April 21, 2018 Legislative Update

A few years ago, I remember a session that felt as though it was rushing to early closure, without enough time to address issues still ahead of us. This year, it seems as though we are ahead of schedule. The difference is the effect of weather. That past session, an early spring created a sense of time running short. This year, the damp and cold makes it feel as though adjournment is months away, not weeks.

It is an election year, however, which means politics is more entangled with legislative actions. There will be bills sent to the governor despite knowledge that they will be vetoed with the primary intent of placing the governor in a bad light, and there will be actions by the governor for the purpose of making a Democratically-controlled legislature look unreasonable. Such is the price of a democracy, where allowing for robust debate from different perspectives really does usually help foster better outcomes in the end.

Toxics Bill Veto

The first such bill would expand state regulation of toxic chemicals in children’s products. It was vetoed by the governor last week and is now coming before the House for the override vote. The governor, in his veto message, said it was a measure that would be bad for business – not a very strong rebuttal to the effort to make him appear willing to sacrifice the health of children.

The reality is that we have a strong law passed just a few years ago that allows the Commissioner of Health to ban “chemicals of high concern” on the recommendations of a committee that includes leaders of several state agencies, based on scientific evidence. This new version would give the Commissioner sole authority to decide that a substance might expose children to harm, and to do so based upon just a single study, regardless of what the weight of the overall evidence is. That’s why it’s bad for business, and for consumers as well. There could be an awful lot of products that are banned or have warning labels required when there isn’t valid evidence of potential harm. I voted against it and will support the governor’s veto.

Education Funding

Last spring, the governor vetoed the budget in an effort to push for cost containment in education funding through a statewide contract for teacher’s health insurance. He won widespread support – it was the legislature that looked bad – but he caved early by assuring everyone that he would not stand his ground to the point of having the state face a Washington-type shutdown. That’s sort of showing your cards in advance.

The compromise deal instead reduced the projected increase in the property tax by spending education fund reserves and one-time funds. It made it appear that the savings the governor wanted were achieved, but everyone knew it would come back and bite this year. It has. There is now a $40 million shortfall in the education fund and property tax rates are being driven much higher despite the very conservative budgets passed by towns this spring. The governor is pushing for savings again, but he will be hard pressed to identify where the money can come from.

The efforts on the part of the legislature, you may recall, have been on changing where the money comes from but not how much is spent. The House bill creating an income tax surcharge to reduce the amount paid through property taxes is still being reviewed in the Senate.

Thus far this year the overall state budget is toeing the governor’s line on “no new taxes or fees,” but there are taxes and fees being snuck into side bills, nickel-and-diming taxpayers. The governor is threatening to veto all of those, which could add up to a fairly long list. I voted against most, but not all of them.

Universal Primary Care

My committee is in the final decision-making phase regarding a Senate bill that would take the next step in establishing access to primary health care for all in Vermont. There is a great deal of value to an approach to curbing health care costs that begins by ensuring that everyone can receive early interventions that can prevent high cost health care needs later. It would also start us on the path towards more equitable access to health care, regardless of what coverage one’s job does or does not offer. That’s something I strongly support.

While almost all Vermonters have some type of insurance, the cost burden is extremely inequitable. The very poor (through Medicaid) and the very wealthy (with only a small percentage of their job compensation going towards health insurance) pay relatively little or nothing. However, some of those in the middle end up with very high premiums and with co-pay levels that make it still too expensive to access care.

The problem, however, is that – for better or worse – we have already embarked on a path to health care cost reform that is making huge alterations in how money flows through the system and how providers are paid. To try to take on a second major, overlapping restructuring at the same time would risk dooming both to failure. There just isn’t enough bandwidth to do it all at once. So I will be voting against the bill in the committee.

Mental Health Progress

Two weeks ago, I reported on the University of Vermont Health Network’s concept of developing a new inpatient wing for psychiatry at Central Vermont Medical Center. The idea has received positive endorsement in the legislature. Among other things, it brings inpatient psychiatry more fully under the wing of our health and hospitals system, instead of being relegated – based on history and discrimination – to being a state function. It has also meant rejection of the idea of creating a 20-bed inpatient wing at a proposed new mega-prison in St. Albans. (That proposal included closing some of our more antiquated prisons and bringing back Vermonters placed in out-of-state prisons.)

The UVM project is still at least four years down the line, however, so the need for a more immediate interim solution to address the desperate shortage of inpatient beds remained with us. Now a potential solution has emerged for that as well. The Brattleboro Retreat has existing space that is being used for offices but can be rehabilitated and restored for hospital use during these next several years. This plan that would come at a much lower cost to taxpayers ($17 million versus $29 million over four years) – and be online sooner – than the administration’s original plan for a temporary 12-bed forensic unit. By the time the CVMC unit is ready, the Retreat will need to be phasing out some of its adult inpatient care because of loss of a federal funding waiver, and that space can be transitioned to much-needed stepdown and geriatric residential programs. Our health care committee has endorsed this plan. I am quite proud of the significant role I played in pushing the state to seek out this better solution.

When Is It a Crime?

Everyone knows that if you punch someone in the nose, it’s a crime. What if you swing and miss? Appropriately enough, that’s still a crime. You don’t get the benefit of having failed in your attempt, and the potential punishment is the same. But what if you are heading down the street with the intent to punch someone, but you haven’t arrived there yet? Have you committed a crime at that point? When does your intent become an attempt? That is the issue in the case of the young man who had put together a plan to shoot up Fair Haven Union High School. The Supreme Court has ruled that he had not yet attempted to actually commit the horrific intended actions, so the charges are now likely to be dismissed.

Many people are horrified at the thought that current law might mean waiting until a person intent on harm actually walks onto school grounds with his guns before he can be arrested. The governor has gone so far as to say that the man’s defense attorneys are exploiting a loophole to get him set free. That’s hardly fair. All his attorneys have done is to point out that he has not committed a crime under our laws.

However, the push is now on for the Legislature to redefine “attempt” crimes so that they would cover this kind of situation in the future. (It cannot, under the constitution, be applied retroactively.) The push, in fact, is to have us recklessly rush changes through to make a show of how much we care for our kids – but without caring in the least whether we are passing thoughtful legislation. When you change a law, you change it for all circumstances, not just for the compelling situation in front of you. That’s the meaning of the old adage, “Hard cases make bad law.”

I certainly think we must address the issue of stopping individuals who are actively engaging in planning a mass murder. But I’m not sure someone walking down the road intending to beat someone up should face the same jail time as a person who actually beats someone up. I think we need to consider all the consequences before rushing to rewrite law in reaction to one situation. The epidemic of gun violence and the fact that its reality has hit home in Vermont seems to be leading us into legislating by hysteria this year. We are stumbling over ourselves to prove how much we care without regard to whether our actions are going to help – and to whether they might actually cause harm.

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Please stay in touch as you hear about issues affecting you and to keep me informed about your views. You can reach me at adonahue@leg.state.vt.us. Thank you for the honor of representing you.

April 7, 2018 Legislative Update

Heading into the final four scheduled weeks of the session, the focus in Montpelier has turned back to our committee work, taking up bills passed by the Senate. In House Health Care, the biggest bill we’re received is a proposal to evaluate creation of a universally accessible primary care system. The original bill that passed the Senate Health and Welfare Committee laid out the steps to create a publicly-funded system, with no co-pays, that gave every Vermonter access to primary care. Its statement of intent included that this was to be a first step towards reestablishing a path to a full single-payer health care system. (Medicare coverage would stay as it is, but the state would cover copays.)

The Senate Appropriations Committee got cold feet over the financial viability of the plan and reshaped it to be an evaluation of options for creating universal access, but not necessarily through public funding. Supporters of single-payer were aghast at the change, and some [not all] are saying they would prefer no action at all. We are already being inundated with emails urging us to go back to the original version of the bill.

There are some huge underlying challenges, and a fundamental bottom line. Our health care spending is heavily controlled by the federal government. We take in so much in federal “matching dollars” that we actually receive more than what we pay out in taxes. In other words, our neighbors in other states are subsidizing us. So striking out on our own is not an option. That is a big part of why Vermont’s vision of its own single-payer system was doomed to failure. That is also what moved us into our current health reform initiative, the “all payer” model that uses a single organization (called an accountable care organization) to funnel money from payers into the health care system to make it more streamlined, with better coordination of care.

It wasn’t based on own choice to pick that system. The federal government set it up for its own Medicare program, and we latched onto it with Medicaid to try to align systems. As private insurers join in, it has some real potential for managing our unwieldy system. It’s in its infancy and it still hard to tell whether we can actually get the Titanic to shift course. Having put at least some of our eggs into that basket, however, raises serious questions for me about whether we can overlay a second major change on top of the first one while it is still just getting off the ground. The broad concept for the new proposal isn’t very hard to grasp: if the state funds primary care for all, everyone’s insurance rates go down – your insurance is left only covering higher levels of care – so the cost savings is transferred to the new system.

However, in the new all-payer model, the ACO is being paid to provide all health care, including primary care. A person is attributed to the ACO’s payment model based upon being the patient of a participating provider. If all primary care doctors became part of a single-payer primary care system, the ACO role might become superfluous for primary care, yet it would need to remain for everything else, plus coordinate between systems. The more that we increase the shuffling of money between different entities and payment mechanisms, the more some of it gets lost in the transactional costs. If the major focus is making sure everyone has access to primary care, another route might be to focus solely on those who currently don’t have access, instead of creating a whole new system. That includes those without insurance, but also folks who can only afford insurance with very high copays and deductibles.

There is very strong evidence that getting good primary care saves in overall health care costs. Illnesses are intercepted earlier and are easier and less expensive to treat. People stay healthier. The evidence is more mixed over whether copays are still a barrier to getting care even if they are low, and thus should be eliminated, or whether they are a protection against overuse of care.  How much is it appropriate to have people hesitate (“Is this worth a $20 copay?”) before heading to the doctor? Obviously striking the balance is very dependent upon individual incomes (what percentage of your paycheck is that $20?) I’m not sure I buy into the idea that the ideal system would have no individual contribution at all for getting care – no “skin in the game.”

The bill that eventually passed the Senate includes evaluating the question of copays rather than starting with the assumption of a system without them and requires looking into methods other than a publicly-paid system to ensure everyone has access. Two questions will be before our committee. First: whether doing a major evaluation of options and mechanisms are likely enough to provide solid outcomes to be worth the cost. Second: whether we should be returning to some form of the original Senate bill and plunge forward with trying to make this happen, faster.

Legislative Update, Part 2

Pharmacy Costs

We are also grappling with the costs of prescription drugs. Specialty drugs are becoming the biggest new cost drivers. We heard data from Blue Cross Blue Shield that although these account for only one percent of the prescriptions written, they are 50 percent of the insurer’s pharmacy costs. These new drugs – you see the names like Humira and Enbrel on television ads -- are life changers for people with conditions that may have left them bedridden in the past. The costs, at least in part, are driven by the time and effort manufacturers put into developing them.

However, the whole arena of manufacturer pricing is kept in a black box. This year, we are taking a number of steps to try to push back. Three years ago we unanimously passed a first-in-the-country disclosure law that requires drug manufacturers to share information to justify the increases for the drugs with the biggest price jumps. The results were a bit disappointing because many of the answers were so vague. We plan to strengthen the bill this year.

There is also a bill to ban the “gag orders” that some drug distribution managers place on pharmacists, prohibiting them from telling customers about a lower cost alternative unless the customer directly asks.

The biggest initiative is to develop a Canadian import plan that would be organized by the state itself. Not every drug is less expensive there, but many are significantly cheaper. This would require receiving a federal waiver, but such waivers are directly permitted under the Affordable Care Act. An interesting aspect is that there is another state that is also aggressively pursuing this idea: Utah. Of particular interest, because Utah is one of the most conservative states, and Vermont one of the most liberal. The idea of teaming up on this is appealing!

There is a slightly more convoluted proposal the Senate has sent us regarding expanded bulk purchasing of drugs by the state. Since Vermont Medicaid already does this in a consortium with a number of other states, it isn’t clear what further gains this might bring.

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Mental Health Care

Just a few weeks ago, my committee said in a memo that it was time for hospitals to step up to the plate and recognize the importance of equity in addressing mental health conditions as a part of health care. Somehow the state keeps being expected to be in charge of providing psychiatric hospital care. Now the University of Vermont Health Network is doing just that – stepping up.

Though the proposal is not at all fleshed out yet, it would be based upon a master plan for future expansion of the Central Vermont Medical Center that would include a new psychiatric inpatient wing. That would add desperately needed capacity for Vermonters who are currently often waiting for days, and sometimes weeks, in emergency rooms waiting for a hospital bed. It would also mean we would more of our statewide psychiatric care into the modern era for the standard of care, which is to be fully integrated with a medical center, since mental health and other medical conditions are so deeply intertwined.

We still need to do more intensive planning for interim capacity, because that plan, if it does gel, will be several years in the making. But it was welcome news to many legislators’ ears.

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Please stay in touch as you hear about issues affecting you and to keep me informed about your views.You can reach me at adonahue@leg.state.vt.us. Thank you for the honor of representing you.