APPENDIX A

Comparison of Commission Recommendations and Final Legislative Action

Health Care Reform Commission

May 20, 2008

Commission Recommendation	Legislative Action
A. Expand Affordable Coverage
1. Improve the health coverage for the ‘underinsured’ population and significantly expand the population benefiting from health care reform.
a. Create a lower-cost health coverage option for small employers and individuals (including those not insured).   Achieve an initial 20-25% premium reduction through a combination of (1) publicly funded reinsurance (2) required enrollee participation in wellness/disease management programs.	(H. 887, sec. 4) Directs BISHCA to expedite rules allowing health insurers to use premium discounts, split-benefit designs, or otherwise modify co-payments, deductibles, and out‑of‑pocket maximums to encourage member participation in wellness/disease management programs.  - Intended to achieve a 10% premium reduction below the rate of a comparable product.  (Publicly funded reinsurance not adopted.) - Targets a January 1, 2009 date for the rules.
b. Require broader use of Section 125 plans to enable employee premium payments to qualify for pre-tax dollars.	House did not favor a mandate.
c. Explore providing post-divorce coverage for families.	House-adopted provision deleted in the Senate. (Note: former spouses are eligible for Catamount.)
d. Reduce the cost shift.	No policy changes which resulted in increase in the cost shift.
2. Make better progress towards the goal of having only 4% of Vermonters uninsured by the end of 2010.
a. Expand participation in existing Catamount Health product:  (1) Reduce waiting period for coverage under Catamount Health and VHAP to six months from the current 12 months (2) Add financial hardship category to list of exceptions: criteria include loss of insurance coverage within the last three months due to a ‘qualifying event’, income < 300%, medical expenses greater than X% of income.	(H. 887, sec. 5) (1) Directs Secretary of Human Services to request a waiver from the Centers for Medicare and Medicaid Services (CMS) allowing Vermont to shorten the waiting period to six months.  The waiver request is to be submitted by February 1, 2009 (after the change in administrations). (2) Adopted exception to the waiting period if individual is on high-deductible plan for 6 months (at least $10,000 for individual; $20,000 for two-person or family).  Cost-neutral because individual cannot receive premium assistance for the first year.
b. Implement automatic eligibility for VHAP and Medicaid eligibles who have incomes low enough that they pay no premium	Does not require legislation.
c. Provide coverage for young adults under their parent’s policies through age 26 regardless of college enrollment.	Deleted during conference committee (Senate objection).
3. Stabilize the individual market	(H. 887, sec. 2) Commission to study, and propose a preliminary design for, the possible merger of the individual (including Catamount Health), small group, and association markets.
4. Related provisions in H. 887: (H. 887, sec. 11) Preexisting Conditions Under Catamount Health Starts counting the 12-month exclusion period for preexisting conditions from the date of earliest application, rather than the effective date of coverage, and does not continue counting a break in coverage after the date of application. Eliminates pregnancy as a preexisting condition. Provides an amnesty from the preexisting condition exclusion for all Catamount subscribers who apply before November 1, 2008, but does not affect claims incurred before the act takes effect. (H. 887, sec. 6-10) Clarifies qualifying events for Catamount eligibility (when waiting period is not required) Loss of employment includes reduction in hours that results in ineligibility for employer-sponsored coverage Loss of college- or university-sponsored insurance includes decreased enrollment below a threshold set for continued coverage.  (H.887, Sec. 12) Modifies 75 percent rule.

B.  Preventing Chronic Conditions through Healthy Lifestyles
1. State grants to communities
a. Support 4-8 pilot communities to engage in comprehensive (multi-sector) change b. State leadership and support: Increase staff capacity at VDH District Offices to support community planning, technical assistance, training, and evaluation.	a. Limited funding available under H. 891 (Also, federal CDC may not review obesity prevention grant to VDH in June 2008). b. (H. 887, sec. 13-14) Prevention specialists in 12 district offices to work with community stakeholders on comprehensive plans that identify and prioritize community needs.
2. State-level policy initiatives to support community-level change
a.  Healthy school environments (1) In collaboration with the schools community, strengthen nutrition and physical activity standards. (2) Strengthen existing state grant programs to support environmental and policy change in schools.	(H. 887, sec. 15-16) (1) VDH, DOE, Ag to update Vermont nutrition policy guidelines.  VDH/DOE to report on number of schools that have policies consistent with the guidelines. (2) VDH, DOE, and other agencies to provide an inventory of school programs for healthy living and recommend ways to improve coordination.
b. Promoting healthy weight in primary care (1) Promote clinical practice changes through toolkits and hands-on trainings (2) Review reimbursement to support best practices (3) Integrate supportive services: such as WIC clinics, non-medical counseling, and behavioral interventions. (4) Increase the proportion of mothers who breastfeed their infants and toddlers.	(H. 887, sec. 19) Blueprint for Health is developing pilot projects to improve attention to nutrition and physical activity in primary care, for both children and adults.  VDH will convene stakeholder workgroup to explore payment improvements.
c. Healthy work environments Public-private collaboration to develop and disseminate resource tools and enhance interactive sharing of best practices	(H. 887, sec. 17, 18, 21) VDH, working with other agencies and private stakeholders, will make recommendations in a consolidated report on all healthy living initiatives by January 15, 2009.
d. Community design Increase opportunities for physical activity and  access to affordable healthy food
e. Nutrition information and eliminating trans fats in food service facilities

C.  Reduce the Rate of Increase in Costs while Improving the Health of Vermonters
1. Explore the restructuring of hospital and physician incentives at the community level to achieve better integration of care and lower costs.	(H. 887, sec. 2) Commission will conduct a feasibility study assessing alternative designs for a pilot project to test a system-wide budgeting initiative at the regional level, including a design based on the accountable care organization model.
2. Control hospital costs by a. Considering use of global budgets and a restructuring of the financing of hospital care as proposed in H.304. b. Revising Public Oversight Commission/ BISHCA annual review of hospital budgets.	a. See, above, feasibility study for assessing alternative designs for a system-wide budgeting initiative. b. Not adopted in House.
3. Promote private long term care insurance.	(S. 284, sec. 13 ) Requires BISHCA to make recommendations by January 15, 2009 for amending the VT Partnership for Long Term Care law to conform to federal requirements.
4. Change state administrative and regulatory requirements to help reduce health care costs.	Jim – can you provide a simple summary here?
5. Related provisions in H. 887: § (H. 887, sec. 2)  Study of health care financing options Commission will study health care financing options and develop a common analytic basis for policy decisions on the public financing of health care.  The study will also look at how to pay for a publicly financed system, identify and assess major federal issues with public financing, and analyze the impact of different financing options on the underlying cost drivers in health care.
D. Use Health Information Technology to Improve Performance
1. Promote Electronic Medical Records (EMR’s).	(H. 891, sec. 6.021) Creates the Vermont Health IT Fund with an estimated $32 million over the next seven years raised through a fee on health insurance claims.  The Fund’s chief purpose will be to assist independent primary care practitioners in adopting EMR systems.
2. Assess electronic prescribing (e-Rx).	(Sec. 25) Commission director, working with VITL project review committee, will study feasibility of a statewide e‑prescriber program, with recommendations by January 15, 2009.
3.  Support VITL legislation to clarify and enhance VITL’s role in building key health IT infrastructure in the state.	(H. 887 sec. 24; H. 891, sec. 5.008, 6.008) Adopted

E. Investing in Vermont’s Health Care System, Workforce, and Public Health Programs to Ensure Success in Health Care Reform
1. Recruit and maintain healthcare staff. a. Expand loan repayment programs (from $1.4 million to $2.0 million/yr) b. Support for nursing education i. Faculty salaries: ($425 thousand/ yr.) ii. Patient simulators ($70 thousand–one time) c. Establish and encourage “Healthcare Employee Pipeline Collaborative” ($50 thousand/yr).	a. Loan repayment programs funded at “same level as in FY 08? b. (H. 887, sec. 26) $40,000.00 appropriated for purposes of loan repayment for nurse educators
2. Leverage existing professional capacity with technological tools or new staffing patterns.  a. Support tele-medicine and other provider-based technologies: pilot in child tele-psychiatry in seven community health centers ($250 thousand) b. Enhance oversight of criteria for changes in licensing and professional scope of practice.	a. (H. 887, sec. 26) $100,000 appropriated to support child tele-psychiatry pilots in community health centers b. No action
3. Enhance “System-ness” and Accountability within the Public Health Infrastructure a. Fund VDH regional offices to integrate services at the community level b. Revisit or Revise the Health Resource Allocation Plan (HRAP)	a. VDH regional offices in Blueprint communities to take on larger role in coordinating public health and chronic care management services. b. ANY action on HRAP?