February 26, 2022 Legislative Update

 

We are nearly halfway through this year’s legislative session, with bill deadlines coming at the close of the week we return after the Town Meeting break. The current week is a good one for reaching out to Rep. Ken Goslant or me to talk about pending issues, since we aren’t tied up in day-long committee meetings and floor sessions.

The weeks immediately after that deadline will be the beginning of a much heavier load of floor debates on specific bills, followed by work in committees on initiatives sent over by the Senate. The state’s budget will also be coming out from the House and headed to the Senate by the end of the month.

***

Health Care Committee

My committee has finished its input into the budget and workforce bills and has three initiatives we are trying to finish by the March 11 deadline.

We wrestled with a large, late-in-the-game budget request from the Green Mountain Care Board – our state’s health regulator and reform czar – for initiating several health reform projects. We’ve spent five years on the major reconfiguration of financing that was supposed to funnel the major payment resources into entities (“Accountable Care Organizations”) that would pay health providers based on health improvements and care delivery, rather than on the basis of each individual piece of service delivered. The key element was the negotiation with the federal government to align its payments from the Medicare system into this new payment system, joining with Medicaid and commercial insurers, ergo, called the “All Payer” model. We ended up with only one accountable care organization, by the name of OneCare. Those are the two names the public may have heard referenced: the All Payer model, and OneCare.

The $5 million request from the Green Mountain Care Board is a bit of a “re-set” button being pushed, though no one has quite said that. Not nearly enough insurance plans or providers have signed on to the All Payer model yet to reach a critical mass that would create real change. It is nowhere near its targets. And the 5-year agreement with the feds is nearing its end. In addition, many of our hospitals are teetering on the edge of sustainability, caught between rising cost pressures and the inability to increase revenues enough to meet them.

So, how to recalibrate?

The Board is recommending two things: First, a deep dive on the actual delivery of health care in each part of the state. It would bring everyone to the table in each regional sector to talk about priorities and how to improve outcomes. Perhaps some hospitals need to be reconfigured to best meet local needs and maintain access. Perhaps there are efficiencies in the infrastructures.  How do we best allocate resources? But the work is intended to be from the ground up, not from top-down directives. That is a $3 million process that will also involve data gathering and analysis and technical assistance to hospitals to facilitate transformation initiatives.

Second, a reframing of how we move away from the current, predominant fee-for-service model into payment based on value received. That would involve establishing fixed payment hospital budgets: they receive overall payments to achieve population outcomes, rather than for each hospital bed they fill. Designing that system and renegotiating with the feds is the purpose of the additional $2 million investment, including the costs of deeper analysis of the hospital markets and their costs and expenses.

I drafted the language to put very clear parameters of our expectations on how this process would move forward, including a report back before any changes move forward, and we included this in our budget recommendations to the Appropriations Committee.

***

Health Care Workforce

We prioritized three areas as most in need of immediate investments in our recommendations to the Commerce Committee for stabilizing the healthcare workforce. Workforce shortages cut across almost every job sector, but my committee’s task was to identify responses for health care.

We have many more applicants to our in-state nursing schools each year than we have slots for, and we are desperately short of nurses. Enhancing nursing education capacity needs to be a high priority. We recommended emergency state investments in several supports for that system, each addressing a specific current barrier. We lack nursing educators; a nurse takes a huge pay cut if they move from clinical practice to teaching. We proposed grants to nursing schools for a bridge to enhance salaries. There is a lack of clinical placements for students; practicing nurses receive nothing extra if they agree to take students under their wing. We proposed grants to hospitals to add stipends. Nursing schools need sophisticated simulation laboratories for students to practice in and they lack the capital funds to upgrade and expand them. We recommended a capital grant fund. (Think of it: would you prefer a student to try their first several IV insertions on you, or on a dummy?) Norwich will be one of the direct beneficiaries if these investments are passed.

I think the most positive initiative we are seeking to fund is a grant program for seed money to start “pipeline” projects modeled on one I heard about from Central Vermont Medical Center a few years ago. It offers staff already working in front line positions the support to advance their education and careers in exchange for commitments to continue to work there. A nursing assistant, for example, can get paid time off for classroom work plus scholarship funds so that they can afford to go to school while still working and earning a salary, and graduate as a licensed practical nurse. It has been a huge success, but the health organizations need start-up funds to create these programs.

The second major priority area is in the community mental health agency system, where year after year, the state budget falls short of funding anything near the same cost of living or inflationary increases that state employees or other government services receive. The governor’s budget proposed a three percent increase this year, and we have proposed making it 10 percent instead, to help with catch-up to market salaries. We also proposed an expansion of scholarship and loan repayments for furthering education.

The third priority area is to address everything we can’t do in the first year of an emergency response, and that is to lay the groundwork for a more cohesive, long-term response. Last year, we asked for a strategic plan for this purpose. A cross-agency work group came out with no less than 40 recommendations, most of them very common sense. But someone has to actually follow-up to make them happen, to pull the players together to reduce barriers and to develop healthcare career-building at earlier points. We recommended staffing a time-limited position to implement components of the plan.

Finally, one of the recommendations in the plan was to establish a single point of information to gather data on the healthcare workforce, which will enable future supply and demand modeling to understand what needs to be targeted. We want that to be developed immediately. This year brought to the forefront the way we have been playing whack-a-mole over the past decade. One crisis pops up; we react. Another one; another reaction. We have no bigger picture of where the most pressing developing needs are – tied together with our changing demographics (read: we are getting older and needing more health care.) We must create that core data if we are to ever be able to act planfully instead of reactively.

***

Healthcare Bills

We’ll be looking to wrap up three bills during the deadline week when we return.

The first is to address hearing aid coverage in health insurance plans. We’ve been receiving urgent pleas to address this issue over the past several years. It is a good illustration of how much our hands are tied when it comes to regulation of insurance plans. We’ve taken the first step of addressing coverage in plans that are offered on Vermont Health Connect for individual or small group coverage. We expect that some plans, beginning next plan year, will begin to include that option. Medicaid already covers them; Medicare does not and we can’t do a thing about that since the federal government controls it. (Some Medicare Advantage plans chip in towards the cost.) Many large employer plans are also controlled exclusively under federal law – but not all. So we will be looking into what steps we can take in that arena.

The second bill is a step forward in addressing financial assistance plans offered by hospitals in the state. Although the vast majority of Vermonters are insured, many have very high deductibles and are financially devasted by a major hospital stay. Hospitals all do have assistance plans, based on income, but they all differ. If you have your heart attack in the wrong county, all the rules – including basic eligibility – will be different. This bill seeks to bring them into more alignment.

Finally, we hope to pass a bill that will at least take the first steps in increasing the oversight of the shadowy middlemen in the sales of pharmaceuticals. They operate within an incredibly complex world of negotiating with drug manufacturers on behalf of insurance company and making some of their money by paying less to a pharmacy than what they pay for the drug. They have already been lobbying us about what an important role they play in health care delivery; that may be the surest indicator that we need to be watching them more closely.

***

Take advantage of our “down time” during town meeting week by reaching out to me (adonahue@leg.state.vt.us) or Rep. Goslant (kgoslant@leg.state.vt.us) to share your concerns, priorities and ideas. We want to work for you – it is an honor representing you.

February 12, 2022 Legislative Update

 Legislative Update

Rep. Anne Donahue

Feb. 12, 2022

It’s a rare day that would see all political parties agree on a $50 million tax break, recognizing that with our current bubble of state revenue, some should be returned to the taxpayers. 

The difference of opinion this week on the House floor was which Vermonters should receive the benefits. The governor had proposed tax relief in multiple targeted areas (money spread wider, but in smaller amounts), and the Democratic majority countered with a bill that focused almost exclusively on one (a big impact for a much smaller group.)

The bill that passed mostly along party lines, 102-46, would provide an annual $1,200 tax credit for every child up to age six for every family with an income below $200,000. It extends to families with incomes above that on a scaled reduction up through $240,000. It also would increase the Social Security tax exemption threshold by $5,000.

The governor’s proposal included increases in the earned income tax credit for lower income families with children and in the childcare and dependent tax credit; tax credits for student loan repayment, first time homebuyers, nursing and childcare workers, and industry workforce shortage areas; and tax exemptions for military pensions and social security income. His proposals were not even vetted by the committee before moving this new bill, and there will be no additional revenues available to take them up later this session.

The first attempt at a floor amendment would have reduced the eligibility for the child tax credit to families under a $100,000 income. That would have also freed up money to include some of the governor’s proposals.

The chair of the tax committee argued that the tax credit was aimed at two separate issues: to help struggling, low-income families, and then for higher wage-earners, to send a message that Vermont was child-friendly and thus induce more young families to move here. This would thus also help our workforce shortage. I asked whether the committee had taken any testimony at all on evidence that such benefits actually do entice families, and the answer was, no. This rationale was purely hypothetical.

The amendment failed, however, 55-88.That meant that other proposed amendments to invest tax credits or exemptions in other areas were immediately found not germane and were blocked from being debated. I supported the initial bill on the first day of debate in the interest of keeping it moving, knowing amendments were coming. I voted against it when those efforts failed.

It is now in the Senate hands, where it might be tweaked, radically altered, or discarded. The final resolution of any configuration of tax relief will come after the House and Senate ultimately come to agreement over differences.

My district-mate, Rep. Ken Goslant, gave a vote explanation that explained the reason for opposing the bill very articulately: “Today I voted against this bill, not because I am opposed to tax relief to young families and expanding the Social Security income tax exemption. In fact, I am thrilled that we are discussing returning nearly $50m to Vermonters… and are finally talking about ways to attract more people to the State. 

“However, I voted no because I believe other tax relief proposals should be vetted and discussed before moving something of this magnitude. It is time that we pay attention to our seniors, and I believe that we can do much more on Social Security than a $5000 increase. I hope that we can continue the conversation on how to provide tax relief to as many Vermonters as possible, including military retirees, those with student loan debt, nurses, childcare workers, those with not just children but adult dependents and more.”

 ***

Committee Work

My House Health Care Committee voted out our bill unanimously on creating a licensing process for providers who are out of state but want to offer health care to patients in Vermont via telehealth. It is now in the Ways and Means Committee to address the fee structure. 

We think it is important to maintain this access for Vermonters, but also protect against practitioners who do not meet standards of care. Permitting it was a huge benefit during COVID, but it is a bit scary to think about it being completely without oversight. 

Most of our current committee work is on reviewing budget recommendations and developing health care workforce proposals for the Commerce Committee's comprehensive workforce bill. There are many competing needs. We recognize that many parts of our economy are desperate for workforce support, but if you don't have health care providers, much of the rest isn't really going to help! 

The most severe current shortages are in nursing and in mental health providers. One clear need is to find better support to bring in nursing faculty and clinician-educators. We had large numbers of would-be nursing students turned away from our colleges’ programs last year for lack of capacity, driven by those lacks.

We also heard testimony about how access to mental health care is crumbling in the state, even as needs increase. Salaries in our mostly publicly funded community agencies are so far below other sectors that they are experiencing vacancy rates between 30 and 50 percent in some programs.

The governor has proposed some additional money in the budget for expanded mobile outreach programs. These are urgently needed, but we have to also face the question about opening new programs if salaries are too low to fill staff for existing ones.

One example is a crisis residence for children which now is closed on weekends for lack of staff. This only increases the problem of children ending up in the emergency room. The lack of inpatient beds that then results is even more children who are held waiting there for days and sometimes weeks. Yet, expanded mobile response could help divert from both of those needs.  

We have also just started work on a bill to address some of the practices of Pharmacy Benefit Managers (PBMs), which are the hidden intermediaries between pharmacies, insurers, and drug manufacturers. They have the ability to manipulate a lot of where the money flows. Our small independent pharmacies are the ones being most hurt by their practices.

***

Abortion

Proposal 5, the “personal reproductive autonomy” constitutional amendment, is now on its way to the November ballot for a vote; it will join the other proposed constitutional amendment, Proposal 2, which makes the prohibition on slavery more explicit. The final legislative vote in favor of moving it forward was 107-41.

It will place voters in an unfortunate position, because anyone who wants to protect the abortion access rights of Roe v Wade in our constitution will feel the need to vote for this amendment. However, it essentially eliminates the balancing that Roe v Wade identified between privacy rights and the right of society to have an interest in the “developing young in the uterus” in the late months of pregnancy. 

As Rep. Carl Rosenquist eloquently said, “This is not who we are,” to choose the exclusive rights of one group of people over the other. Most Vermonters support some restrictions in the third trimester and measures such as healthcare provider conscience protection, but these would likely be barred. It will also leave it to our judicial branch to interpret the undefined term “reproductive autonomy;” abortion is never directly mentioned in the language and this is intended as a much broader concept.

In my lengthy floor speech (and you can ask for a copy if you would like one) I argued that it was irresponsible of us to propose such an all-or-nothing, extreme perspective to the voters, ignoring the reasons for the deeply ethical questions that have divided people of good will both across the globe and through the centuries. I truly believe everyone in our legislature – and all Vermonters -- hold the positions they do based upon an interest in protecting human rights. But we interpret those rights under very different lenses.

I reflected on the times in the past that we have chosen to deem some lives as inferior to others with consequences now recognized as horrific: slaughter of indigenous peoples for their land; buying and selling of captives from Africa; sterilizing those we believed to be unfit to procreate. Each of those actions were deemed acceptable in their time. I quoted Eric Metaxas, author of Seven Women and the Secret of Their Greatness, who said: “Each era has the fatal hubris to believe that it has once and for all climbed to the top of the mountain and can see everything as it is, from the highest and most objective vantage point possible.”

I closed with a request to my colleagues: “Let us each have the humility to leave today a slight bit less certain that our perspective can stand the test of time.”

***

Town meeting week is just around the corner, and the legislature is in recess specifically to help provide access to constituents. It’s the best time to connect with Ken or me to discuss pending issues, ask questions or share your input. Please contact us at any time with comments or input at adonahue@leg.state.vt.us or kgoslant@leg.state.vt.us. It is an honor to represent you.