition to the features of the Affordable Care Act that applied to everyone with health insurance: the requirement that all policies cover 10 “essential health benefits,” including maternity and mental health care, the ability to stay on a parent’s insurance up to age 26, and the provision of preventive services free of charge.

Trump could weaken health insurance subsidies for people who buy insurance on the exchanges. He could allow health insurance plans to be less generous with their benefits. Congress could take a number of actions. But the longer they delay, the more uncertainty for the health insurance market. And that could affect premium prices for any Rhode Islander as insurers try to hedge their bets for the coming plan year.

What can Rhode Island do to shore up the strength of its health insurance market? Lawmakers could pass legislation codifying certain parts of the Affordable Care Act at the state level, such as the 10 essential health benefits. They could opt to continue funding and subsidizing HealthSource RI and find the money to keep the Medicaid expansion population covered. But there’s not enough money to do it all, and the state may be faced with some difficult tradeoffs.

What does this mean for you? If you have health insurance through your employer, you probably have less to worry about. If you have Medicaid, you may see changes in eligibility, or possibly in the kinds of benefits covered. If you’re a health care provider, you could see payment cuts.

Seize opportunities to collaborate to improve health outcomes

When health care providers work together to care for patients, good things can happen. Emergency department visits can be avoided. Duplicate tests can be avoided. New ideas for helping some of the most difficult to care for patients can surface.

In Rhode Island there are some exciting initiatives going on to provide this kind of coordinated care. Maybe you’re in a medical home, or your doctor’s office participates in an Accountable Care Organization. That means doctors have to work together to manage your care or they could lose out on some incentive payments. Maybe your hospital shares medical records with your primary care doctor, as well as your mental health care provider. That means your doctor can follow up with you after a hospital visit, and maybe get your condition under control. These are all examples of ways in which health care is converging around the patient, rather than around services or providers.

Rhode Island has tried to encourage this collaboration. There are efforts to coordinate services for seniors who want to and can safely stay in the community – and out of expensive nursing homes. There are teams of community health workers going out into communities to care for people who don’t usually make it to the doctor’s office or who need help managing chronic diseases at home. All sectors of health care seem to be focused on coordination in some way: whether it’s hospitals, insurers, community health centers, or primary care doctors’ offices. And although the jury’s still out on the degree to which these efforts save money, it’s clear that some patients are benefiting.

Keep the attention on health disparities

I hope Rhode Islanders will continue to fight to erase disparities in health outcomes and access to health care. Whites still fare much better on most health measures in the state than blacks and Hispanics. That’s a common story across the country. But Rhode Island could take steps to narrow the gaps. The state could invest more in healthy, affordable housing. It could raise the minimum wage, to help bring families out of poverty. It could sharpen its focus on identifying young children at risk and providing them the health and educational services they need before problems blossom. Why these measures? Because poverty is usually at the heart of health disparities. And minorities are more likely to be living in poverty.

Mental health needs investment

For five years, I’ve been covering the devastating effects of Rhode Island’s opioid addiction and overdose crisis. Throughout this time, I’ve learned much about the history of Rhode Island’s mental health system. It was once, I’m told, well regarded, well funded, and a model for the rest of the nation. There was a solid system of community mental health centers, and a focus on taking care of people swept up in the deinstitutionalization craze.

But the funding has slowly eroded, insurers have cut back on what they cover, and Rhode Islanders are left searching for psychiatrists who take insurance, among other access problems. We don’t have the infrastructure needed to care for children on all levels of the spectrum of mental health issues. And we have some of the highest rates of depression, substance abuse, and suicide attempts.

What might help? Keeping the pressure on insurers to maintain parity in covering mental and physical health, recruiting more psychiatrists, encouraging insurers to increase their reimbursements, and screening children earlier for mental health issues. The legislature can help, but so can insurers, and the public – by reducing the stigma that surrounds mental illness and addiction.

When it comes to opioids, I think we’re in for problems for the foreseeable future. A generation has been hooked on prescription painkillers, some of whom have turned to heroin. And the heroin supply is infested with deadly fentanyl. We need bold, comprehensive, widespread addiction treatment. We need to not give up on people who relapse or overdose (and survive). And we need to encourage everyone with even the slightest risk of overdose to keep Narcan on hand. Now it’s up to parents and educators to warn younger children of the dangers of opioids – and hopefully prevent them from popping that first pill. The state has a comprehensive plan to fight opioid addiction and overdose, but we need to keep asking whether or not it’s working.

Pay providers what they’re worth

Doctors, hospitals, and other health care providers who take Medicaid have seen their payments cut time and again. Some psychiatrists believe it’s not worth taking insurance, including Medicaid, because the payments are so low. Primary care doctors still earn less than their counterparts in other specialties. And certified nurse’s assistants – the people who do the heavy lifting – may be making barely above minimum wage. All too often, Massachusetts lures our health care providers away with higher pay. How can we approach this problem with a tight budget – one that could grow even tighter under the Trump administration? I think we could continue to pay more for the quality, not the quantity of care, and rethink the way we allocate health care resources. It’s a problem for a state budget with little wiggle room, but losing providers is too risky.

Take advantage of the wealth of resources for staying healthy

Rhode Islanders are lucky in many ways. We have some outstanding health care providers and institutions. We have a big community of medical researchers and, often, the clinical studies they offer. And we have many state lawmakers who spend a lot of time thinking about the health and well-being of their constituents. I say take advantage of these resources: get a primary care doctor. Follow the recommendations for regular screenings and immunizations. If you’re able, enjoy the gorgeous Ocean State by getting outside for a little exercise. And show up for public hearings on legislation that could affect your health.

But mostly, take care of each other. And thanks for the privilege of hearing your stories.

– Kristin Gourlay