Rep. Anne Donahue
February 17, 2017
Vermont is moving forward with efforts at health care reform at the same time as watching and waiting to see how Washington will address the future of the Affordable Care Act.
Those monitoring tasks are among the priorities that my Health Care Committee has identified for this session, along with review and input on the state’s budget and addressing the crisis-level pressures on our mental health system. They will dominate our committee work, although we are also taking up some specific bills.
The payment reform plan known as the “all payer” model (it doesn’t actually include all payers, but it has the big three: Medicare, Medicaid and Vermont commercial) is in what is called “year zero.” That is the planning year; year one will be when it goes into effect next year.
The insurers will be paying a group of medical providers, called an accountable care organization (ACO), which will reimburse doctors for all care to patients who see a primary doctor who is a member of the ACO.
Vermont’s Medicaid program will be giving it a trial run this year with providers of patients in the northwest and northcentral parts of the state (including ours). Hospitals in those counties and the primary care doctors working for them will get money up front each month for meeting patient needs and helping them to avoid higher cost care.
During the pilot, Medicaid will be tracking all the actual services patients get, and what those services would have cost if they were being paid per-service. Quality measures will also be tracked.
Will it actually bring good results?
Here is what Vermont’s Medicaid administrators told us:
“Like any new program, we cannot guarantee that it will succeed.”
“Financial Projections: Numbers are being developed without experience. Not clear whether number will be too little or too much. Missing the mark may impact program performance and perceptions of the program.”
“Operations: Implementation challenges are likely to occur in the first months of any new program. Such challenges can affect public perception of the program, and may poison the well for other statewide readiness activities during Year 0 of the All Payer Model agreement.”
What incredibly refreshing honesty!
In fact, it is a more refined way of saying what I have said for a while about the All Payer Model. There are clear possibilities that it will not result in the hoped-for savings. But it is something that seems rational to try, and certainly better than doing nothing while the costs of healthcare skyrocket beyond reach.
The governor’s decision to do this test run first will allow us to back out if it does not demonstrate good outcomes.
Our committee will also be watching the implementation process closely.
Affordable Care Act
Major changes to – or total repeal of – “Obamacare” would have a profound impact on health care in Vermont. Our uninsured rate dropped from eight to four percent under expanded eligibility for Medicaid and with the premium assistance for Vermont Health Connect insurance plans.
If that rate moved back up, we would see the impact in areas such as “free care” provided by hospitals; it’s not actually free, as the cost is shifted to other payers, so it would show up in insurance rates.
Some key provisions that could come to an end would be the ban on annual and lifetime limits on essential health care and the ban on copays for preventive care. It could also bring an end to the annual maximum amount that someone has to pay in co-pays or deductibles. Those protections do not exist in Vermont law.
One well-known (and popular) part of the ACA is its ban on excluding coverage of pre-existing conditions. When you enroll in an insurance plan, it can’t tell you, “no coverage for your diabetes; you already have it.”
There is a rational reason for this traditional exclusion. Expecting coverage is sort of like saying you should be able to buy car insurance and have it pay for the fender you crumpled the week before.
If you could get health coverage for an expensive illness after you get the illness, why would anyone bother to buy insurance until they are already sick? And if the only people buying insurance are already sick, that insurance is going to be extremely expensive. It defeats the whole point of sharing risk by having a large group pay into a pool for those who end up needing it.
The Affordable Care Act addressed that problem through the (very unpopular) insurance mandate. If everyone is required to have insurance, there is no longer the problem of having people only get coverage after they are sick, so “pre-existing conditions” are no longer a problem to cover. So these two provisions really need to go hand-in-hand.
President Trump has already directed the IRS to stop enforcing the individual mandate. (It is enforced through the health insurance coverage form required with your tax return.) That places the ban on exclusion of pre-existing conditions in jeopardy.
That is one feature Vermont had in place, in part, before the ACA, so we could restore it. We required a new insurance plan to cover pre-existing conditions as long as a person had been maintaining insurance coverage at least up to six months prior.
That protected people who did have coverage, but needed to change plans, for example as a result of a job change.
What remains unclear for now is what other protections we could, as a state, preserve.
A major budget pressure this year is the crisis in our mental health system. Patients often wait for days – yes, multiple days – in emergency rooms because no hospital beds are available.
We held a joint hearing with the Senate Health and Welfare Committee last week to hear from front line workers about the severity of the problems, which includes the lack of capacity for geriatric psychiatry for elders, lack of adequate staffing, and lack of resources for mobile crisis services.
Some of the most compelling testimony came from staff at Central Vermont Medical Center and the Vermont Psychiatric Care Hospital.
Our committee will be making recommendations to the Appropriations Committee for the budget that is currently in development, as well as in further review later during the session.
Bills in Committee
We have identified five bill proposals that are priorities for testimony and consideration in our committee:
- Copays for physical therapy. A proposal to limit insurance copays for physical therapy to the same as primary care. The theory is that encouraging the use of physical therapy may prevent higher-end health care costs, such as surgery.
- Worker’s comp coverage for PTSD. If a person has a diagnosed condition of post traumatic stress disorder that resulted from an occupational hazard, why would it not be covered in the same way as other work related injuries or illnesses? A first responder coping with having intervened in a horrific tragedy comes to mind, and this is not currently covered.
- A commission for in-depth post-incident reviews of mental health crisis responses that result in death or serious injury. This review of law enforcement and mental health crisis worker efforts would focus on the background and causes of such outcomes. We can learn a lot when, instead of pointing fingers, we look at what might be done differently in the future. We already heard testimony from law enforcement agencies and advocates very supportive of this bill.
- Allowing consent by a minor for mental health counselling about sexual orientation issues. This waiver already exists for getting treatment for substance abuse or sexually transmitted diseases. If a teen would avoid getting help rather than allowing parents to know the situation, likely even the youngster’s parents would prefer that getting treatment came first.
- Suicide data review. This bill would direct the Department of Mental Health to review suicide deaths in Vermont to look for causes, similarities, or trends -- something not currently done. Our rate of death by suicide is 30 percent higher than the national average. It is hard to address a problem without knowing, “Why?”
On the House Floor
Last week, the Judiciary Committee presented a bill on a new crime that bans “open and gross lewdness.” It is being created as a lesser offense than the current crime of “open and gross lewdness and lascivious behavior.”
Problem: we have no definition in current law for the existing, “lewd and lascivious” conduct, let alone segmenting out when it is merely lewd, but not lascivious. According to the legislator reporting on the bill, it is simply recognized based on social norms.
(Dare I say it comes under the standard, “I know it when I see it?”)
That hardly gives a fair warning about what conduct might get you arrested for a crime.
My questions brought a round of “no” votes, but the bill still passed.
Afterwards, new legislator and retired judge Ben Joseph, who sits adjacent to me, leaned across the aisle both literally and figuratively to tell me that he thought my points were exactly correct.
Thank you for the honor of representing you. Please contact me with your questions and your opinions. You can reach me by message at home at 485-6431, at the statehouse at 828-2228, or at this email at firstname.lastname@example.org