April 23, 2022 Legislative Update

If we are truly going to finish the session by May 6 – a week ahead of what we are budgeted for – everyone’s heads will be spinning in the last few days. Most major bills have not even reached the point of a conference committee to resolve competing House and Senate versions. The budget just went to conference on Friday.

What is the big rush? Three members of the Senate are running for U.S. Congress member Peter Welch’s open seat, and they want to get onto the campaign trail. Hopefully we will not succumb to pressure by voting bills through without even time to read them. I’ve fought that in the past and certainly would again.

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Health Care Example

My committee just voted out a significantly changed version of the major health care bill of the session, which was initiated in the Senate. It still has to clear our Appropriations Committee, so it won’t be voted on by the House until near the end of the week. That would only leave a week for the Senate to assess our changes, push back, negotiate, and then move an agreement through both House and Senate, which would not be possible without suspending our ordinary rules and expediting the process.

The hospital association opposes the bill, fearing that cost-containment efforts will force cuts in services, but they testified that our version is better than the Senate’s. The real focus of the bill is how to ensure the sustainability of our rural hospitals. According to media accounts, the Senate does not like our version, which takes a more thoughtful and inclusive route to the next phase of health care payment reform and the negotiations with the federal government necessary to achieve them.

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Intra-House Disputes

When one party has control, disputes between committees never reach the surface publicly as a debate on the House floor would; the House Speaker will resolve it in advance. I can’t predict what will happen with my committee’s bill protecting patient genetic information.

The issue is whether life insurance companies can access patient tests for genetic markers which do not result in a diagnosis but may indicate an increase in risk for a disease. We placed health care as the priority to encourage testing and preventive measures, passing a bill that blocks life insurer access. The Commerce Committee, however, is worried about an impact on the health of life insurance companies. Right now, it doesn’t look as though there is a compromise available, so whether our bill makes the light of day may well be decided in the Speaker’s office.

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A Brilliant Opportunity

Amidst all the angst over ways to help reduce carbon emissions, there is one easy place where we could all step up. According to an estimate cited in a bill we passed this week, “if every motor vehicle in Vermont reduced unnecessary idling by just one minute per day, over the course of a year Vermonters would save over 1,000,000 gallons of fuel and over $2 million in fuel costs, and Vermont would reduce CO2 emissions by more than 10,000 metric tons.”

Don’t panic; we didn’t just pass a bill to ban idling… it’s already the law! This is a section of a routine motor vehicle law update bill that simply directs the state to increase public awareness. If you see more public service announcements reminding you that in Vermont, “A person shall not cause or permit operation of the primary propulsion engine of a motor vehicle for more than five minutes in any 60-minute period while the vehicle is stationary,” that will be why.

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Legislators Are Special?

We passed two new bills that are problematic, at least in part, for me. One creates a new crime for making threats to an elected official – separate from what the law already says about threating. I think we are flirting with free speech and the right to “petition for redress of grievances.”

Serious threats against anyone are covered under existing law. Yes, I’ve had constituents who may use some hyperbole in expressing anger over legislative actions. But I don’t want to see a chilling effect on political debate based upon some folks who may cross the line and need to act with greater civility.

I think we also really insulted our state’s physicians in our new legislative ethics law. I absolutely agree we needed to set ethics standards; we’re one of the few states without any. But some years back we banned physicians from even accepting a free cup of coffee at conferences being hosted by pharmaceutical companies, lest they be “bought off” by it. We legislators, however, can accept up to $100 without fear that our motives will be impugned.

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Removing an Exemption

A question has arisen about the federal Americans with Disabilities Act and its applicability to our House proceedings. There have been federal court cases that establish that the independence of the process means that state legislatures are exempt from laws that we have not placed on ourselves. I believe strongly in the importance of this kind of separation of powers, but I also believe strongly in the importance of equality in access to our government for all. I am pushing a proposal in our House Rules Committee to adopt an affirmation that we assert our exemption – followed by setting our own rule that we choose to be governed by the standards of the ADA.

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The Housing Registry

We seem to be explosively increasing areas of government bureaucracy and the number of state-funded positions this year. That includes six and a half new positions to enforce a new statewide rental safety oversight process that would replace local oversight. One Appropriations Committee member who acknowledged being part of the problem in terms of earlier bills this session voted against this one in his committee saying, “enough is enough.”

It was vetoed last year and once again enough Democrats joined Republicans in opposition that although it did pass, it would not survive a governor’s veto. This year, it was embedded within a bill with major federal funds for grants to help improve rental housing conditions, and those are funds everyone wants to see move forward. So, it will be brinksmanship on the legislature banking on the governor caving in, versus moving the funding to a separate bill and letting the registry bill die.

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Tough Decisions

One difficult part of voting on bills that require budget investments is our inability to have a big picture in front of us. If we know we cannot have it all – and there is certainly no way government can pay for everything that everyone would like to see it do – how do we identify the priorities? It comes down to the big budget in the end, but that is made up of many of the components we vote on separately as the initiatives come before us. If you vote for each of the individual bills as being good, legitimate initiatives, it wouldn’t be fair to turn around in the end and say, “That has added too much and I’m voting against the budget.”

And thus, the dilemma of the proposal for universal school meals. Despite the appearance of simply “helping the rich” since poor kids already get free meals, there are legitimate reasons for it. A large number of eligible (hungry) kids don’t get meals for a myriad of reasons, including the fact that some struggling families are overwhelmed even just in trying to fill out complex paperwork.

The feds have paid for universal meals for two years under COVID. The current proposal would extend that for a year at a cost of $30 million paid for with “extra” money in the state’s Education Fund, for further review for a funding (tax) source next year. “Extra” money actually means that there is a surplus ($90 million) because last year the tax rate raised more money than we predicted to be needed for school budgets. It’s your money being proposed for various uses over and above last year’s education costs.

There are other demands for it. Most proposals include returning some to taxpayers. There are also school needs to address chemical contaminants and deferred maintenance. Which take priority? Where do we get the biggest bang for the buck in helping those most in need?

A big concern I have regarding the current bill as it heads to the floor for Tuesday is that it includes five permanent positions in the Agency of Education for implementation, including for creating a universal income declaration form. Permanent positions don’t sound like a one-year extension. And a universal declaration form? Will that require every family to make this disclosure – even if they didn’t ask for or want free meals?

So, I’m still hesitant and waiting to hear the full floor debate.

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Your Voices

I’ve heard from constituents on the school meals issue. How does that impact a decision on a bill? It does, in part – and by different degrees. Individual, thoughtful letters that add insights matter a lot. Petition-type communications, less so. All of these reflect serious interest by a few people but not a public referendum. We have a representative democracy, not a direct one. That means you elect your representative based on what they stand for in a broad context; hopefully I act in ways that are consistent with that and if I don’t, you do not re-elect me. 

Ultimately, I need to vote based on the values I’ve expressed, not based upon limited specific constituent input on individual bills. I do listen. The impact is greater when I am more on the fence. That’s the case here – so you still have until Tuesday to share more thoughts.

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All my past updates are available on my blog at representativeannedonahue.blogspot.com. Please contact me or Ken Goslant 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.

April 10, 2022

 When you do surveys or polling, expertise and how questions are asked can heavily influence its accuracy. But if you ask the exact same questions over time, even if the questions are not hitting on the exactly right point, the ways the responses change can still provide valuable insights.

That’s how I look at the newly released results of Vermont’s Household Health Insurance Survey, something we have been conducting every three years or so since 2005. My House Health Care Committee heard a presentation on the new numbers this past week. It is based on in-depth interviews with more than 3,000 Vermonters. If you’d like to look at it directly, it’s at www.healthvermont.gov/stats/surveys/household-health-insurance-survey

So what does it tell us, and what does it fail to tell us? Some of the key “good news” components are that we have continued to maintain the level of 97% insurance coverage in the state. In addition, of the 70,000 or so Vermonters who lost jobs during COVID, 84% were able to maintain health coverage.

On the not-so-good news front, the number of Vermonters under age 65 who are underinsured has risen from 36 to 40 percent in the past seven years, despite all the increases in financial supports. In addition, the number of those who are on Medicare without having any coverage beyond the basic Parts A and B is 64%. Those are both important numbers but require a much deeper dive. I’ll try at least sharing a shallow dive.

What does “underinsured” mean? Broadly defined it means that based upon one’s income, a person cannot get the level of health care they need because their insurance does not cover enough of the costs to protect them. A simple example would be a plan that has a $10,000 deductible for someone making $40,000 a year. They would have to pay one fourth of their income in health costs before their insurance would start paying. If almost all Vermonters have insurance but a significant percentage of them still can’t access health care, the high level of insurance coverage is not exactly comforting.

The flaw is in trying to define underinsured, so that it isn’t just based on subjective perception. The survey uses a formula. Underinsured means that either the deductible is more than 5% of household income, or current medical expenses (co-pays and deductibles paid) are greater than 10% of income for those at 200% of poverty or more or 5% of income for those below 200% of poverty. (For a single person in 2021, 200% was $25,760; for a family of four, it was $53,000.) Even though it is considered the best available definition, it’s flawed for several reasons. 

First, it does not include the amount you are paying for your insurance premiums. If you are paying a staggering amount for coverage and as a result your out-of-pocket co-pays and deductibles are lower, that doesn’t get considered in the overall cost-burden of your health care. It also includes costs for health care that are not routinely covered by insurance at all which can skew the comparison of out-of-pocket costs. Finally, it doesn’t capture health savings accounts that are funded (fully or partially) by employers. If your insurance has really high co-pays but you have an HSA that covers most of them, you might still be counted as underinsured.

However, since we are using the same flawed formula every time, the relative change over the years still gives us important information. If under any definition those who fit under it are growing as a percentage, it is not good news in assessing whether our health care system is accessible and affordable.

Better Definitions?

It seems to me that in order to tackle a problem, we need to define the goal. Otherwise, if our goal is “affordable and accessible,” how do we know if we are getting closer to meeting it? 

Last summer and fall, I was on our legislative study committee that was aptly titled a Task Force on Accessible, Affordable Health Care. Several of us pushed for the need to develop a definition as a first step, and there was general agreement. We had a consulting firm that was doing the legwork for our evaluation, and it began straying more into subtopics that identified various projects that might help reduce system costs, thereby impacting affordability. Setting a standard fell by the wayside. For that reason, as well as the Medicare issue that I will discuss in a moment, I voted against adopting the consultant report as our Task Force Report. 

Who Are They?

Even without a definition, one would think we could identify the subgroups of people who have the least access to affordable coverage and target our problem-solving towards them. But we can’t, because much of it goes back to the fact that so much of our health coverage is employer-based. As per the updates from this year’s survey, 24% of Vermonters get their primary insurance from Medicaid, 22% from Medicare, and 49% through private companies.

Given our aging demographics, it’s no surprise that the Medicare percentage has gone from 15 to 22% since 2005. The Medicaid increase from 15 to 24% may be slightly off in this year’s data because the federal rules have forbidden reassessments of eligibility during COVID. However, much of it relates to the Affordable Care Act expansion of coverage. Of the private insurance group – which has dropped from 59% in 2005 to the current 49% in 2021 -- 10% are individual buyers on the health exchange (“Vermont Health Connect”.) Right now, as long as the increased subsidies from the federal government are in effect, most of them have some of the best accessibility. For all the remainder, who are getting insurance through their employer, we have no way of identifying what level of coverage they are receiving. 

Under the Affordable Care Act, you can switch to the health exchange if your employer’s insurance is not considered “affordable,” which is defined as a premium share that is greater than 9.6% of your income. Once again, this is not a rational standard. If your premium is low because of a huge deductible and huge co-pays, tough luck; you can’t opt for the much lower costs on the exchange. The formula looks solely at the premium you pay.

There is a worse problem that affects families directly. The affordability standard is based on the single employee, without including the costs for the rest of a family, even if the employer contributes nothing towards that. This “family glitch” can leave families paying 20 percent of their income for health coverage but still without access to the exchange. One of the brightest bits of news to come out of Washington this past week is that the administration has filed for a rule change for that particular definition.

The Medicare Problem

We don’t know about employer plans, but we do know about Medicare – and it’s a disgrace. Anyone who thinks “Medicare for All” is a grand solution doesn’t know enough about Medicare. And anyone who thinks Vermont is particularly generous in health care for those with very low income doesn’t know about Medicare in Vermont.

The typical person turning 65 faces complex decisions about an array of options that will determine their coverage for the rest of their lives. Basic Medicare leaves someone with high-cost risk, because although 80% of costs are covered in general, there is no upper limit to what a person may have to pay. At a bit over $2,000 a year for “Part B”, what it does cover may be a good deal for the money, but this is already a steep price if you are on a low fixed income, and prescription coverage is extra. If you delay paying for Part B, a permanent increase of 10% a year in cost is imposed for every year of delay.

If you can afford another $3,000 or so a year, you can get very comprehensive “gap” insurance. You can also trade it all in for an “Advantage Plan” which ranges in cost from just your existing Part B premium to an added premium. Instead of having no limits on possible out-of-pocket totals, these limit them to a range around $7,500. Your provider network is also restricted. It is a good approach for some folks, but once you choose it and finish a trial period, you can lock yourself out from the full “gap” coverage option forever, or at minimum, are locked into paying a much higher premium.

The number I referenced at the start – that 64% of those on Medicare only have basic A and B coverage – is much scarier when you realize how unprotected those folks actually are. And here’s the issue if you are low income: if you at the very lowest end, you are eligible to have Medicaid on top of your Medicare. But if you are at the higher end of current Medicaid eligibility (in other words, still quite low income) and you turn 65, you lose Medicaid protection, because we change the standard to a lower income level.

You turn 65, and we drop you off the proverbial cliff – you become another of that subgroup of folks who end up paying as much as 20% of their income for health coverage. There is some assistance available to pay your premium, but Vermont offers a lot less than some other states. Our Household Insurance Survey only reviewed underinsurance among those under age 65, as if it was never an issue for those on Medicare, so we don’t know how many folks may be at this level of severe need. We have our heads in the sand. 

To me, this is a huge affordability and access issue, and I pushed all last fall to include it in our Task Force study. Our consultants fell down on the job on it – which was the other reason I voted against adopting the report. This past week, my Health Care Committee voted out a bill that will focus on Medicare for the first time, looking at how to help Vermonters understand their options and what tools we may have, given that this is a totally federal program.

I pressed for an amendment that we added to this Senate bill, instructing our Department of Financial Regulation to review the “cliff” group, and what other states do to help. It might give us a first window on steps to address this particular inequity in accessible, affordable health care. 

This is all only about regular health care, not about the costs of long-term care that isn’t covered at all by Medicare – a massive looming crisis as our population ages.

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Please contact me or Rep. Ken Goslant 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.

All of my legislative updates are archived at representativeannedonahue.blogspot.com