Healthcare issues

Home Births and Insurance

The last few weeks House Health Care was pursuing an insurance mandate for home births. Midwives are licensed in Vermont, have been for a decade. VHAP and Medicaid already cover home births but private insurance in Vermont hasn't taken the leap. They will now.

When I reported the bill on the House floor, I said: "Home births are already happening. In fact, Vermonters chose home births more per capita than any other state. What we're discussing today is giving someone who already pays for health insurance the chance to get their midwife paid for by insurance."

The data behind this mandate is compelling. In 2010 VT's Medicaid programs covered 60 home births for a cost of about $58,000. In hospital it would cost 3-7 times as much. In a year when patient choice and cost-control have been major themes in Montpelier it was exciting to see this small but important change grab hold.

Marijuana Dispensaries

Within one year, Vermont could have four dispensaries registered to dispense marijuana to qualified patients under a bill passed by both the House and Senate last week. Under very strict guidelines, S.17 authorizes the Dept. of Public Safety to begin rule-making that will allow four nonprofit dispensaries to grow and sell a limited amount of marijuana to patients on the Vermont marijuana registry without threat of prosecution under state law.

Dispensary activities will, of course, remain illegal under Federal law, a fact that sparked fierce debate in the House last week. Just as the bill was scheduled for a vote in the House, the U.S. Dept. of Justice began flexing its muscles in states across the country that are starting to implement marijuana dispensary laws. Because most state laws allowing “medical marijuana” were passed by voter initiative, the rules in each state are distinct, idiosyncratic, and often clunky. Vermont is also unique. First, we don’t use that term. Our law allows certain patients to use “marijuana for symptom relief.” We don’t ask doctors to prescribe the drug, only to verify that the patient has a condition described under the law. And we are the only state that regulates patient marijuana use through the Dept. of Public Safety (rather than the Health Dept). Under S.17, Vermont will continue to have the tightest laws in the country on this issue.

A timeline for health care reform

May 6, 2011, vt Digger, Richard Davis

Editor’s note: This op-ed is by Richard Davis, a registered nurse and the executive director of Vermont Citizens Campaign for Health.

It is clear that the legislature is moving full steam ahead and there is little doubt that the governor will be signing H.202 very soon. One of the most often asked questions about this bill is, “When will it affect me?” Here are some tentative answers based on a document created by the Joint Fiscal Office titled, “Draft H. 202 TIMELINE (as passed by Senate Health & Welfare). Keep in mind that everything is a moving target and subject to change.

If we assume that Shumlin signs H. 202 into law right after the end of this legislative session, the first official event will be the appointment of a nominating committee to vet nominees to the Green Mountain Care (Vermont’s new health care plan) board.

Once the nominating committee does its work sorting through applicants to the high-profile, powerful Green Mountain Care board, it will recommend the appointment of five members of the board to be hired by October 2011. At that point, the full board will begin its work. The board will then have the power to begin the approval process for insurance rate increases, provider rate setting and payment reform.

In May 2012 legislation will need to be passed that finalizes exchange-related implementation. There are many requirements that states must meet, according to federal law, relating to setting up an easy-to-use insurance marketplace, known as the exchange. That marketplace must work in concert with Vermont’s new health care plan.

I won’t get into exchange issues here because they are so complex. It is important to understand that exchanges must offer at least two insurance plans, and Vermont eventually would like to have only one operating insurance entity. There is a way to make that happen, but it requires special permission from the federal government, one of the so-called waivers.

The board will begin the work of approving hospital budgets and certificates of need in July 2012. Those are duties that were previously within the purview of the Public Oversight Commission, which will be eliminated.

In September 2012, the board will produce a draft of GMC benefits so that work can begin on a financing plan. The board will then approve benefits to be offered in the exchange in October.

The next major step in the process will happen at the beginning of a new legislative session in 2013 when the administration delivers a financing plan to the legislature. This is where the rubber meets the road and it will most likely take the entire legislative session of 2013 for a Green Mountain Care budget to be developed. If all goes according to plan, a budget for the system will be enacted in May 2013.

All of these activities depend on the outcome of waiver requests. Exchange waivers could be granted as early as the fall of 2013, but other more critical waivers may not be able to be secured until 2017. The hope is that the 2017 date will be moved up to 2014 so that Vermont can implement something close to a single payer system rather than just a redesigned insurance marketplace.

Once the state has everything in order relating to exchanges, then exchange coverage benefits and coverage under GMC could begin in January 2014. That would be the earliest date that all of the health care reform efforts in Vermont would actually bear fruit. People would be able to have new health insurance coverage that is comprehensive and affordable while providers would be paid at a rate that reflects reality and, perhaps, not be forced to subsidize the health care system.

If the federal waivers are not enacted in 2014 then the fruit bearing part of GMC, the time when Vermonters are actually able to sign on to the program, will have to wait until 2017.

While that seems like a long time to wait, we have to keep in mind that everything we do now will make a new system possible. We must keep the process active and all of us must stay engaged. Each step along the way makes the next step possible.

It would be better to have all of this begin in 2014, but if we have to wait until 2017 our biggest challenge will be to remain focused. Sadly, people will suffer and die as a result of a delay, but Vermont will still have the chance of becoming the first state in the nation to offer its people affordable access to comprehensive health care benefits under a single payer insurance system.

Health care bill en route to the governor

May 6, 2011, vt Digger, Carl Etnier

Green Mountain Care is set to become law now that the House and Senate have passed the final version of the health care reform bill, which was hammered out in conference committee earlier this week. The House approved the bill Thursday on a 94-49 vote.

The legislation now heads to the governor’s desk where it is expected to be signed into law with fanfare. Gov. Peter Shumlin, a Democrat, is the architect of the single-payer health care plan, and he will likely sign the bill into law next week.

The House vote was intensely partisan with minority leader Rep. Don Turner, R-Milton, noting afterward that no House Republicans had supported it. He complained that the House GOP was shut out of the three-member House delegation to the conference committee, and he called on Shumlin “to ensure that minority position concerns are addressed.”

One Republican, Rep. Anne Donahue, D-Northfield, who voted against the legislation, said she would collaborate in implementing the state’s pioneering reform of its health care system.

Rep. Mark Larson, D-Burlington, and chair of the House Health Care Committee, reminded lawmakers that the health care reform initiative is the result of the problems inherent in the current system.

“Too many Vermonters continue to be uninsured, and even more face financial risk if they get sick or hurt because of inadequate insurance,” Larson said. “Vermont businesses continue to struggle with the skyrocketing cost of health insurance. And the way that we fund health care is inequitable, inefficient, and unfair to many. It continues to support the ability to cost shift, one to the other.

“Most importantly, our health care system lacks the ability to control costs and to ensure that the dollars Vermonters do spend provide Vermonters with quality and go towards things that help Vermonters get better when they’re sick or hurt, or to stay healthy, to avoid not just the cost of getting sick, but also just to preserve their health,” Larson said.

Green Mountain Care sets the state on a path towards universal health care coverage for Vermonters, regardless of where or whether they are employed. It would not, strictly speaking, be a single-payer system, as private supplemental insurance plans will continue to be available, and federal programs like Medicare and Medicaid will continue, but Larson expects the plan to reduce the number of insurers now operating in the state. He also says that the coverage of Green Mountain Care will be such a comprehensive benefits package, he is not “sure why somebody would want to purchase additional insurance beyond that, but that would be a choice that they could make.”

The conference committee resolved a number of issues that had mobilized health care activists in the waning days of the session. The Senate had specified that undocumented immigrants be excluded from the coverage of Green Mountain Care. The final bill asks for a study of the costs of including or excluding undocumented immigrants. Larson pointed out that fear of deportation keeps undocumented workers from seeking treatment when they need it, and if their condition worsens so much that they require emergency care or hospitalization, then those costs are borne by other Vermonters. It’s possible, he said, that it would be less expensive for everyone to cover even those immigrants without papers.

Another thorny question relegated to further study is whether to cover and require payments from those eligible for TRICARE and other federal coverage. In this case, too, Larson said, it’s possible that creatively including these individuals in Green Mountain Care could lower costs for everyone.

Health insurers were both helped and hurt at the conference committee table. The bill’s supporters want Vermont to set up by 2014 a health benefit exchange of the type mandated by the federal Affordable Care Act. Some people had feared that no insurance providers would want to participate in Vermont’s exchange; the bill now requires that the state try to entice at least two insurance companies to underwrite Vermonters. On the other hand, the number of insurance company representatives allowed to serve on the Green Mountain Care advisory committee was reduced from three to one.

The bill was a signature issue in Shumlin’s gubernatorial campaign. In the Legislature, it has been the subject of intense lobbying, both by supporters and opponents. With passage virtually a foregone conclusion, representatives largely confined themselves to clarifying or debating the changes from the conference committee.

A few had the energy left to argue the larger questions of the bill. Rep. Cynthia Browning, D-Arlington, lamented the “lost opportunity” to help uninsured and under-insured Vermonters sooner than 2014. She also said that there were so many unanswered questions, it was like “Scarlett O’Hara health care: ‘We will think about that tomorrow.’”

Rep. Willem Jewett, D-Ripton, countered that the current approach is not working, and though the bill “does not provide a solution to our problems, it does provide a process through which we can reach one.”

Deb Richter, a physician who has lobbied for decades for single-payer health care, was on hand for the vote, and she was “overjoyed” at the passage of “an amazing piece of legislation.” She says that she gets a lot of letters from people who don’t understand the legislation, so she expects to be part of a group that travels around the state to explain to Vermonters how the bill works. When asked whether she would like to be a member of the five-member board the bill creates to implement Green Mountain Care, she replied, “I would never turn away a position that could be helpful to the process.”

What does Universal Mean to You?

When I made my pitch to the Speaker, hoping to secure a seat on the House Health Care committee, I promised to vote for the bill if it covered everyone and saved Vermonters money. H. 202, when it passed the House, set Vermont on a path to do just that.

When the Senate passed the bill they tacked on two amendments that are particularly troubling, and clearly violate the "universal" in universal health care. Keep in mind the title of the bill is "An Act Relating to a Universal and Unified Health System."

The first floor amendment, offered by Sen. Galbraith, takes a big step to carve a few people out. With broad support, he excluded anyone enrolled in TRICARE (the VA system). The logic is simple, these people already paid for health care through their service to the country. What he fails to understand is that Green Mountain Care, our hoped-for single-payer system, may well want to enroll eligible people into TRICARE. For some Vermonters that would be the cheapest way to get health care. This is part of what Hsiao meant when he said a hybrid single-payer system.

We ought to figure out a fair way to finance Green Mountain Care without asking folks who've already paid their health care bill to pay again. But that can be done without excluding this population from the outset. They are Vermonters and part of guaranteeing that they have coverage means being able to work with TRICARE, not prohibiting it.

A more troubling moral change coming from the senate is the Brock-Sears amendment to exclude undocumented workers from care. Charming! It's unclear what happens when an undocumented farm-worker shows up at the emergency room after his arm was half ripped off in an accident. We know Vermont doctors will care for this person. The Brock-Sears amendment leaves us wondering how that care will get paid for. One of the beauties of a universal system is that the cost shift is eliminated. Carving out this or any population reinstates the cost-shift and is a bad idea.

H. 202 is a long-term plan to get significant health care reform into reality for our state. We shouldn't start out of the gate by excluding certain populations. And if we do, we should have the integrity to remove the word "universal" from the title. Many in the legislature are fighting to undo these last-minute changes. We should have an update by late Tuesday.

Sugar Sweetened Beverages

Houston, we have a problem. In the mid-nineties Americans' consumption of sugar-sweetened beverages (soda, sports drinks etc) eclipsed milk for the first time. Since then the trends have continued in the unhealthy direction.

Last week, House Health Care heard from Yale's Dr. Kelly Brownell. He directs the Rudd Center for Food Policy and Obesity and explained that part of the problem arises because our bodies aren't good at recognizing calories from fluids. If half of you reading this drank 200 calories at the end of your meal and half of you ate 200 calories worth of cheesecake those of you who drank the calories would be eating again sooner.

When you consider that up to 10% of American's calories now come from drinks it's not hard to believe the link to obesity and therefore to type II diabetes.

So what do we do? H. 151 before the House Ways & Means committee asks for a $0.01 tax per ounce of sugared-sweetened beverages (not juices but anything where sugar is added). Economists believe this is a significant enough rate to curb consumption by as much as 20%. While this concept has been proposed in states and cities around the country it hasn't been enacted anywhere yet.

The Philadelphia city council came within one vote of imposing a 2 cent per ounce tax. Since then Coca-Cola has donated $10 million to the local children's hospital for studying childhood obesity. Professor Brownell compares the debate to the public discussion around taxing cigarettes.

For Progressives, part of the challenge is that a consumption tax is, by nature, regressive. And since a lot of marketing for soda, etc. is targeted to low-income consumers, the concern is exacerbated. Meanwhile, costs of healthy foods have climbed while soda prices have remained fairly stable. Obviously public health suggests we need to drink less soda. But is it fair to target a population whose incomes have declined in the last decade and who already feels left behind by policy makers and government?

H. 151 isn't moving this session but the issue isn't going to go away. We need solutions to slow our consumption of sugar-sweetened beverages or else we will continue to face significant health-related expenses both as taxpayers and as a community.

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