Rep. Anne Donahue
March 3, 2017
Town meeting week break: it means we are almost half way through the session. The week we return, known as “crossover,” is the deadline for policy bills to be voted out of committees in order to be voted on and cross over from House to Senate, or vice-versa. It will be a packed week with committees working late to finish work on proposed changes in laws.
One week after that is the deadline for the money bills, which are required to start in the House. That includes the annual state budget and the 2-year capital budget, along with any tax or fee bills.
The budget dynamics are all new this year, because we have a governor who has drawn a line in the sand: he will not sign a budget if it requires new taxes or fees to balance it.
I have heard no talk in the House this year, thus far, about trying to challenge that and attempt to override a veto. The Appropriations Committee is chewing through budget details to look for savings and cuts – and asking for policy committees to weigh in.
In Health Care, my committee, we grappled with two subjects that Appropriations asked us to review: analyzing the savings proposed in the governor’s budget, and looking at what we could do this year, on an urgent basis, to respond to the crisis in meeting mental health care needs.
The issues that have led to days of waiting for psychiatric patients in the emergency rooms of our hospitals are many-layered. This backlog has been ongoing for several years now. The prior administration kept saying that the “flow” of the new, post-Irene system just hadn’t fully calibrated itself yet, and needed some time. It is clear now that the problem is deeper.
Any plan to completely restructure a system on a crisis time frame – the crisis being the sudden loss of the Vermont State Hospital due to flooding from Irene in 2011 – is likely to run into trouble. The plan was inadequate from the start.
Our work to make revisions needs to be more careful, yet there is huge urgency. Last fall, for example, an 11-year-old boy from Northfield was held in an emergency department room at Central Vermont Medical Center for six days while waiting for an inpatient bed to become available in Brattleboro.
The task before my committee was to identify targeted actions – and the money to achieve them – that might help allay the worst of waits like that while longer-term system solutions are developed and take hold.
In keeping with the governor’s line, however, “the money to achieve them” meant finding resources that could be shifted based on priorities, rather than increasing the budget (often referred to as a “budget neutral” proposal.)
I led a work group from our committee, and by Friday, we had achieved that goal. It doesn’t mean everyone will like it or that the Appropriations Committee will agree.
Here is what we recommended:
Inject $2.5 million into the crisis intervention system to steer patients away from emergency rooms if they don’t need to be there. We have mobile crisis teams throughout the state, but they often can’t stay staffed because salaries aren’t competitive, and there aren’t enough clinicians to meet the need.
Add $.5 million into new initiatives to create nursing home capacity and supports for elderly patients who are stuck in psychiatric inpatient beds solely because there are no nursing home beds available to meet their needs.
When people stay in the hospital after they are stable and ready for discharge, it uses a space that could otherwise be for a new admission; instead, the person waiting for admission sits in the ER.
Another set of persons who are delayed in discharge are those who are homeless. The last piece of our proposal is to add $.4 million into specially-supported housing for such individuals.
Where’s the Money?
That’s $3.4 million in total… from where?
One part of the governor’s budget proposes cutting 10 percent of special payments to hospitals called “DISH” payments. It is federal money, matched with state funds, that is intended to help hospitals with the costs of free care they provide to persons without insurance.
Over the past five years, the amount of that unreimbursed care has dropped significantly, because our rate of uninsured persons has dropped. The governor felt it was reasonable to reduce those payments.
We looked at that and considered: if we cut the payments even further, but reallocated the additional money to help address the emergency room crisis, it was actually shifting the money to a different category of need at the hospitals: the need to relieve the backlog.
Cutting a second 10 percent of the DISH payments but reallocating it to the targeted mental health responses seems like a better way of using the same money. Ten percent equals $3.4 million, which became the basis for the recommended levels of emergency new funding.
Elsewhere in the Budget
Other health-related budget items we reviewed included the governor’s proposed savings in Vermont Health Connect and in the administrative functions of the Green Mountain Care Board, which oversees health insurance and hospitals in the state.
The governor expects to save $2.8 million by re-directing individuals who are not receiving subsidies to get their insurance directly from the insurance carriers, rather than signing up through the Vermont Health Connect exchange.
We started allowing people to use direct enrollment just a few years ago, when Vermont Health Connect was failing rather catastrophically to meet enrollment needs. Now, we realize we can save money if they all opt to do it.
The problem we found it that the amount of the savings projected is highly optimistic. We warned the Appropriations Committee to use caution in booking the full savings.
On the second issue: The Green Mountain Care Board is partially funded through billing the insurance companies and hospitals they regulate. It is a common funding mechanism for regulated entities.
The governor’s budget identifies a savings by increasing the amount of the Board’s budget being billed to insurers and hospitals, and decreasing the amount being paid for out of the state’s budget.
That sounds rational, but there is a glitch. The state budget money is matched by federal money, at least for now. The costs that are billed to insurers end up being paid by individual purchasers of insurance, in their rates, and there is no federal match. Depending on the insurer, this could mean up to $72 per person a year as a rate increase.
So by shifting the source of the funding, we are losing out on the ability to get federal money to help pay, and instead placing the full cost on the purchasers. In cash terms, to balance it out means we would no longer be using $1.2 million in federal matched money; we would be billing $1.7 million more to insurers (purchasers); and the grand sum of the desired savings for our state general fund budget would be $180,000.
It’s all in the interest of a balanced state budget, but it isn’t a true savings in costs. It is simply shifting the costs from taxpayer to ratepayer. They (we) are often the same people.
On the House Floor
The hottest topic of debate last week in the House was a bill to shorten the length of time after a sentence is served that a person can apply to have a criminal record wiped clean.
I support the concept of expungement: that if you have paid for your crime and have then proven yourself in staying clean for long enough, you should be able to get a new chance at a clean record.
The issue was how long is “staying clean for long enough.” Our expungement law is fairly new, and this bill reduces the waiting in one category from 20 years to five, and another from 10 years to three. I think that too much, too soon, so I voted “no.”
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