Legislative Update, February 15, 2020

We’re approaching the major shift when the detailed work of committees begins to emerge as proposed bills to be debated on the House floor to send on to the Senate. (Per the old saying: it is not the beginning of the end, but it is the end of the beginning.)

This means that the thinking on some of the big priorities for this year are becoming visible; in particular this past week, the responses to climate change.

The first stage of budget review in the Appropriations Committee is also ending. The committee has walked through all of the governor’s proposals and identified the gaps and areas for discussion and potential disagreement.

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Budget Issues

In the opinion of the Appropriations Committee, the legislature has not been presented with a balanced budget proposal. That response is pretty typical in any given year.

When the “squishy” numbers involved in trying to get to a bottom line are removed, revenues and expenditures don’t align. Ultimately, what we pass will have squishy numbers of our own, with a budget partially based on hoped-for outcomes.

Each committee evaluates the portions of the budget within its policy domain, and what the budget gap means at this stage is that House Democratic leadership is telling committee chairs that their recommendations back to Appropriations in response to the governor’s proposals need to identify priorities (meaning, what they least object to being cut.)

Committees also cannot be asking for their own new projects unless they identify an existing source of revenue, such as eliminating a currently existing budget item.

Within those constraints are embedded the money that House leadership believes needs to be reserved for its own priorities. (See climate change bill discussion, below.)

In my Health Care Committee, there are only a few new budget proposals we have to review, but it will be tough to not be able to tell Appropriations that each one is equally essential, because they all directly relate to the state’s mental health crisis and rising rates of suicide.

They include further investments (about $400,000) in education and training within the health care system for identification and response to suicidality under a program that has proven to be highly effective when implemented in other states, and which has already been initiated in three Vermont counties.

They also include the start of a mobile response program for families in crisis in Rutland County (at a cost of $600,000) which, if successful, would be rolled out in other counties in future years.

We have two committee priorities of our own. First is to keep chipping away at the subgroups of Vermonters who face the greatest barriers and inequities to health access.

We’d like to invest some money for just a small amount in premium support for the “cliff” that occurs when low-moderate income working families who must buy their own insurance are just over the financial threshold for eligibility for any assistance.

These are folks who are paying more than $5,000 per person for policies that have deductibles of more than $6,000, amounting to more than 20 percent of their income.

I just needed cataract surgery; the successful surgery has restored my ability to read normal size print. The bill will exceed $5,000 but my out-of-pocket cap is $1,350.

That’s still a lot to come up with, but if I had to pay for the whole thing, I’m not sure if I could have swung it without taking it out of retirement savings.

That makes me pretty lucky, and even as a low-moderate income person I’m willing to chip in for those who don’t have that level of access.

We are also working together with the Commerce and Economic Development Committee on mechanisms to help bring more health care workforce to Vermont.

We have a growing shortfall in all levels of nursing and in rural primary care doctors, and must compete with states that have strong incentive programs such as educational loan repayments.

That takes money. But we don’t do it, it increasingly raises our health care costs, such as the need for hospitals to use high-cost “temp agency” providers.

We are working on several bills that may help in ways that don’t cost money, by expanding access to tele-health, increasing the scope of practice for providers like physician assistants, and easing the barriers for licensure for those already licensed in other states.

In the coming weeks we’ll see the wish lists from other committees, and it’s likely that none of them will be frivolous – whether childcare, afterschool programs, tourism development (i.e., investments to bolster state revenues), or state support for local roads and bridges, just as a sampling.

One investment recommended by the governor that is not getting much legislative traction is a particular frustration for me, because I’ve been pushing for it for so long. That’s the tax break for veteran pensions.

It is an investment because anything that reduces state revenue is, in reality, something that costs the same money as if it was a new appropriation, yet it is highly likely that it will raise more revenue than what it may cost.

Retired military are a middle-aged, skilled workforce with families that are still young. They are exactly the folks we desperately need to attract to Vermont to reverse our sharply aging demographics. The taxes they will pay on the income they make in their new jobs will increase state revenues.

The problem is that nearly every other state gives tax breaks on their pensions. Why would they move (or stay) here, in the face of that?

Compare that investment to our current scheme of offering $10,000 to remote workers willing to relocate here. Yet it’s perceived as something that will be a benefit to higher income earners, which doesn’t sell well.

It’s a real issue for recruitment for Norwich, and I’ve convinced the chair of the Commerce Committee to hear testimony from several Northfield families to explain its importance.

My hope is that if that committee “gets it,” it will push the Ways and Means (tax) Committee to be more receptive. Right now, it remains a very uphill battle.

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Every Vote Counts

If anyone doubted the importance of every legislator’s vote, it was proven last week in the single vote that sustained the governor’s veto of paid family leave. (The coming vote on the minimum wage supplemental increase will be equally close.)

Democrats were not able to rally all of their members in support of a veto override, which was what made the difference. There were some ugly public statements made, unfortunately, by party leadership about one of their own who stuck to her opposition to the bill despite a good deal of pressure from them.

The thing that has enabled me to stay a Republican in the face of the pretty horrible national scene has been that in our caucus here, I have never faced approbation when I have voted my own conscience contrary to a party position.

It’s a commitment of our leadership that has always held true. I am not lock step on every issue, and when my views differ, they are respected by my peers.

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Climate Change

That segues well into the climate change bill, where I may well find myself at odds with many Republicans.

The first major bill has come out from the Energy and Technology Committee, titled the “Vermont Global Warming Solutions Act.”

“Solution” is undoubtably an exaggeration, but some will still find it quite overbearing. It changes our greenhouse gas reduction goals from goals to mandates and creates a Vermont Climate Council that will create an action plan to reach them. The Agency of Natural Resources would be empowered to adopt rules to enforce the plan.

That last piece is worrisome to me. Delegating major decision-making powers that are usually the responsibility of the elected legislature into the hands of an administrative agency threatens to disenfranchise the public.

On the other hand, such a statute isn’t written in stone, because no law ever is. If an agency ran amuck, a future legislature could change the law. But it’s harder to reign something back in once it’s been let loose.

The two Republicans on the 9-member committee voted against it; the one Independent, one Progressive, and five Democrats voted for it.

It includes almost one million in new appropriations to implement, so it has been sent to the Appropriations Committee to be vetted before coming to the floor.

That is one of the new money items that will push others off the table. (See budget discussion, above.)

Incidentally, if you sometimes worry about the quality of education today, you should see the set of letters I received from Northfield students who recently took a marine biology course and learned about impacts of pollution and climate change.

They thanked me for last year’s vote for the plastic bag ban and asked me to support climate change legislation this year.

They were thoughtful, articulate, well-written, respectful letters that showed independent thinking skills. They were obviously part of a class assignment, but so much the better; they are being taught how to make use of their voices in a democracy.

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And One Tidbit

I’m getting a lot of reaction to a brief bill I just introduced that would require car rental companies to place prominent notices on contracts if they ban use of their cars on dirt roads – reaction from folks saying, “Is this an issue in Vermont?”

Yup; I’ll bet you didn’t know it either. It’s in part of the tiny print on those multi-page contracts: no driving on dirt roads. On cars being rented in Vermont?!! The fact that they aren’t equipped with snow tires is a related issue.

Within a day I got a visit from the lobbyist for Enterprise (and the bill doesn’t even demand that they allow driving on dirt roads; it’s just a notice as a consumer protection issue.)

I explained the issue; she is going back to discuss it with her client; fingers crossed that it may be one of those bills that won’t even have to be taken up because the mere threat of it solves the problem.

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Feel free to get in touch any time during the session with Rep. Goslant and me. There is a lot going on, so if you have questions about something – ask. We are buried in committee work and don’t always know what is happening in other committees, but we can find out for you. It is an honor to serve you. (kgoslant@leg.state.vt.us; adonahue@leg.state.vt.us)

Legislative Update, Feb 1, 2020

Legislative Update

Rep. Anne Donahue

Feb. 1, 2020

In my last report, I tried to drill down into explaining OneCare, Vermont’s accountable care organization, created by hospitals and doctors to be able to accept lump sums to provide all of a person’s care instead of getting paid for each separate service they provide.

The important thing to understand is that this is payment reform, not financing reform.

When most people think about health care reform, they think about the financing issues: affordability and equity for those who pay for care, rather than how providers are being paid.

The amount of money people pay for their health insurance ranges from zero to 15 percent of their income or more. That is obviously not equitable.

What are we doing about that? Last year, we asked for a report on the disparities and how we might address them.

The vast majority of Vermonters have their care paid for through three avenues: either Medicaid (24 %) (very low income), Medicare (21%) (elders and those with disabilities), or an employer buying a commercial product in what we call the “large group” or self-insured market (32%.)

Only a small share – 7% -- of folks receive their insurance through the small group (employers with fewer than 100 employees) or individual markets (5%), which are combined under what we call the Vermont Health Exchange. No one else is on that infamous Exchange.

Insurance is generally more expensive for individuals because they are not mixed into a larger pool of people, so they present greatest risk for an insurer. Vermont has tried to help address that by combining individuals into the same pool with small employer groups.

We learned from the new report that if this market was split, small employers on the Exchange would be paying 5% less for insurance, and individuals would be paying 7% more.

We don’t want people who have to buy their own insurance to have an even greater cost burden, but it’s only a small slice of small employers who end up paying to help with that burden.

Even larger inequities come in two other places. Folks who are low income and buy individual plans get a lot of help with subsidies. At a certain tipping point, however, they lose all subsidies.

In 2019, the federally defined poverty level for a couple was $16,910. Because of subsidies, a couple earning 300% of poverty (each making slightly under minimum wage) would pay nothing for the lowest-cost Exchange plan and at 400% of poverty they would pay less than 3% of their income.

However, the same couple at just over 400% (that is, $67,600) would have to pay more than 15% (more than $10,000) of their annual income to pay the premiums in the lowest-coverage Exchange plan.

This is the cost for the premium only, and these numbers are for plans with a $6,000 deductible before coverage begins, with a $7,900 out-of-pocket cap, per person, so if either had any significant medical event, they’d be into well over 25% of family income.

The hidden group (the state doesn’t know what plans employers provide) are those who receive insurance from employers, but have plans that have those same very high co-pays and deductibles.

When we look at the cost of housing and other basic needs, the high costs and the variation in what people have to pay out of their income in order to get access to health care is profoundly inequitable.

It is because I think that this is a greater inequity and a greater need to address that I oppose both the family leave act. Family leave would be creation of a new social benefit when we haven’t invested yet in fixing access to a more essential social benefit.

What would it cost to help address some of these disparities – the question we asked for the report this year?

If we divided the individual and small markets, giving a boost to small employers to provide more affordable coverage, we could protect individuals who need to buy their own insurance by increasing subsidies for those who have to pay more than a certain amount of their income.

The study we requested tells us that for $2.2 million, we could reduce premiums by 10% for those between 400% to 500% of poverty (the “cliff”). For $10m, we could reduce all Exchange premiums by10% via state back-up insurance for high claims.

Where would money for market reforms or support like this come from? It would need to come in from others of us, in order to bring more equitable access for everyone.

For example, if we didn’t implement the family leave act but imposed the same tax that it is going to cost, $29 million would be raised for health access equity.

Another example could be an increase in the rate of the penalty we impose on employers who do not provide insurance for employers; that would level the playing field among those who do and don’t.

I’m hoping we can put together some concrete options for detailed fiscal analysis that could result in a plan to enact next year.

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Drug Pricing

We’ve heard two pieces of hopeful news regarding the ever-increasing costs of drugs.

The effort to create a multi-state buying pool for Canadian drugs that we initiated last year is moving from pie-in-the-sky to serious potential.  The feds are moving forward on rulemaking, and Vermont has submitted a concept paper.

And Blue Cross/Blue Shield has just formed a partnership with a non-profit pharmaceutical company that is going to begin producing several lower cost generic drugs.

Yes, you read that right. A non-profit pharmaceutical company. (It you’re interested in details, look up this company at CivicaRx.org)

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Data Sharing

Last year, we approved the change from an “opt-in” to “opt-out” system for Vermont’s Health Information Exchange. That’s the information data base that allows statewide health provider access to your medical information.

Opt-in meant you had to give affirmative consent, and because people weren’t being asked, not enough people were consenting to make it a useful tool for providers. Opt-out means your records are accessible unless you initiate the contact to say, “no.”

We approved this change only with insistence on an aggressive public information campaign and very easy and accessible ways for people to exercise the right to opt out. We have now received the report on how that is being done.

I admit to being pleased and impressed, because government doesn’t always do a great job with this sort of thing.

If you haven’t already seen the information on Front Porch Forum or elsewhere, go to this website for a highly consumer friendly explanation and a direct link for opting out: vthealthinfo.com

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Marijuana

The bill on a “tax and regulate” sales market for marijuana – which is currently legal to possess but illegal to buy or sell – is moving through evaluation on the House side, and came to my committee for input on health issues.

I though the best testimony came from a physician with the Department of Mental Health, who said, in effect, that the problem is not that marijuana presents extreme dangers but rather, that there is such casual dismissal of the health risks that actually do exist, in particular when it involves heavy use or use by youth.

We recommended that the required health warnings on packaging be provided directly by the Department of Health rather than – as the bill had proposed – listed information set by the (not-well-educated) legislature or a lay oversight board.

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Bill Sponsorships

I’ve had longstanding concerns about transparency and a lack of public confidence in how we review the use of lethal force by law enforcement. Last spring, California enacted a law that created a new standard of review, and I asked for a bill that proposes that Vermont look at that approach.

I think our law enforcement community is highly professional, but there is a lot of public misunderstanding about how these deaths are reviewed, based solely on the seconds before the use of force rather than any broader context.

We also look at whether the lethal force was “justified” rather than whether it was “necessary” to protect the police and public.

The bill was taken up for initial testimony last week, and our state Attorney General strongly urged that Vermont look at these potential revisions.

He is the one who has made most of the findings over the past decade that these deaths in Vermont were justified, and he said he is deeply concerned about the need for greater public trust in how we review them.

On other bills, I’ve co-sponsored new efforts to eliminate state taxation on social security and on military retirement pay, and for increasing hospital price transparency and ownership of medical data.

I missed the sponsorship sign-on but am supporting a bill introduced by Topper McFaun of Barre to eliminate co-pays and to significantly increase access to contraception.

This should be an area whether “pro-life” and “pro-choice” can unite. Preventing unwanted pregnancy prevents the need for a choice to end a life.

I have also co-sponsored a resolution stating apology for our state-sponsored eugenics movement in the 1930’s, under which we created a system of sterilization for society’s unwanted: the Abenaki people, immigrants, and people with disabilities.

I first brought this resolution forward some 10 years ago, but now others are helping to lead the effort and there is momentum to move forward.

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Feel free to get in touch any time during the session with Rep. Goslant and me. There is a lot more going on than we can summarize, so if you have questions about something – ask. We are buried in committee work and don’t always know what is happening in other committees, but we can find out for you. It is an honor to serve you. (kgoslant@leg.state.vt.us; adonahue@leg.state.vt.us) You can see my archives of legislative updates at www.representativeannedonahue.blogspot.com, and can sign up directly with me to receive them by email.