Rep. Anne Donahue
February 22, 2014
It was the calm before the storm, with almost no action on the House floor last week as committees worked to finish bills that will need to be in the Senate within the next several weeks if they are to have a change of passing this term. So I will focus this update on bills that my Human Services Committee is preparing to pass.
This bill as introduced had an extension of the workplace smoking ban to include “semi-enclosed” spaces. Semi-enclosed included anything with a roof and two sides. This part has been removed.
The rest has strong committee consensus. It creates a 25-foot no smoking area around state buildings to eliminate the “smoker gauntlet” the public sometimes faces to get inside, as well as to protect from smoke from entering windows and vents. It also places restrictions on child care facilities, on the grounds of the new state psychiatric hospital, and in all hotel/motel rooms, and enables state parks to create “smoke free” areas.
It does not touch the controversial subject of smoking inside a car with a child – controversial apparently because it is personal, instead of public, space. With what we know about the effects of second-hand today, I think that trapping a child inside a small, contained, smoke-filled area borders on child abuse. There may be an amendment on the House floor to add this to the bill for any child in a car seat, and I would welcome it.
The state is being fined by the federal government because it far exceeded the error rate in processing food stamp applications for the past several years. The feds are also reclaiming the overpayments from those who received them unknowingly because of our errors. This bill will at least partially make those individuals whole. The challenge will be in coming up with almost a half million in state funds to pay for our errors.
We have been working on a bill to address some of the financial barriers that result in families on the Reach Up program losing income if they begin working. This long-vexing problem is known as the “benefits cliff.” The bill is good public policy, but it is not an expenditure of tax revenue that I will be able to support unless funding can be found to be shifted from another program.
The longstanding way that funding for developmental services has been allocated by the administration has been to cut more people off altogether when there is less funding to go around. Currently, only about 20 percent of those who are eligible receive help, and the priority list keeps getting tighter. This bill looks at whether the legislature should have a greater policy role in determining how the resources are shared.
Substitute Medical Decisions
Vermont has a strong law on enforcement of advance directives, which enables someone to have an agent fulfil their wishes about treatment if they lose the ability to provide informed consent. Substitute consent can also occur through a guardianship. However, we are a minority state in having no other person authorized by law to provide consent if needed. (Message: fill out your advance directive.)
It now appears that Medicare may begin to require a legal surrogate for admission to hospice, which could create a barrier for care.
In addition, six years ago a new law that clarified the process for end-of-life “do not resuscitate” orders specified that substitute consent could be through an agent, a guardian, or “other individual” – unspecified. Our committee agreed to address that the next year, but hasn’t yet.
So I introduced a bill this year that created a family or close relationship criterion for hospice and DNR consent. It also clarified that agent or other substitutes cannot speak for a patient requesting a “Death with Dignity” prescription to end life early. Our committee decided this past week that we will address hospice, but on two straw polls, 6-4-1, decided to defer the DNR issue yet again, and to not clarify the intent of the Death with Dignity bill from last year.
Budget Policy Input
Our committee is also working on input for the Appropriations Committee regarding policy issues in the budget. The system redesign developed two years ago for mental health services was intended to put more money in community resources and reduce the need for, and costly use of, inpatient care.
Construction of the new hospital in Berlin is progressing beautifully, but we have now learned that its 25 beds will cost as much to run as the former Vermont State Hospital (54 beds), while we also pay additional costs for 20 high-level inpatient beds at the Brattleboro Retreat and in Rutland. The per-person per-day cost at the new Vermont Psychiatric Care Hospital will be $2,250 per day, or almost $20 million a year, compared to about $1,450 per day at the Retreat and Rutland. The cost difference adds $5m to the inpatient care budget.
Why so costly? First is the loss of economies of scale created by a 25-bed hospital. Some of us predicted that from the start. Secondly, according to the administration, a much higher staff-to-patient ratio is required by the design of the brand new hospital. (You read that right. Higher.) In my view, as someone who invested a great deal of time helping in that design, the budget is significantly over-staffing a facility that was designed to increase efficiency. However, it is hard for legislators to overrule the “experts” on a subject like this.
It will also be opening without a full electronic health record (due to false starts in planning) and without money set aside to implement one next year; it requires an addition to the budget because furniture costs had been left out; and it faces some likely insurmountable obstacles to fully opening on schedule.
There is no full-time person in the administration overseeing the project, and no one at all with significant experience in running a hospital. Last December I urged my colleagues to address this; we have not, so the process stumbles along. Our committee will be recommending close monitoring.
I look forward to seeing you and hearing from you during the town meeting week break. Thank you for your calls and messages, and please continue to keep me informed about your priorities. My email is firstname.lastname@example.org; home phone, 485-6431; at the state house for messages, 828-2228; and my blog to review past updates is at http:// representativeannedonahue.blogspot.com.