Healthcare issues

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.

Leading with retreat

In an amendement offeredby Health Care Committee Chair Mark Larson (D-Burlington), the term "single payer health care" was excised from the H.202, the single payer health care bill, in part (according to vt Digger) to make it "more palatable to Republicans."

How did that work out? Was it successful, despite the long track record of Democrats watering down health care reform in order to get Republican buy in? Well, the streak remains unbroken, as no Republican voted for the bill as it passed third reading in the house early this morning.

How big a majority is needed before abandoning the idea that you lead with retreat? If the Republicans were down to one member in the house, would we still be watering down legislation to try (and fail) to get that one vote?

Health Care, Taxes, Budget

The week ahead will be a busy one on the House floor and Progressives will be right in the middle of things since the bills up for debate include the miscellaneous tax bill, the health care bill, and the budget.

House Health Care voted H. 202 out of committee late Thursday night with my support. The vote was 8-3. I assembled a short video to explain the vision for Green Mountain Care, Vermont's single payer system. Watch it here.

Last week Progressives were at the forefront of a discussion about raising revenue. H. 401, my bill to increase income taxes on the wealthiest Vermonters, has been the subject of lots of discussion in Montpelier. While it seems unlikely H. 401 will pass it's worth mentioning that we've been able to prevent our system from getting more regressive.

Following the advice of the Blue Ribbon Tax Commission House Ways & Means was poised to switch Vermont to using "Adjusted Gross Income" (AGI) rather than "taxable income" as we have today. This change makes sense because it makes our system simpler and is already used by most other states. Plus, it eliminates the 40% capital gains tax exemption Progressives have been fighting for years.

In the proposal to switch to AGI, there were some troubling details. To begin with, 2/3 of the folks earning $1 million plus would have actually seen a tax break! You read that right. I quoted Sen. Sanders during his testimony in front of Ways & Means calling the change "Unconscionable."

The next day the shift to AGI was scrapped and will not be part of the Miscellaneous Tax bill debated this week. While that is good, the bill still doesn't do much to increase revenues so we can protect important state programs. Watch for an amendment along the lines of H. 401 to be brought forward by me and Rep. Poirier (I- Barre).

We will also be watching the budget bill closely. End of the week rumors suggested up to $30 million of Shumlin's proposed cuts had been restored but we will tell you more as details emerge. Obviously a successful amendment to the tax bill would go a long way to easing the pain handed down in the state budget. While many members agree this should be our direction it remains to be seen how many will be willing to buck their leadership.

The Other Health Care Bill

House Human Services has continued its focus on Hospice and palliative care services. The problem is that too few patients receive timely referral to either service. Informed patient choice of care requires that patients be advised of all their options. Treating physicians tend to offer only the most invasive and aggressive medical interventions. One cannot receive Hospice services without a referral. In Vermont those referrals, if made at all, often come just days before death is probable.

Hospice is a great service, and Vermont has excellent providers. But doctors see any referral as “giving up” so patients are denied access to services that can make them much more comfortable, physically, emotionally and spiritually. An insurance company study found that increasing access to hospice services not only improved quality of life for its patients, it increased their longevity and it saved money.

Among the current obstacles to increasing access are the funding limitations of Medicare, Medicaid and most insurers. Currently one who requests hospice services must agree to give up further curative care. Payers also require that a physician certify a life expectancy of less than six months. By broadening eligibility to expand services to one year and allow the continuation of curative treatment, we could improve the quality of life for many Vermonters. And research shows that we would also reduce health care costs.

H.201 will increase access by assuring that physicians recognize the role of palliative care and hospice in treating their patients. Vermont is one of only six states that do not require continuing medical education as a condition of license renewal. As a result many physicians do not fully understand the advances in palliative care and hospice and their place in the range of available medical services.

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