March 19, 2016 Legislative Update

Legislative Update

Rep. Anne Donahue

March 19, 2016

 

The House passed some 29 bills last week to get them over to the Senate in time for action this session, but they ranged widely in importance. Some were clarification of existing law and some set out study committees to research more tangled questions of law.

This coming week will be the heavy lifting: the state budget (with increases), the tax bill (with increases), and the fee bill (with increases.)  Amongst House committees, many eyes will be on Judiciary, which is beginning to take testimony on marijuana legalization.

I sympathize when people say we pass too many laws, so I’ll offer one example of a minor bill that nonetheless made sense to act on. Sports teams on the college level or above often travel with their own team doctor. When our teams go out of state, their doctors are usually permitted to practice in that state, as long as they only treat their own team players or staff.

We don’t offer the same courtesy to those coming here, simply because we never passed a law authorizing that exception from medical practice laws. That was one of last week’s 29 bills.

A sampling of others:

Health Care Reform

My bill establishing limitations on the governor’s proposal for a federal waiver for health care payment reform passed on a 124-2 vote of the House. For the first time, we have laid out in law that reform agreements must bar the state from touching any Medicare money.

The bill – described in detail in my previous update – also would establish state regulation of the federally-created “accountable care organizations” that are gaining an increasing role in coordinating, and paying for, health care in the state.

Suspended Licenses

Many Vermont drivers are so overwhelmed by accumulated motor vehicle fines that, unable to pay them, they drive with a suspended license, and then get sucked further down by new fines. This bill proposes an amnesty period with reduced fines, and a new system that will allow for payment plans and fewer suspensions.

There is a fundamental inequity about offering amnesty when thousands of other Vermonters have faithfully paid their fines in the past, even if it was a huge financial struggle for them.

Unfortunately, two counties in Vermont already ran amnesty programs for their own unpaid tickets. That meant relief from old tickets was based purely on what part of Vermont you live in. To me, that is an even greater injustice, and it led me to support the bill.

By rebuilding the system to help people to avoid losing their licenses for failure to pay fines, we will raise less money in the future for the transportation fund in “driving while suspended” fines. That lost revenue will cost each of us a dollar a year in increased vehicle registration fees.

E-Cigarettes

Electronic cigarettes are getting more and more kids hooked on nicotine, and many of them move on to smoke tobacco. Although sale is already banned to those under 18, they are being widely marketed as though they were not dangerous to health.

This bill had two parts: extending the requirement that e-cigarettes be sold out-of-reach of customers along with tobacco products, and extending “no smoking area” bans to e-cigarettes.

I asked that the bill be divided in order to vote in favor of the store restrictions but against the public smoking bans. Such bans are based on protecting persons from the actions of others, and there is not clear evidence that the vapor that e-cigarettes produce have the “second hand smoke” risks of tobacco. Both sections passed, so I did vote for the final bill.

A surprise developed in the form of a proposed amendment to raise the smoking age to 21, on the grounds that it would protect thousands of younger teens from ever starting to smoke.

It is a rare moment on the House floor to see a roll call where there is no predictable outcome, and no party-line voting.  The amendment failed to get a majority, stalling at a 71-71 vote.

I did not support it. I think rights and responsibilities go hand in hand, and our rights as adults include the right to make bad decisions. We have chosen as a society to deem 18-year-olds able to make decisions to shoot others and be shot at war, and to be accountable for criminal actions even to the point of the death penalty. It is hypocrisy to deem them too immature to make decisions about unhealthy activities.

Ban the Box

The goal of this bill is to help persons with a past criminal record to “get through the front door” for job interviews. It doesn’t stop employers from asking about criminal involvement, or doing background checks, but it bans asking the question on a first-round written application.

Timber Trespass

This bill would create civil penalties for cutting timber on another’s property, and was one of several that promoted the importance of our forests as a resource, and as worthy of similar designations as our farm lands.

Corrections

Another bill addressed our aging prisoner population, focusing on system costs, public safety, and compassionate release. It would make persons eligible to be considered for parole at age 65 after serving at least five years, or at age 55 after serving at least 10 years, even if the minimum jail term had not been served, as long there are no public safety issues.

Impaired Driving

This bill would extend the length of license suspensions for impaired driving, and expand the use of ignition lock systems that require breath testing before and while a car is being driven.

Potable Water

We have drinking water standards for well systems, but not for surface water. As a result, water systems were not receiving permits if they used surface water as a source. This bill sets up standards to allow the use of surface water for drinking water systems for private homes.

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Thanks for the honor of representing you! You can contact me or Rep. Patti Lewis by email (counterp@tds.net for me; pattijlewis@myfairpoint.net for Patti) or by leaving a message at the statehouse at 828-2228. We welcome your feedback and input.

 

March 6, 2016 Legislative Update

Legislative Update

Rep. Anne Donahue

March 6, 2016

 

The pace will begin to speed up as we near the end of the first half of the second year of this legislative session. This Friday is “crossover” – the deadline for bills to be voted out of a policy committee if a House bill is even to be considered by the Senate, and vice-versa.

So, what to expect from the House Health Care Committee, where I sit?

I have drafted a bill that we are taking up this week to set parameters for any agreement with the federal government about an alignment between Medicare, Medicaid and private insurers.

Most important of all is this language:

“The Green Mountain Care Board and the Agency of Administration shall only enter into an agreement with the Centers for Medicare and Medicaid Services if the agreement… continues to provide payments from Medicare directly to health care providers without conversion, appropriation, aggregation, or any other involvement by the State of Vermont.”

The talk about Vermont entering into an “all payer” model has worrisome overtones.  I have heard unequivocally from Vermonters: “hands off our Medicare.”

The administration has said that no such agreement would involve the state controlling Medicare money.

There is no state law, however, preventing Vermont from doing that, and I think we should put it into law: no agreement permitted unless the agreement itself guarantees that the state doesn’t touch Medicare money.

It isn’t just about the money, either. So the bill includes other requirements. The agreement would be allowed only if it:

-- preserves all existing the consumer protections (including not reducing Medicare covered services, not increasing Medicare patient cost sharing, and not altering Medicare appeals processes), and

--  allows Medicare patients to choose their providers.

The federal government is already deeply involved in pushing for health care reform through new ways of paying for Medicare. One route is through contracting with organizations made up of health care providers that agree to be accountable for all services for its patients for a single lump sum.

These groups of providers are called Accountable Care Organizations, and there are three that already operate in Vermont. A Medicare patient who sees a primary care doctor who is a part of an ACO is “attributed” to that ACO. The ACO coordinates all of the patient’s care.

If you are on Medicare, you may already be attributed to an ACO. Apart from having received a letter about it two or three years ago, you wouldn’t notice anything different, and your doctors have not been paid any differently.

The coming change from Medicare is through paying via that agreed-upon lump sum, instead of paying through the traditional fees for each service you receive.

The biggest difference in the arrangement that Vermont is proposing to the federal government is that we make it possible for our Medicaid program and private insurance plans in the state to align into the same model.

All the major payers in Vermont (thus, the “all payer model”) could establish contracts with an ACO, creating a unified method of payment. Having more payers involved creates economies of scale, both in administrative costs and in managing good coordination of care.

A participating doctor wouldn’t need to worry about which insurance you had or how much each particular procedure costs, and could concentrate on best care.

But if the ACO does not meet its target for costs, it is the ACO that loses money. Perhaps the biggest fear for many is, how can we be assured that the ACO won’t scrimp on care in order to meet its budget targets?

In addition, for an ACO to function successfully and survive financially under the new lump-sum model, it must be made up of a very large network of providers, including hospital and physician services. As a result, the three Vermont ACOs are planning to fold into one.

That brings other worrisome features. If there is only one ACO, will it create too much of a monopoly? How do we ensure that the big hospital partners don’t control the decisions, and keep most of the money?

That brings us to other parts of the oversight bill my committee is working on.

Although Medicare allows ACOs to operate fairly independently as long as they meet budget and quality of care targets, we want stronger oversight of what will be Vermont’s single ACO.

The bill would require that the all-payer model allow providers to choose whether to participate in an ACO or remain independent. The ACO would be required to contract with non-ACO members to ensure their patients can access the providers they need and choose.

The ACO would be required to invest in primary care and other parts of the health care system that help prevent expensive hospital use. It would also require shared decision-making between doctors and their patients.

Under the bill, the Green Mountain Care Board would monitor quality of care and patient protections, including the right to appeal denials of care. It would require that the ACO governing body represents its participants equitably.

The ACO would not be permitted to “diminish access to any health care service for the population and area it serves.”

The Board would also review and approve the ACO’s annual budget, in the same way it currently reviews hospital budgets.

I think this oversight is crucial if this new model of payment is to be successful in helping to make the most efficient use of health care resources while also protecting the highest quality of care.

The “all payer model” is intended to help make the system pay greater attention to the full spectrum of patient health care needs instead of separate pieces, through changing the way providers are paid.

That alone is not going to radically alter the trajectory of increases in health care costs. But it may “bend the curve” of increases, and that bending is a necessity if we are to keep health care even remotely accessible.

What must come next? Greater equity in access.

Right now, if you are very low income, your access to health care is well protected. If you have a good health care plan through your job, your access to health care is also well protected; it is affordable mostly because the costs are hidden through the employer contribution.

Neither of those routes is sustainable. We are seeing that now in a state budget that is being crushed by the expansion of Medicaid access, and employers are seeing it in the impact on the costs of doing business. It only takes looking at the effect on school budgets this year to know that we can’t keep on this course.

But those in the worst situation are those who are not covered by their jobs, yet are over the limit for state-sponsored Medicaid coverage. Insurance on the health care exchange still leaves health care inaccessible for many: the cost-sharing on top of high premiums is too expensive.

We have to do better.

The all-payer model, if done right, is likely a good step, but it is only a baby step in the big picture of achieving access to quality health care.

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Thanks for the honor of representing you! You can contact me or Rep. Patti Lewis by email (counterp@tds.net for me; pattijlewis@myfairpoint.net for Patti) or by leaving a message at the statehouse at 828-2228. We welcome your feedback and input.