In record-breaking time – literally, on the first day –
committee assignments were made in the House and the work of educating new
members on the issues before us began. There are far more new members than
average, so many committees had to be juggled to balance the numbers of those
with experience, and those without.
I was reappointed as Vice-Chair of the Health Care
Committee, and as a case in point, only the chair and I have been in the legislature
for more than one term. The rest of the committee is made up of those who were
on the committee last session for the first time (4 of them) or who are brand
new to health care (5). With such complex issues in health care, that means we are
spending the better part of the first several weeks on an overview of the
different parts of the system.
Icebergs Ahead
Health care will face both old and new priorities this year.
How do we adjust Vermont law to protect the stability of the
Vermont insurance market given ongoing federal changes? Should those who take a
free ride – fail to buy insurance that they could afford, knowing that the rest
of us will pick up the cost if they end up in the hospital – face financial
penalties? How do we help those who do not have access to any affordable way to
get coverage?
Is there more we can do as a state to address drug pricing?
What are the best responses to the crisis in access to mental health care? Is
our “all payer” model for coordinating care across the payers (private,
Medicaid and Medicare) and progressing as hoped? Is our health exchange
(Vermont Health Connect) finally functioning as it should?
And one of the sleeper issues for this year: should Vermont
shift from getting permission to add health information to a statewide
electronic health record network (called “opt in”) to automatically adding it
unless a person objects (“opt out”)?
Primary Care Access
One report we received last week was the results of the
Household Insurance Survey which is conducted every three or four years to get
a clearer picture of coverage issues. The big positives: our
second-lowest-in-the-nation rate of uninsured – just over three percent –
dropped even a tad lower. Also, the number of people who said they delayed or
couldn’t afford needed health care dropped.
The negative: those who are considered under-insured
increased. Under-insured means you have insurance, but the money you have to
spend for co-pays or deductibles is an unaffordable percentage of your income.
People in this category are in the income level just above those eligible for
Medicaid, but are working in jobs that do not offer insurance.
There has been a clamor for a while about creating a
“universal primary care” system to ensure that everyone has access to basic
preventative and routine health care. This survey supports my perspective that
the majority of Vermonters have really good access: almost everyone with
Medicaid, Medicare or strong private coverage. I think we need to target our
efforts on ensuring access for the much smaller group of uninsured or
under-insured folks.
Mental Health
Our committee attended a community presentation on the
efforts of the University of Vermont Health Network to address access to mental
health care, and one part of CEO John Brumsted’s overview was striking. He said
that the all-payer model is finally enabling the system to invest in meeting
mental health needs.
That would be a striking sign of success in at least one
aspect of this health reform initiative.
A key to the reform is that health
care providers will eventually no longer get paid for each service they give. Part
of the problem with that system was that the way a particular service was
valued determined how much access there was. Mental health has a long history
of being under-valued, and low reimbursements meant there was a dis-incentive
to giving that care.
On the other hand, specific types of care fell in the
opposite category. For example, some services actually created revenue for
hospitals because they were reimbursed at more than what they cost to provide.
That created a financial incentive to do more of those services. After all,
even though they are non-profits, our hospitals still need to keep afloat
financially.
The reformed model pays per-person for all of that person’s
needs to keep healthy. The new incentive is to ensure care is well coordinated
to avoid wasting resources, and to ensure that people get what they need early
on, before needing more expensive services.
Because we now recognize how interconnected our mind and
body are, we recognize that mental health is a crucial investment in keeping
people healthy. According to Brumsted, the new flexibility of the payment
reform is enabling UVM to move more money into mental health with the prospect
of better health outcomes. The UVM network is moving more mental health
providers onto primary health care teams. It is also developing a project to
increase inpatient psychiatric capacity at Central Vermont Medical Center to
help address the crisis in emergency rooms around the state, where some people
wait weeks to get access to a hospital bed.
There is one clear consensus on this issue: we won’t resolve
that crisis without investing in both hospital and community mental health
service. Some of those people waiting in emergency rooms might not have ended
up there if they had access to care before they reached a mental health crisis
point.
Artificial
Intelligence
Artificial intelligence and health care? Yes, it’s already
here, and our committee attended a meeting of the new study commission that is
working on recommendations for whether state oversight is needed. What is AI?
Your email server may already be one that offers a choice of replies that you
can click to answer a message sent to you. There are no people on the other end,
reading your incoming email to identify answers you might want to send. Instead,
there is artificial intelligence: a complex computer algorithm that scans for
key words in the message to spit out (with amazing accuracy) your possible
desired response.
There are a lot of health care applications that could get
to the point of diagnosis and recommended treatment. That could be promising;
it could be scary.
Picture going in for your annual physical. Your doctor
states aloud some symptoms you’ve been having and her thoughts about causes.
The computer (secured by voice recognition of the provider) has your full
electronic health record, and might respond, “That is a reasonable diagnosis,
but did you remember the family history of xyz? Perhaps a test for pqr is
indicated in this situation.”
But think about the vast amount of information you already
give out via the choices you make on your social media accounts, plus the
tracking of your physical location you make available on various devices.
Research has shown that based on your online choices and the
messages you send, it is possible to identify that you may be depressed. If you
are now identified as walking towards a high bridge crossing, your iPhone could
ping you to ask if you are OK and offer support. Do we want Google to be doing
this? What if instead of offering help,
it automatically sends police to pick you up to involuntarily hold you for
screening at a hospital?
In our grand balance of altruism versus personal liberties,
there is a lot to think about in this brave new world.
***
Forced Mergers
Act 46 established a statewide public policy to create
larger school districts in order to ensure that students had more equal access
to educational opportunities. Even though we have some local control of our
budgets and thus our property taxes, all of us fund education on a statewide
basis and the state has the obligation to ensure equal opportunity. Act 46
mandated larger districts, but first provided a window of time for communities
to decide the best ways to achieve them locally. The new Paine Mountain School
District (Northfield-Williamstown) is an example of a forced – yet
self-directed – merger. We have reached the end of that window, and the law created
a mechanism for reviewing alternative proposals from towns that did not
establish a merger plan.
Berlin was one of those, and the state Board of Education
rejected its alternative plan and has mandated an involuntary merger with a
number of its surrounding, un-merged communities. These remaining communities
are now crying foul, saying it is undemocratic for the state to overturn the
decisions of local voters. The reality is more complex than that. Act 46 was
passed as state public policy by democratically elected state legislators, and then
allowed local decisions about how to accomplish the policy.
The issue now is how to address communities that appear to
not be meeting that state policy. It would be very unfair to simply allow those
communities to do as they please. Northfield might not have wanted to merge
with Williamstown but did so in compliance with the law; others should not get
to opt out by not complying. (As an aside, I would say the early evidence is
that the Paine Mountain district’s school board is pursuing the exact benefits
hoped for under the law. It is working as intended.)
On the other hand, we need to make sure as a legislature
that our process for assessing the situation of those remaining communities is
actually creating the intended result. If the alternative plans they developed
are a better route towards the goal of equal opportunity, but the state Board
of Education did not give adequate deference to how it met the goals, it would
not be supporting that intent. Berlin, as a community, worked very hard to
reach a solution that complied with the law, and we need to make sure that its
plan was assessed fairly before being rejected. Yes, we in the legislature do
sometimes create laws that have unintended consequences and don’t produce the
results we wanted.
That is why I signed on to a bill proposing a moratorium – a
delay – on the forced mergers until we have a change to do a more thorough
assessment of whether we sent up the right process for making those decisions.
My district-mate, Rep. Ken Goslant, also co-sponsored it.
It will be the Education Committee that ends up with the
responsibility to do the “deep dive” and assess whether changes are needed, and
propose a response for the full legislature to consider.
***
It is truly an honor
to represent you. Please contact me with your concerns and thoughts; I’m best
reached via email at adonahue@leg.state.vt.us.
