Ver­mont’s sin­gle-payer ex­per­i­ment starts to take shape

Re­ports, bill re­veal path to first-of-its-kind sys­tem

Modern Healthcare - - MODERN HEALTHCARE - Jaimy Lee

Aclearer pic­ture of the path­way to the na­tion’s first pub­licly funded sin­gle-payer sys­tem has emerged as Ver­mont of­fi­cials re­leased a set of re­ports and in­tro­duced a bill aimed at lay­ing the ground­work for Green Moun­tain Care.

The bill would merge the in­di­vid­ual and small group in­sur­ance mar­kets; award the Green Moun­tain Care Board au­thor­ity over health in­surer rate re­views, hospi­tal bud­get re­views and cer­tifi­cate-ofneed pro­cesses; and autho­rize a state agency to seek waivers from the CMS. It would also re­quire the state’s 16 hospi­tals to cover 15% of ex­penses in­curred by the board to col­lect data and in­for­ma­tion re­lat­ing to bud­get re­views, a re­quire­ment that the Ver­mont As­so­ci­a­tion of Hospi­tals and Health Sys­tems does not sup­port.

The is­sue for hospi­tals, said VAHHS Pres­i­dent and CEO Bea Grause, is that the Green Moun­tain Care Board is in­tended to be in­de­pen­dent of state gov­ern­ment. The Bank­ing, In­sur­ance, Se­cu­ri­ties and Health Care com­mis­sioner pre­vi­ously had over­sight over hospi­tal bud­get re­views and cer­tifi­cate-of-need pro­cesses.

“Our main con­cern is to make sure that hospi­tals have due process,” Grause said, “and that it’s a fair and pre­dictable process.”

The bill pro­poses giv­ing the board emer­gency rule­mak­ing au­thor­ity for hospi­tal bud­get re­views, which have to be fi­nal­ized by Sept. 15, also raised con­cerns with VAHHS.

While Grause said she un­der­stands that the nor­mal six- to seven-month rule­mak­ing process could place the board in the po­si­tion of hav­ing ju­ris­dic­tion with­out rules in place, the as­so­ci­a­tion plans to stay en­gaged on the is­sue dur­ing on­go­ing dis­cus­sions over bud­get re­views and pay­ment re­form pi­lot projects.

Most health­care in­dus­try or­ga­ni­za­tions have re­mained neu­tral about the state’s health­care law, which Gov. Peter Shum­lin signed into law in May.

The de­vel­op­ments of the last week, in­clud­ing this ini­tial round of re­ports and the in­tro­duc­tion of the bill lay­ing the ground­work, are caus­ing some groups to be­gin to voice con­cerns about the shape the law is be­gin­ning to take. The re­ports touch on a num­ber of is­sues, in­clud­ing the state health ben­e­fits ex­change re­quired by the Pa­tient Pro­tec­tion and Af­ford­able Care Act, the ex­change’s tran­si­tion to Green Moun­tain Care, the board’s an­nual re­port and a pub­lic en­gage­ment plan. “These stud­ies pro­vide light on the next steps of health re­form, but they do not pro­vide long-term an­swers,” Grause said.

The Na­tional Fed­er­a­tion of In­de­pen­dent Busi­ness and Blue Cross and Blue Shield of Ver­mont have ques­tioned the bill’s pro­posed def­i­ni­tion of small groups as 100 em­ploy­ees or less for three years start­ing in 2014, and the pro­posal that in­di­vid­u­als and small groups are re­quired to buy in­sur­ance off the ex­change. The state now de­fines small groups as em­ploy­ers with 50 or fewer em­ploy­ees.

Kevin God­dard, a spokesman for Blue Cross and Blue Shield of Ver­mont, which rep­re­sents nearly 45% of those en­rolled in pri­vate health in­sur­ance plans in Ver­mont, said the av­er­age small group size of em­ploy­ers that use the in­surer’s plan is eight em­ploy­ees. “It would be pru­dent to wait and start with busi­nesses with fewer than 50 em­ploy­ees,” he said.

The Green Moun­tain Care Board also faced crit­i­cism from the Shum­lin ad­min­is­tra­tion for plans to spend $50,000 on a com­mu­ni­ca­tions con­sul­tant to sup­port the pub­lic en­gage­ment plan. The board later voted to re­scind the re­quest for pro­pos­als, though Anya Rader Wal­lack, the board’s chair, said there is a pos­si­bil­ity the board will is­sue a sim­i­lar RFP in the fu­ture.

A bill was in­tro­duced this year by state Sen. Randy Brock, a Repub­li­can plan­ning to run for gov­er­nor, to move up the dead­line for the fi­nanc­ing plans. By re­leas­ing the plans Sept. 15, rather than Jan. 15, 2013, vot­ers can bet­ter un­der­stand the cost im­pli­ca­tions of Green Moun­tain Care be­fore the elec­tion, Brock said.

Other states with pend­ing sin­gle-payer health­care leg­is­la­tion are keep­ing watch over the Green Moun­tain Care Board’s ac­tiv­i­ties. Last week in Cal­i­for­nia, the state Se­nate Ap­pro­pri­a­tions Com­mit­tee voted 6-2 for a bill that would cre­ate a uni­ver­sal health­care sys­tem.

Ac­cord­ing to Physi­cians for a Na­tional Health Pro­gram, an ad­vo­cacy group that sup­ports a na­tional sin­gle-payer sys­tem, 12 states have ac­tive sin­gle-payer bills. That Ver­mont “is tak­ing con­crete steps in a tough en­vi­ron­ment is very in­spir­ing,” said Dr. Ida Hel­lan­der, di­rec­tor of pol­icy and pro­grams for PNHP.

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