BRATTLEBORO—As the Vermont Senate takes up debate on the health care reform bill, questions such as “How will we fund it?” and “What about...?” in all its permutations aren’t going away.
An audience peppered the special assistant to the governor for health reform, a health insurance executive, a health care provider, and a former resident of Sweden with questions Monday night at the Brattleboro Retreat.
Richard Davis, a health care reform advocate from Guilford, organized “Health Care Reform in Vermont: What’s Happening? A Broad Perspective” at the suggestion of Sen. Jeanette White, D-Windham, and Rep. Michael Mrowicki, D-Putney.
White told the more than 30 people gathered in the Retreat’s Educational Conference Center that she sees the process of implementing health care reform in Vermont as analogous to the process of building a house.
Constructing a house requires a vision, blueprints, design approval, and cost estimates, White said. Even then, “we don’t know where all the doors will go, or if we’re using oil heat,” she added.
However, what the Legislature does have right now is a schedule for the work, and White said that lawmakers have entered the design phase.
“This is not a new plan,” said Mrowicki. “It’s [the current system] a house that’s falling down.”
Mrowicki said that health care in Vermont costs more than people can afford, and more than municipal or school budgets can handle. He reminded the audience that, as a nation, the discussion about universal access to health care is nothing new. It began in earnest during the late 1940s, when President Harry S. Truman was in the White House.
“It’s not like we’re rushing into anything,” Mrowicki said.
He also warned the audience that “it is easier to kill a bill than to get it passed.” He said that he is worried when people say things like “I support this bill, but...” or “I love this bill, but I don’t know about...” He said that sort of thinking kills the good bill in the hunt for the perfect bill.
“The time to act is now,” said Mrowicki.
What is not working, and where we are
Anya Rader Wallack, Ph.D., Special Assistant to the Governor for Health Reform, provided a summary of the health care reform bill, H.202.
Vermont’s health care system suffers under fundamental flaws, despite past well-intentioned attempts at reform, said Rader Wallack, who held the same position during Gov. Howard Dean’s administration.
She said that 45,000 Vermonters don’t have insurance and that another 50,000 are under insured.
“There’s complexity in the system that costs us all opportunities and money,” she said.
The system costs too much, devours personal and state budgets, and does not insure everyone, said the native Vermonter, who now lives in Rhode Island.
Quite simply, she said that the current state of health care “is not good value for the money.”
The system bursts at the seams with administrative waste from the insurance companies, to the providers’ offices, to the desks and kitchen tables heaped with the “this is not a bill” letters that hospitals send out to settle accounts.
She described Gov. Peter Shumlin’s vision for health care reform as “big and bold,” but warned implementation would take years.
Rader Wallack explained that H.202 “sets Vermont on a course” to control health care costs, insure every Vermonter, preserve individuals’ choice of physician, reduce complexity and administrative waste, and encourage prevention and primary care.
The bill will be phased in over three stages.
The first will commence July 1, provided that H.202 passes the Senate. It establishes the Green Mountain Care Board, a five-member, Governor-appointed panel whose members would each serve six-year terms.
Rader Wallack said that the board is expected to remain independent from political pressures and two-year shifts in governors and Legislatures. Once board members are appointed, they can only be removed “for cause,” she said.
The boards’ primary responsibilities are cost control and designing a benefits package to cover all Vermonters.
We must be able to look the public in the eye and say, “This won’t cost you more than it would have,” by demonstrating that universal health care is financially sustainable, said Rader Wallack.
She said that cost reductions will occur through incentives, rather than government dictates.
This “payment reform” will move health care providers away from the fee-for-service model used now. The new system would allow doctors and patients to manage chronic conditions like diabetes, thus avoiding expensive care.
Phase two would begin in 2014 with the establishment of a Vermont health benefit exchange. Through the Federal Health Insurance Reform Bill, the federal government will require that “states create their own health care exchange or allow the feds” to establish an exchange, said Rader Wallack.
To comply, the state will set up a website for Vermonters looking for coverage. The website will “provide one-stop shopping for health insurance, with apples-to-apples comparisons of plans.”
Vermonters, at this second stage, will have multiple plans to choose from but, behind the scenes, explained Rader Wallack, will exist a simplified administrative structure with a single claims process.
She added that this benefits exchange will “act as the engine of health care reform” by implementing payment reform and streamlining insurance administration across “as much of the market as possible.”
Launching Green Mountain Care, the final phase and ultimate goal, will happen after 2017.
A single-payer system, Green Mountain Care, will replace the benefits exchange.
Unlike now, everyone will pay into a single, public system, said Rader Wallack.
According to Rader Wallack, making this shift will require a federal waiver, but the state can’t request the waiver for another six years.
Vermont’s Congressional Delegation has begun pushing for these waivers to be issued by 2014.
When the single-payer system launches, the Green Mountain Care board will have the authority to design the minimum level of benefits everyone must receive and set its overall budget.
What H.202 does not do, said Rader Wallack, is raise taxes, expand coverage before 2014, or identify how Vermont will pay for universal coverage.
“No one likes [this plan] 100 percent, so we must have gotten it right,” she said.
Rader Wallack said the plan has received criticism for not embracing a pure single-payer system and for not having every financial detail hammered into place.
To those critics, she said that the first step ought to be providing 95 percent of Vermonters with coverage.
To those who say the state is moving too quickly, her response is that, until there are cost controls on health care and a sense of what the federal government will pay into the system, there is no way the state can know exactly how much it will cost.
She admits that there are complexities to sort out, but she is confident that the state can come up with a comprehensive health care plan.
Not utopia, but not chaos either
In his presentation, Brattleboro Retreat President and Chief Executive Officer Robert E. Simpson advocated for an integrated medical and psychological approach to illness.
The current system separates the body from the mind. But, said Simpson, it’s estimated that one out of five people will experience mental illness in his or her lifetime.
Mental illnesses, like depression or substance abuse, often accompany other diseases. Simpson said that anywhere from 15 to 45 percent of visits to primary care providers stem from a mental illness.
Yet, said Simpson, mental illness is treatable, adding that an estimated 85 percent of people seeking treatment for depressive disorders and 70 to 90 percent for panic attacks improve with professional treatment.
A better collaboration between medical and behavioral practitioners would lower costs, said Simpson.
“You can’t just leave [mental health] on the side,” he said.
Ralph Meima, Ph.D., spoke briefly on his 14 years of experience living in Sweden, which provides universal health care coverage.
Meima said Sweden has had a long relationship with social welfare policy as far back as the mid-1800s, and not always under socialist governments.
Meima, the program director of the MBA in Managing for Sustainability at Marlboro College Graduate School, said that on average, Sweden gives its population of almost 10 million the equivalent of the health care that the wealthiest 2 percent of Americans receive.
About 70 percent of health care in Sweden is funded through local governments and taxes. National standards exist, but the finances and delivery happen locally.
Sweden has high taxes, said Meima. About 31.42 percent of a person’s income goes to the state to cover benefits. But, he added, only 5.02 percent of that total goes to health care. Taxes also pay for benefits like pensions.
Despite the taxes, said Meima, the national discussion only focuses on how to deliver services better or for less. Never does the discussion focus on ending benefits.
“It’s not utopian,” said Meima.
Tax cheaters, freeloaders, and lines will always exist, he said, but there’s a basic difference living in a society where everyone will be covered by predictable and reliable care.
In the United States, people “fall through the floor,” creating a “chaos factor,” he said. And, in the end, it’s society as a whole that pays the price.
Leigh Tofferi, director of Government, Public, and Community Relations for Blue Cross and Blue Shield of Vermont (BCBSV), wrapped up the presentations.
Health care reform is nothing new for Blue Cross, said Tofferi.
The company started instituting reforms 20 years ago, he said, referring to a payment reform experiment between BCBSV and Fletcher Allen, Rutland, and Dartmouth-Hitchcock hospitals.
BCBSV, during a leadership transition in 2008, reassessed the state of health care in Vermont and the insurance company’s health care role, said Tofferi.
Although part of a larger organization, he said, BCBSV has been locally and independently owned for 30 years. The nonprofit company employs 340 people at its offices outside Montpelier.
The reassessment revealed that BCBSV didn’t meet the needs of all Vermonters, he said. This led the company to a “new mission.”
“Every Vermonter should have access to timely and affordable health care,” said Tofferi.
Tofferi said that BCBSV supports Vermont’s health care reform, even though the company isn’t clear what it will mean for its future within the state.
“Still, we believe the status quo is unacceptable,” he said.
Tofferi said that the company expects to play the largest role in future payment reforms because these reforms must align with future delivery systems.
The wish list
Most of the audience’s questions fell to Rader Wallack, and the common thread linking the questions was structure and cost.
John Field, of the Retreat and Brattleboro Memorial Hospital, asked what incentives will drive the system to transition from the health care exchange to Green Mountain Care.
What if the transition doesn’t happen? he asked.
“That’s a valid concern,” she said. “No, you can’t be sure [it will].”
A future Legislature will have to figure out the taxes and vote to reduce multiple insurance companies to one, said Rader Wallack.
Ultimately, a movement from complexity to simplification will act as the incentive to adopt Green Mountain Care, she said.
Complexity creates more cost than it has to, said Rader Wallack. Also, Green Mountain Care would also separate health insurance from employment.
Cliff Duncan of Wilmington said that he has been involved in the health insurance debate for 20 years, after the birth of his son brought him face-to-face with Southwestern Vermont Medical Center in Bennington’s cost shifting practices.
Duncan, who owns Duncan Cable TV Service, described past and present Vermont health care policy changes as a “train wreck.”
He said that he objected to asking people to pay for someone else’s alcohol rehabilitation treatment and to requiring an 80-year-old to pay into maternity benefits.
“As we consider this wish list [of reforms], I hope we’re more realistic,” said Duncan.
He hoped that the state was not going down the same road as it did with Act 60, the educational funding bill that made numerous changes to tax policy but “never defined what education is.”
Many Vermonters wary of H.202 have cited Act 60 as an example of what can go wrong with big, sweeping changes in state policy.
Rader Wallack answered that the federal government will define the initial minimum benefits package and that the state will decide what, if any, additional benefits it wants to fund.
Another audience member asked whether Vermont could implement H.202 if the federal bill failed at the national level.
Rader Wallack answered that the state could still move forward, but the costs of implementation would jump. She said that Vermont expects to receive $100 million in federal tax credits to kick-start its program.
Dr. Robert Nassau, a retired pediatrician, asked how doctors would care for all the new patients covered under Vermont’s new health care system when the state can’t attract enough general practitioners because of low salaries.
“Vermont is not unique [in having this problem],” said Rader Wallack.
It is an issue that the Green Mountain Care Board will examine over time, she said. To meet needs, the board may suggest actions like providing more Vermont-based training or expanding the capacity of non-M.D.s to provide general practitioner services.