Healthcare issues

Meaningful Strides for Health Care, but a Long Way to Go

It was almost an annual rite over the last twenty years. Just like Sen. Sanders in Washington, Progressives in Montpelier have offered a single-payer amendment to whatever piecemeal health care bill lands on the House floor. In the past we were lucky to get 20 votes.

2011 saw a seismic shift. Suddenly single-payer was the talk of the town. Instead of us offering a hail mary amendment, Democratic leadership was whipping votes, making sure their members would support H. 202. What a difference a change in leadership makes. And it just goes to show that we need never take no for an answer. When political leaders tell you something is impossible remember this example.

But remember too that a lot went into the shift, more than just electing the right person governor. Three years ago the VT Workers Center focused their sights on health care and refused to take no for an answer. In large part, they made the current debate possible. Every single public forum, every single day of testimony and deliberation in committee, on every editorial page and more - the health care is a human right campaign was present. The impact was that law makers could honestly say they keep hearing from folks who want this to happen while few opponents bothered to show up.

It is a model of social change that we need to see more of. Progressives have softened the ground for real health care reform for decades. And eventually, after years of loud, sustained public pressure, mainstream political leaders pick up the banner and run with it.

Gov. Shumlin deserves credit for his unwavering commitment to universal coverage. His leadership helped us craft a strong road map, laced with solid principles that we can all applaud. But the real work lies ahead. We have to keep the political pressure on. And we have to demonstrate that the theories will work.

Vermont can be proud of where we stand today. We are leading the nation striving for single-payer health care. But setting a goal isn't the same as establishing a program. The real work continues to unfold. Progressive legislators are part of that discussion and we hope Progressives at the grassroots level will continue their activism, continue speaking up and rejecting the naysayers and pushing for justice. Together we will get there.

The Other Health Care Bill

More than 80% of Vermonters say they would like to die at home, but 50% are in a hospital when they die, and another 27% die in a nursing home. Among those enrolled in hospice, 76% are able to die at home. Sadly, Vermont’s hospice rate is one of the lowest in the country. The obstacles are many. First, doctors just don’t refer patients soon enough or often enough for them to get hospice services when they need them. Insurance (and Medicare) reimbursement guidelines were set 30 years ago and discourage enrollment. The health care reform bill has gotten all the press, but H.201 has important provisions that will improve health care delivery in Vermont.

The Hospice and Palliative Care bill brings Vermont into line with the rest of the country by requiring continuing medical education (CME) for all doctors. Until now, we were one of only six states with no mandatory CME. The practical result of this gap is that doctors are not always up to date on best practices in areas outside their fields of expertise. Far too many physicians do not understand the advances in palliative care and hospice services and their place in the range of available medical services. This has meant that patients do not get the information they need to make informed choices about their treatment. H.201 will increase access by assuring that physicians recognize the role of palliative care and hospice in treating their patients.

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.”

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