Richard Davis | Another View: Trust me


A few legislative activities are happening in Vermont that have the potential to change the way health care is organized, paid for and delivered. But, there have not been any persistent headlines as in past years when health care reform dominated news cycles. Much of what is happening is below most Vermonters' radar and that means that there have been no polarizing public debates

A bill, H.812, passed the Vermont House on March 17 and is now in the Senate Health and Welfare Committee. The bill is called the "All-Payer Model; Medicare Agreement" and I suspect the reason is that it has not gotten much press is because it lies in the weeds of health care policy.

According to language in the bill, "This bill proposes to establish consumer protection guidelines and principles in the context of accountable care organizations." So what's going on behind the jargon?

H. 812 is a way to mandate Medicare consumer protection principles. Even if the federal government allows Vermont to pool the money it receives from health insurers such as Medicare, Medicaid and commercial insurers into a single pot of money, H. 812 still requires Medicare dollars to go directly to Medicare providers

The original goal of a single payer plan was to receive a federal waiver allowing the pooling of all health insurance dollars coming into Vermont. That kind of waiver was essential to moving along the single payer path. If H.812 passes and other federal waivers are granted to Vermont, it is not clear if enough pooling of insurance money will take place to realize the original vision embodied in the all-payer concept.

In order for a state to have complete control over its health care system it is critical for that state to have control over all of the health (insurance) care dollars that flow into the state. Vermont needs to control all the money so it can move to global budgeting.

Vermont would like to be able to tell all of its hospitals that they will have to be subject to a yearly budget that they have to live with (a global budget). The state would then give each hospital the money to execute that budget, but it can only do so if it has control over all of the health insurance dollars. In order for that to happen, the state needs special waivers from the federal government and it is not clear if H. 812 would or would not be an obstacle to global budgeting.

Stay with me. This can get twisted. If global budgeting is to be a viable plan most, if not all, money that insurers pay has to go into one big state pool. That could happen in 2017 because there are provisions in the affordable care act that would allow states waivers to do that kind of monetary pooling. If those waivers are approved, then the state might be able to institute global budgeting. But as far as I can tell, at this point it is not clear if the stars are aligned to make global budgeting possible.

There is also another piece to H. 812 that is even more complicated than the global budget and that has to do with accountable care organizations. They are a model of delivering health care for a population of people which now only includes Vermont Medicare beneficiaries. The Centers for Medicare and Medicaid Services (CMS) defines them. "Accountable Care Organizations (ACOs) are groups of doctors, hospitals, and other health care providers, who come together voluntarily to give coordinated high quality care to their Medicare patients. The goal of coordinated care is to ensure that patients, especially the chronically ill, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. When an ACO succeeds both in delivering high-quality care and spending health care dollars more wisely, it will share in the savings it achieves for the Medicare program."

Vermont now has three ACO's but there are plans to try to unify them into one entity. If that happens then the state could impose the all-payer model onto the ACO's and have control over a large chunk of health care in Vermont.

The question in many people's minds is, "How will this affect me?" In particular, Medicare beneficiaries who are learning about these plans are concerned about how it will all play out and how their benefits and costs may or may not change. The language in H. 812 provides for many consumer protections and it appears to help protect Medicare recipients.

The devil is in the details and once more Vermonters start finding out about these possible changes the more questions they will have. So far, people I have spoken to don't have a lot of answers although they seem to believe this is a step in the right direction. If you can accept the simple phrase, "Trust me," you will be OK The rest of us need a lot more answers.

Richard Davis is a registered nurse. He writes from Guilford and welcomes comments at


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