September 22nd, 2011

Vermont on the road to universal health care

On May 26, Vermont Gov. Peter Shumlin signed into law a landmark healthcare bill designed to control escalating healthcare costs, expand insurance coverage to all residents and create the first publicly-funded, single-payer insurance system in the country.

“This law recognizes an economic and fiscal imperative, that we must control the growth in health care costs that are putting families at economic risk and makes it harder for small employers to do business,” said the Democratic governor at the bill signing ceremony as he turned campaign promise into reality.

The law does three main things, says Cassandra Gekas, M.S., health care advocate at the Vermont Public Interest Research Group (VPIRG). First, it lays out an ambitious vision of health care as a public good that should be publicly financed and cover all Vermonters.

Secondly, it sets the stage for Green Mountain Care (GMC), the name of the new system, in a series of steps, starting with the appointment by October of a five-member independent governing board that will figure out the benefits package, how the system will be funded and how providers will be reimbursed. The next step is to set up the health insurance exchange called for by the federal Affordable Care Act, a virtual marketplace where consumers can comparison shop for health coverage and that will ultimately be transitioned into Green Mountain Care. Every state is required to set up an exchange by Jan. 1, 2014.

Thirdly, the law requires Vermont to seek waivers to allow it to pool federal subsidies, such as Medicare and Medicaid and administer them, like one big bank account, from Green Mountain Care. In essence, GMC will take advantage of federal money to expand benefits, which is key, Gekas says. To get the waiver, Vermont will have to prove it can cover at least as many people at the same level of benefits without more cost. Green Mountain Care is targeted to open for business by 2017 provided the legislature affirms certain milestones.

“The whole goal is to simplify the administration of a system that’s fragmented,” Gekas says. The more a small state like Vermont breaks up its insurance market, the less negotiating power it has. She thinks that’s one reason Vermont’s health care costs are growing 12 times faster than the state economy. Another reason is that fragmentation leads to high administrative costs, which proponents are counting on cutting in their fiscal calculations. The advocacy group Vermont Health Care for All writes in a Frequently Asked Questions pamphlet that savings could amount to hundreds of millions of dollars per year.

Rep. George Till, M.D., (D-VT Chittenden-8 District) the only practicing physician in the Vermont legislature, thinks proponents have inflated the potential administrative savings in Vermont’s annual $5 billion health care expenditure. He also thinks the term “single-payer” is a misnomer (the term doesn’t actually appear in the bill) because it’s unclear whether a large swath of the federally-managed insurance market, such as veterans’ benefits and self-insured plans, can be compelled to join Green Mountain Care, though advocates are going to try. But the Democratic lawmaker did vote for the bill because he believes in universal access and coverage for all Vermonters. Still, with only 47,000 out of 630,000 residents uninsured, he says Vermont has one of the lowest percentages in the country.

Till is concerned about costs to individuals and payments to providers, as is every doubter. Under Green Mountain Care, public taxes, private premiums and out-of-pocket costs would be rolled into a “public premium,” a major change in how people pay for health care. Providers, per the law, must be paid equitably and amply enough to sustain their practices. Nobody knows exactly what those amounts will be and proponents chafe at being asked because nobody knows how much their current health insurance will cost next year, either.

“We have no dedicated financing for the health care services we expect to be there. My question [to doubters] is always the same: who should pay for that? They can’t answer,” says Deb Richter, M.D., president of Vermont Health Care for All and one of nine nominating committee members that will recommend Green Mountain Board members for appointment by the governor and confirmation by the legislature. “We’re paying, either publicly or privately, for more services than our society needs. And if we do nothing, we’ll be even worse off. We need a system to figure that out.”

According to Gekas, wording in the law guarantees mental health will be part of the benefits package, but as always, the devil is in the details. Richter assures the mental health community that there will be a process in place to assess how such benefits can be included and says it’s understood that prevention and treatment are the best ways to keep mental health costs from escalating. She says providers should look for reassurance to Canada where mental health workers are paid “far better” than in the U.S.

Rick Barnett, Psy.D., LADC, president of the Vermont Psychological Association says 75 percent of VPA members support universal health coverage as long as mental health and substance abuse services are reimbursed at adequate rates that are comparable with physical health care and do not require authorizations in a manner that is discriminatory.
“We are committed to making sure that Vermonters will continue to have access to and receive excellent mental health and substance treatment,” Barnett says. “Anything less than true parity is unacceptable.”

By Nan Shnitzler

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