Policy Issues: Health Care Services and Health Benefits. Robin Lunge, Legislative Council Nolan Langweil, Joint Fiscal Office September 13, 2010

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1 Policy Issues: Health Care Services and Health Benefits Robin Lunge, Legislative Council Nolan Langweil, Joint Fiscal Office September 13, 2010

2 Health Care and Taxes: Intersection of Multiple Reform Efforts Multiple health care and tax reform efforts are either completed, underway, or anticipated Federal Health Care Reform State Health Care Reform State Tax Reform Expiration of Federal Tax Cuts How do these policy efforts interact?

3 Today s Presentation Basic facts about Vermont s investment in health care Lessons from Vermont s recent health care reforms Contours of successful health care reform and associated challenges Health care reform and extending the sales tax to health care services Taxing employee health benefits

4 Basic Facts Approx. 621,000 Vermonters Approx. 47,460 (7.6%) uninsured Approx. 365,452 (59%) have private insurance Of those approx. 134,780 (47%) have employer sponsored health insuance Estimated health care spending on Vermont residents in 2010 = $5.2 billion 41% is paid for through private insurance 23% is paid for through Vermont Medicaid 35.6% is hospital spending 12.3% is for drugs & Supplies Source: All figures are based on data provided by BISHCA and/or DVHA

5 Basic Facts Approx. 150,000 (24%) of Vermonters are enrolled in state-funded health insurance programs Includes those with multiple sources of coverage Does not include those covered by state employee, teacher, or municipal employee plans Of these, approx. 63,000 are children Enrollment in state-funded programs has grown 27% between since November 2007 Source: All figures are based on data provided by BISHCA and/or DVHA

6 Health Care Reform: Vermont History Lessons Early efforts focused on expanding coverage Children & pregnant women Dental coverage for kids Mid-1990s Universal access for kids Dr. Dynasaur Low-income single adults VHAP Quality initiatives Attempts at delivery system and payment reform largely failed

7 Health Care Reform: Vermont History Lessons Late 90s - Early 2000 Separate focus on cost-containment Prescription Drug initiatives Promotion of generics Preferred Drug Lists Bulk Purchasing in Medicaid Efforts to maintain access Part D wrap-around Rx coverage 2004 to present Renewed push for major reform

8 The Vermont Lesson: Successful Reform Increase Access Contain Costs Improve Quality

9 The Tri-fecta: Cost Containment, Quality, Access Catamount Health and Medicaid waivers Improves access and affordability sliding-scale subsidies No cost sharing for preventive services Rate band narrowed to contain costs Focus on prevention & chronic care management Blueprint for Health Prevention & chronic care management Medical Home pilots Payment reform efforts

10 The Tri-fecta: Cost Containment, Quality, Access Insurance Administration Simplification Common forms & unified payment provisions Community Health Promotion & Individual Responsibility CHAMPPS Shared decision-making pilots HIT HIT Fund, HIT Plan, VITL ACO pilot

11 Challenges to State-level Health Care Reform Unrelenting increases in health care costs Revenue downgrades / budget shortfalls Shortage of primary care practitioners Medicare & other federal payers No state control Drives the system to some extent Lack of participation in payment & delivery reform

12 Sales Tax on Health Services Provider tax: legal issues Intersection with health care reform goals Potential practical issues

13 Provider Tax Federal Medicaid law and regulation Definition of provider tax Licensing fee, assessment, or other mandatory payment Related to health care services At least 85% of burden falls on providers

14 Provider Tax Fed law defines maximum rate & types of providers Vermont at max hospitals, home health agencies, nursing homes, intermediate care facilities, and pharmacies Vermont revenue funds Medicaid Consequence of violation Loss of Medicaid funds

15 Health Care Reform Goal 1: affordability for consumers How will sales tax impact on affordability of health services for the consumer? Administrative costs Amount of tax itself Impacts on low-income consumers on public programs Point of service costs impacts utilization Will sales tax violate federal limits on amounts charged to consumers in Medicaid and Medicare law?

16 Health Care Reform Goal 2: right care at the right time in the right setting E.g. preventive services versus emergency services How will sales tax impact on utilization of preventive services? How will it impact on individuals with disabilities? Constitutional issues? ADA?

17 Health Care Reform Goal 3: Reduce health care spending overall Again, administrative costs? How will a sales tax drive utilization of services overall? How will a sales tax drive provider behavior?

18 Practical Issues Calculation of tax on services Cost of services varies Negotiated between insurer and provider Uninsured pay highest rates Except: hospital charity care policies Difficult to determine in advance (consumer) Negotiated rate: proprietary Unclear what services will be provided in advance Difficult to comparison shop

19 Practical Issues Collection by providers Current issue: uncompensated care, uncollected co-payments and cost-sharing (deductibles) What happens if person can t pay sales tax? Hospital emergency services mandatory can t deny Doctors & technology Changing landscape of federal and state law

20 Income tax: employee benefits Affordability Will individuals drop insurance? Up-front/Premium costs impact take-up rate Increased enrollment in state-sponsored programs? Medicaid budget pressures Increase in uninsured? Application of tax to public programs How do you treat Medicare & Medicaid benefits? Do these individuals file?

21 Income tax: employee benefits Federal Health Care Reform Several changes to health-related taxes Limits on tax deduction for medical expenses Health Savings Account limits New federal subsidies for insurance exchange Tax credit structure Individual mandate: Tax penalty for violations

22 Income tax: employee benefits Calculation Actuarial value of insurance? Premium paid? Varies depending on other cost-sharing Varies depending on covered services Varies depending on population covered

23 Everything is hitched to everything else. - John Muir

24 Contact information: Robin Lunge Nolan Langweil