BRATTLEBORO — Vermont has taken many steps on the road to health care reform, including the passage of Act 48 two years ago that laid the foundation for the state's health care system called Green Mountain Care.
For many of its citizens, however, questions and concerns remain.
The Vermont Workers' Center held the fifth of six planned health care forums at St. Michael's Episcopal Church in Brattleboro on Jan. 20.
The center's top question that night for the three panelists: How might the state develop a health care system focused on care, not health insurance, that also comes with equitable financing?
According to VWC forum speakers, health insurance and health care have separate, not necessarily complementary, priorities. Health insurance companies focus on maximizing profits. Care focuses on the quality of people's overall health.
The VWC, as part of its Healthcare is a Human Right Campaign, launched in 2008, has also called for the state to deliver options for health care consistent with the human rights principles the center has identified as universality, equity, transparency, accountability, and participation.
Multiple people speaking on behalf of VWC said the state needs to make key decisions around financing and the range of health services it will offer if the state wants to build an equitable health care system. Members of the workers' center stated that all residents should have access to health care without barriers, and that people should be charged based on their ability to pay.
The three panelists agreed that Vermonters will make compromises along the way in whatever publicly funded health care system the state develops.
Panelist Richard Davis, a nurse and seasoned health care reform advocate, said he couldn't answer how to move from coverage to care: “It's the wrong question,” he said.
Right now, he said, Vermont needs to ask itself how it moves forward with health care reform.
Nothing in health care reform happens outside the political system, he cautioned. Citizens must push Vermont's political system harder so everyone can move the issue forward.
“Vermont has actually done quite a bit already [reforming health care],” said panelist Dr. Ani Hawkinson.
Hawkinson, who founded and operates HeartSong Health In Community, a nonprofit naturopathic clinic in Putney, emphasized the need for consumer education.
She said that people needed to have the right information to advocate for their health care, work with their doctors, and take responsibility for their health.
“Your health is yours,” Hawkinson said. “I'm talking about universal self-care.”
When asked how the administration planned to implement a health care system that focused on care rather than coverage, third panelist Robin Lunge, director of health care reform for the Shumlin administration, said the state legislature has two big steps ahead of it.
The first, she said, is changing how health care providers receive reimbursement for services. The current fee-for-service system pays providers based on “things,” such as what tests they order, she explained. The state is shifting to a system that reimburses providers based on health outcomes and results.
Lunge said the next step is developing a funding method for the publicly-funded system that it is transitioning to by 2017.
The administration anticipates taxes will eventually pay for the statewide health care system but details are still being working out, said Lunge.
Taxes are a “politically uncomfortable” conversation, she said, but the outcome will be that people will pay for care through taxes rather than premiums.
When asked what the panelists viewed as obstacles to universal health care, the panelists spoke mostly about priorities.
The United States has never had a conversation on what it considers guiding principles for its health care system, said Davis. In contrast, Canada had this conversation through national forums. Its citizens voiced their priorities, and the provincial governments then set the health care to-do list, he said.
“Until we do this, I think we're at a real loss,” said Davis.
Lunge said that, in her experience, “Health care gets very personal very quickly.”
People are used to living in a broken system. This makes them afraid they won't receive better care under a new system, she said.
“We [state government] wouldn't do health care reform to break the system,” said Lunge.
The biggest obstacle is ideological, said Hawkinson, who reminded the audience that the state has developed its priorities for health care through its Blueprint for Health plan launched as part of larger health-care reform legislation passed in 2006 under then-Governor Jim Douglas. But, for many providers, the Blueprint is merely a new way of delivering care, so gaps in services or delivery still exist.
Lunge said that Vermont has enough money to fund universal health care.
The state commissioned five health care reform studies since the 1990s, each of which showed that Vermonters can have a publicly funded health care system with the same or superior coverage than they have now for the same, or less cost, than they were paying for health care when the studies were conducted.
This session, the administration will speak with lawmakers about funding Vermont's emerging health care system, Lunge said.
Next year, the administration will present the Legislature with a concrete finance program, said Lunge.
The Legislature would have to vote to enact any new taxes related to financing health care.
Last week, Sen. Peter Galbraith, D-Windham, sponsored two bills, S.252 and S.254, proposing a health care funding structure.
Galbraith admits the bills likely won't come to a vote this session, but he felt lawmakers and the public needed to at least start the conversation.
One of Galbraith's proposed bills would enact a transitional fund. He said he feels that if the state doesn't set aside money now, it might not have enough to pay for claims when the system goes into effect in 2017.
His second bill outlines funding mechanisms for the state's publicly funded health care system.
Galbraith said the funding system would allow all Vermonters to have health coverage, relates to a person's ability to pay and services received, maximizes federal tax benefits, and saves Vermont money.
Galbraith's bill proposes to raise $1.6 billion. The funding would come through a 19 percent payroll tax. Employers would kick in 11 percent and employees would pay 8 percent. Non-wage income, like dividends or unemployment monies, would be taxed at 10 percent.
He noted that payroll tax is a deductible business expense.
The bill also eliminates “passthrough of federal itemized deductions in Vermont Income tax” filings. According to Galbraith, these kinds of deductions include such things as interest on mortgage payments.
The payroll tax would also apply to non-Vermont residents working in the state, and Vermont residents working outside of the state. It excludes federal and military personnel.
Galbraith's bill also requires ERISA companies to pay the payroll tax because they can't be excluded as a matter of law.
Galbraith said he considers a payroll tax the only economically sustainable path for a publicly funded health care system. And, he said, he anticipates that funding structure will have the least economic impact on Vermonters.