HEALTH CARE SYSTEMS ELECTION 2012 ISSUE PAPER NO. 3 SEPTEMBER Where Are We Now?

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1 ELECTION 2012 HEALTH CARE SYSTEMS ISSUE PAPER NO. 3 SEPTEMBER 2012 Vermont League of Cities and Towns 89 Main Street, Suite 4, Montpelier, VT (802) or (800) Where Are We Now? The State of Vermont has embarked on a path of health care system reform. This will be a challenging and complex process addressing a health care system that constitutes almost 20 percent of the state s gross domestic product. Vermont s cities and towns provide excellent health insurance benefits to their employees. After payroll expense, the cost of health insurance is one of the biggest line items in municipal budgets. In fact, municipally-provided employee health insurance amounts to over 20 percent of the total amount spent for payroll. Not only are health insurance costs high, they are one of the fastest increasing costs in municipal budgets, jeopardizing a town s ability to respond to increased salary demands and to maintain current services, much less undertake additional services. Health care system costs are increasing at a rate much higher than that of inflation. Rising health insurance premiums are merely a symptom of an expensive health care system that is unable to control its costs. Annual premiums for family health insurance provided by employers nationally rose about 4 percent to $15,745 in 2012, according to a survey by the Kaiser Family Foundation and Health Research and Educational Trust. That s a fairly modest increase by historical standards, and well down from last year s 9 percent. Still, it s more than double the 1.7 percent increase in average wages and way above the 2.3 percent rate of general inflation this year. The Green Mountain Care Board, which is attempting to address the issue of high health system costs in a comprehensive manner, recently reviewed all Vermont hospital budgets for FY13 and found that they are expected to rise 5.84 percent. This is an important figure because hospital budgets represent about 40 percent of total health care costs in the state. Vermont hospitals share of the total health care cost pie is greater than most states because so many of our physicians are now employees of the hospitals. Vermont has its work cut out for it. From a shorter term perspective we continue to be concerned about some of the hidden cost drivers of health insurance. In addition to coverage mandates (see below), Medicaid and Medicare cost shifting continues to load additional costs onto health insurance buyers. These cost shifts arise because the state and federal governments do not pay medical providers and hospitals the full cost for the services Medicare and Medicaid recipients receive. To make up for this lost revenue, providers charge their other paying customers more for the services they receive. ELECTION 2012: VLCT ISSUE PAPER NO. 3 HEALTH CARE SYSTEM ISSUES 1

2 Current Issues Mandates. Even in these tough economic times, the Vermont Legislature found ways to drive health insurance costs higher by instituting new health insurance coverage mandates. New state mandates adopted last year included early childhood developmental disorders coverage and prescription drug outof-pocket maximums. In addition, the federal coverage mandate for women s preventative coverage went into effect in August. The cost of these mandates along with new taxes and assessments is substantial. Based on recent health insurer filings with the Vermont Department of Financial Regulation these mandates, taxes, and assessments will add from 2.5 to 3 percent to health insurance premiums, most resulting from the state mandates. This increase alone is more than the current inflation rate. And this is before taking into account the rate of medical inflation, which is a multiple of the consumer price index. Health Reform Moving Forward. In the short- to mid-term, the federal Patient Protection and Affordable Care Act s (ACA) provisions for a health benefit exchange will be implemented while plans for Green Mountain Care, a universal care/single-payer health care system, are developed. There are both opportunities and challenges for municipal governments in these processes. It is critical that the process be prudent and transparent, and that input is considered from all sources. The 2013 legislative session will be a watershed as far as the future direction of health care in Vermont is concerned, as the funding mechanism for the single-payer system is determined. The vast majority of Vermont municipalities are small employers (having 50 or fewer employees) and will therefore be required, under Vermont s unique version of implementing the ACA, to participate in the Vermont Health Connect health benefit exchange starting January 1, At that time, municipalities with more than 50 employees will continue to be able to purchase their group health insurance as they do now. However, in 2016, the definition of small employer will be changed to encompass employers with up to 100 employees. Those employers will then be required to purchase their health insurance through Vermont Health Connect. Finally, in 2017, all employers will be eligible and required to purchase their health insurance through Vermont Health Connect (unless Green Mountain Care has been launched). Employers that self insure (mostly very large employers) and are exempt from state regulation under the Employee Retirement Income Security Act of 1974 (ERISA) do not have to purchase health insurance through Vermont Health Connect. As municipal employers move to Vermont Health Connect, they will encounter health insurance plan options that do not match their current health plans. This change will pose significant challenges to these municipalities and their employees as their plan design and funding arrangements must be altered to fit with the state-required exchange health care plan options. As health care reform moves forward, it is critically important for state policymakers and administrators to get it right when it comes to implementing a high quality, accessible, sustainable and affordable health care system. Vermont Health Connect will be the first time many small employers and Vermonters will encounter health care reform. Remember the saying, you only have one chance to make a good first impression? The impression, good or bad, left by the launch of Vermont Health Connect will impact the process of health care system reform. Launch of Vermont Health Connect. As noted above, Vermont Health Connect will launch on January 1, The transition to the exchange is challenging not only because of the likely changes in plan design, but also because many details of the exchange such as participating health insurers, coverage plan designs, provider responses to these changes, and costs are not yet known. While we should know those details by October 1, 2013, when Vermont Health Connect opens for business and ELECTION 2012: VLCT ISSUE PAPER NO. 3 HEALTH CARE SYSTEM ISSUES 2

3 starts the enrollment process, that date will not be soon enough to allow small municipal employers, particularly those with collective bargaining, to adequately work through and implement the changes. It can take at least six months to complete a full collective bargaining process on an issue of this importance. This process needs to be completed prior to the opening of Vermont Health Connect on October 1, 1913 for those municipalities with a January 1 health insurance renewal date. But in true which came first, the chicken or the egg? fashion, lack of information about coverage plan designs, costs, and other details will greatly hamper the ability of municipalities and their employees to complete the collective bargaining process in a timely manner. This may lead to additional costs for employers, grievances filed by employees, and a general dissatisfaction with the process from all quarters Unlike many small employers concerned about moving to an exchange that only offers richer, more expensive health insurance plans than they offer, many Vermont municipal employers are looking at an exchange that offers plans that are not as rich as they currently provide. Most Vermont municipalities provide their employees with high deductible health plans coupled with generous assistance through health savings accounts (HSAs) or health reimbursement accounts (HRAs) to help them meet their outof-pocket costs. The plan offerings in the exchange will create challenges for these municipalities. Municipalities that offer rich plan designs will be faced with moving to a health plan that is not as rich as their current plan, a reduction of benefits to the employee. Municipalities with high deductible plans may find that moving to the limited high deductible plan choices in Vermont Health Connect will result in higher premiums paid to the health insurer and fewer dollars to help employees meet their out-of-pocket costs. Added to this is the intriguing opportunity for an employer to discontinue its group health benefit and instead provide pre-tax funding to employees that will allow them to shop Vermont Health Connect as individuals who may be eligible for significant federal tax credits. This is a potential first step toward separating provision of health insurance from employment, one of the goals of Vermont s health care reform initiative. A sea change of this sort requires time for the employer to consider the impact, time to communicate the change to employees, and still more time for employees to participate in the market as direct health insurance purchasers for the first time. This cannot be accomplished without timely and comprehensive information. Most small employers have health insurance policy years that run from January 1 to December 31, meaning that they will be renewing their health insurance policies on January 1, 2014, the first day Vermont Health Connect will offer insurance. For coverage to be in place on January 1, open enrollment must conclude by early December of With new coverage plans, all small employer employees will need to go through an initial enrollment process for coverage to take effect. While some of this may be automated, both small employers and their employees will require considerable guidance and handholding. Vermont Health Connect needs to be prepared for this onslaught. Adequate staffing, internet, and phone capacity must be available to handle the high volume of complicated enrollments. If Vermont Health Connect is not 100 percent ready at start up, it should consider staggering renewal dates. Although staggering renewal dates comes with its own complications, they pale in comparison to the problems caused by not having people enrolled in their health insurance plans on January 1. It is clear to us that much time will be needed to allow for employers to make these decisions and communicate them to employees and other interested parties. It is critical that the state make and communicate its decisions as soon as possible. Otherwise, the chance of a successful Vermont Health Connect launch is considerably diminished. ELECTION 2012: VLCT ISSUE PAPER NO. 3 HEALTH CARE SYSTEM ISSUES 3

4 Development and Implementation of Green Mountain Care. The implementation of Vermont Health Connect is only one step on the path to Green Mountain Care. The Green Mountain Care Board, the administration, and the legislature are all players in the process of building and launching this ambitious program. Current health care reform statutes allow for supplemental health plans to those mandated in the exchange and under the Vermont single-payer successor. This is fine to the extent that these are health care plans for services outside of Green Mountain Care, such as dental or vision insurance (if Green Mountain Care does not include this coverage). On the other hand, allowing employer-provided supplemental plans that help pay deductibles and co-pays for basic health care coverage is a bad idea. Here s why: A single-payer plan cannot be a true single payer when multiple insurers/payers are involved. Supplemental plans will increase health care system costs. While paying a portion of co-pays and coinsurance does not add medical cost to the system, it does add administrative cost. Involved multiple insurers would expect to cover their administrative costs, be compensated for taking risk, and make a profit. Medical providers would not know how much in co-pays and co-insurance to collect from patients and/or which insurer to bill for the balance because they would not be the same for all of their patients. This adds to provider administrative costs. While overall system costs might not change much, the distribution of costs would. Individuals who purchase these plans are simply pre-paying their out-of-pocket costs plus an administrative and profit margin to an insurance company. Employers that pay for these supplemental benefits are directly increasing their costs by allowing employees to shift costs, for which they would be responsible, onto their employer. Supplemental plans can sabotage plan design intended to encourage healthy lifestyle choices. This occurs because the cost features of the health care plan, such as no co-pays for chronic disease treatment if the individual participates in a chronic disease management program, are diminished or cancelled out. The same is true for efforts to encourage prudent health system use by individuals. The cost features of the underlying health plan such as higher co-pays for non preferred prescription drugs are diminished or cancelled out. All Vermonters cannot receive equal health benefits and health care system access if some Vermonters are more equal than others by having their employers provide coverage for additional health care costs. In a system in which all sides have to give up something to obtain a better outcome for all, why aren t equal and rich health benefits good enough for all? Implementation Issues and Decisions to be Made Vermont Health Connect. January 1, 2014, is fast approaching. For the launch of Vermont Health Connect to be a success, decisions relating to health care plan design, exchange choice options, selection and education of navigators 1 and brokers and premium costs, among others, must be made as soon as possible by the administration and the Green Mountain Care Board. These decisions need to be communicated to all, especially municipalities. 1 Navigators are individuals or organizations paid by the exchange that help individuals and employers purchase health insurance through the exchange. In many ways, navigators will fill the role of insurance agents, except they can t have a conflict of interest, such as selling other insurance products. Insurance agents will also be able to sell health insurance through the exchange. They will no longer be paid commissions by the health insurer, but will instead be paid by the health insurance purchaser. ELECTION 2012: VLCT ISSUE PAPER NO. 3 HEALTH CARE SYSTEM ISSUES 4

5 Legislators should make sure that work is being done to implement the laws passed to create Vermont Health Connect. If tweaks to the enabling legislation are needed, they must be accomplished thoroughly and quickly. These decisions must be made in an open manner allowing for input from municipalities and other impacted parties, and done so as soon as possible. Mandates are an ineffective way of ensuring that all Vermonters receive a benefit that the legislature has determined to be in the public interest. All state health insurance mandates should be treated as public health issues. If these needs are truly public health needs for all Vermonters, they should be publicly funded and available to all Vermonters, not just those with state-regulated health insurance. This will allow these services to be managed for quality and cost. What better opportunity is there to develop a small scale demonstration program that shows that efficient, high quality, and cost-effective health care delivery can come from a coordinated universal/single-payer health system? Legislators must avoid doing what is politically expedient spending other peoples money and instead provide public funding for public health care needs that they deem is in the public s best interest and raise the taxes necessary to fund those services. Cost Shift. In theory, when Green Mountain Care is implemented, the issue of cost shifting, at least as it relates to Medicaid, will go away. In the shorter term, additional cost shifts from Medicaid and Medicare to the new health insurance options must be avoided. The legislature must not allow any increase in Medicaid cost shift. Adequate state funding must be provided to cover increases in cost for the Medicaid population. VLCT Recommendations Vermont Health Connect should: offer a wide choice of plans to meet the varied needs of municipal employers and employees used to having a wide choice and who will be required to purchase health insurance from the exchange; be designed for the convenience and benefit of users, not program administrators. Navigators to assist the people making these choices should be selected in a manner that recognizes the diversity of employers and individuals; recognize this diversity in developing and implementing wellness and health promotion programs, if any, provided through the exchange; consider staggering enrollment dates to better manage its start up; remember that a one size fits all approach will not be successful; and look to organizations, such as the Vermont League of Cities and Towns, to partner with in its implementation. Green Mountain Care Green Mountain Care must provide a comprehensive, equitable health care system that ensures the same benefits for all and avoids provisions that allow for additional levels of benefit for some. To be successful, the system must assign financing, responsibility, and accountability in one place. Green Mountain Care must be funded by one or more broad-based taxes and that will be decided this coming year by the legislature. A payroll tax on both employers and employees has been an acceptable option to VLCT. ELECTION 2012: VLCT ISSUE PAPER NO. 3 HEALTH CARE SYSTEM ISSUES 5

6 All participants in Green Mountain Care and others in the Vermont economy must pay a fair share of the costs. Municipalities pay a disproportionate share of health care costs because they provide a greater degree of insurance to their employees and a higher employer-paid proportion of the premiums than employers generally and because of the cost shifting noted above. As the financing plan for Green Mountain Care is developed, the legislature must ensure that any universal employer contribution to help fund the health care system will reduce costs to municipalities. The conditions established in Act 48 and amended in Act 171 must be met before Green Mountain Care is launched, viz.: Each Vermont resident covered by Green Mountain Care will receive benefits with an actuarial value of 80 percent or greater. When implemented, Green Mountain Care will not have a negative aggregate impact on Vermont s economy. The financing of Green Mountain Care is sustainable. Administrative expenses will be reduced below 2011 levels after adjustment for inflation and other relevant factors. Cost containment efforts will result in a reduction in the rate of growth in Vermont s per-capita health spending without reducing access to necessary care or resulting in excessive wait times for services. Health care professionals will be reimbursed at levels sufficient to allow Vermont to recruit and retain high-quality health care professionals. The Green Mountain Care health benefit plan design to be developed by the administration and approved by the Green Mountain Care Board must encourage responsible, healthy behaviors through appropriately designed cost sharing, healthy lifestyle incentives, and wellness and health promotion programs and services. Consistency of Goals Program, policy and funding goals must be consistent. For example, the Catamount Care tax for employers not offering health insurance continues while state officials encourage employers to drop group health plans and send employees to Vermont Health Connect as individuals so they can take advantage of federal tax credits. Catamount Care will cease to exist with the launch of Vermont Health Connect. The tax to support this program that is ending should be eliminated in conjunction with the launch of Vermont Health Connect. The legislature should repeal this tax in the 2013 session. Supplemental Plans Legislation allowing for supplemental health plans after implementation of Green Mountain Care must be repealed. Failure to eliminate supplemental plans will threaten the ultimate success of Green Mountain Care. ELECTION 2012: VLCT ISSUE PAPER NO. 3 HEALTH CARE SYSTEM ISSUES 6

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