The Vermont Senate approved the governor’s plan for a 16-bed, state-owned psychiatric facility as part of a decentralized, regional mental health system on Wednesday night. The vote was 28-0.
Though in the end the decision was unanimous, senators debated the issue for nearly four hours and defeated three amendments which would have expanded the replacement facility for the Vermont State Hospital to potentially accommodate at least 25 beds.
The discussion centered on the merits of a community-based system and on the uncertainty regarding federal funding for the construction and operating costs for the facility, which would likely be sited in central Vermont.
Republicans and liberal Democrats joined hands in opposition to the governor’s plan; Shumlin Democrats outnumbered the minority two to one.
Proponents of the smaller facility cited financial concerns and said they had faith that a community-based approach would work; opponents questioned whether patients from northern Vermont who need intensive mental health services would be turned away because of a lack of bed capacity.
There were fundamental disagreements on community versus institutional care, but the debate largely revolved around numbers — the number of beds, the number of patients, the number of caregivers and especially the amount of money it would cost to run the new system.
Senate President Pro Tempore John Campbell told the senators that they had a choice between an institutional model and a community-based model with one smaller central facility — and the difference between no federal support and $8 million to $12 million a year in Medicaid subsidies. The 60 percent match isn’t available for Institutes for Mental Disease, or standalone psychiatric facilities with more than 16 patients, he explained.
“We’ve heard many times about what the Centers for Medicaid and Medicare will pay for and won’t pay for,” Campbell said. “The federal government decided they were going to make a policy decision we were not going to go along with the institutionalized model.”
The state would need to obtain a federal waiver to operate a larger facility. Campbell held up a letter that outlined a conversation the governor had with CMS officials. Shumlin says the federal agency will not fund a facility with more than 16 beds. Calls and emails for information about the waiver from VTDigger.org have not been returned by CMS.
Sen. Peg Flory, R-Rutland, asked why the governor wasn’t seeking help from the congressional delegation for a waiver, in light of Shumlin’s assurances in press appearances that the state could obtain waivers from the federal government for his signature, single-payer health-care reform plan with assistance from Rep. Peter Welch and Sens. Patrick Leahy and Bernie Sanders.
“I can remember being on the floor passing bill requiring five waivers, two of which couldn’t be applied for for five years,” Flory said. “We have a wonderful congressional delegation that will help us get the waivers. I agree with that. We have a wonderful delegation that would help us.”
Another Republican senator, Joe Benning from Caledonia County, pressed for an option to expand a 16-bed facility to 25 beds if needed. He cited monthly declined admission numbers from regional hospitals. Forty patients a month are turned away by Fletcher Allen Health Care in Burlington, he said. Rutland Regional and Brattleboro Retreat also decline patients access to care because of a lack of capacity. When Fletcher Allen goes off-line, Benning questioned whether the community-based system would have enough beds to accommodate roughly 160 patients who regularly need intensive psychiatric care, since 68 percent of those patients live in northern Vermont and the governor’s plan relies on facilities in southern Vermont. Benning’s amendment was defeated 10-19.
“There are two steps to the financial question of how do we pay for what we’ve built — that’s where the FEMA money comes into play — and how do we pay for what we’ve built to operate it,” Benning said. “The Medicaid money is in a state of flux. No one can tell us if we will receive the money. … If we’re unable to obtain waivers to continue operations already granted to us for $10 million in costs if we don’t get that waiver, then the cynic in me says how is it then possible to obtain waivers to run a $5 billion health-care system. If the governor believes we can do that then there are ways to get operating costs for this facility.”
Sen. Claire Ayer, D-Addison, said the debate was not about 16 beds or 25 beds for patients with severe psychiatric problems, but about 41 or 54 beds that would be available to Vermonters in the proposed community system model.
“It’s about providing intervention and support at the local level,” Ayer said.
Sen. Philip Baruth, D-Chittenden, said lawmakers frequently repurposed a quote from the film, “Field of Dreams” — “If you build it they will come” in discussions about building a facility with more than 16 beds that would be “magically” filled.
“I don’t believe that myself,” Baruth said. “If you followed that logic you’d build nothing and no one would come. That is simply fantasy.” His amendment for a 25-bed facility, which was co-sponsored by Sen. Tim Ashe, D/P-Burlington, failed 10-19.
The legislation, H.630, was precipitated by Tropical Storm Irene. The Vermont State Hospital was damaged on Aug. 28 when floodwaters from the storm swamped the Waterbury facility, which housed 54 patients and cost about $22 million to operate. Because the hospital had been decertified by the Centers for Medicaid and Medicare the state was not eligible to receive federal funding.
That changed when patients were placed in regional hospitals after Irene. The state received a 60 percent match for qualifying patients, totaling about $10 million a year.
Gov. Peter Shumlin urged lawmakers to move quickly to approve a plan for a decentralized system of mental health care that includes “step-down facilities,” more supports from a regionalized community care system, peer services and a state-owned hospital for patients with severe mental illnesses for 16 patients. The Department of Mental Health would also outsource services for “level one” patients to regional hospitals in southern Vermont. Brattleboro Retreat would provide 14 beds and Rutland Regional Medical Center would have six beds. The state would pay for new units to accommodate the additional patients at the private facilities.
Under the governor’s plan, about 41 patients would receive care in intensive institutional settings and an additional 40 patients would be treated in community-based residential programs. The state would plow new money — about $9 million a year — into local support services.
Making the new system work financially is difficult because much of what the state wants to do is tied to complex rules and formulas for federal funding. The Federal Emergency Management Agency will likely back the construction of a new facility with a 90 percent federal, 10 percent state match, after the state’s insurer pays its share of the replacement cost for the state hospital in Waterbury.
Lawmakers have said they don’t want to leave one-time FEMA money for construction on the table.
Though federal funding will likely be available for the structure, it’s possible the Centers for Medicaid and Medicare could drop funding for annual operating costs if the state builds a facility with more than 16 patients, according to lawmakers and Shumlin administration officials.
The Senate vote comes on the heels of a mass layoff of 80 Vermont State Employees Association members. The Shumlin administration announced the reduction in force of the workers last Friday.
After Irene, state workers had been reassigned and asked to provide support for patients who were moved to Rutland Regional Medical Center, Fletcher Allen Health Care and Central Vermont Medical Center. In many cases employees were asked to work 12-hour shifts and drive long commutes to their new workplaces, leaving their families for periods of time.
Sen. Vince Illuzzi, R/D-Essex-Orleans, pushed for a union-friendly amendment that would have created a 50-bed hospital and required regional hospitals to hire state employees. The proposal failed 10-18.
Though senators praised state employees for their dedication in the aftermath of Irene, they stopped short of approving provisions for early retirement options, or guaranteed placements at local hospitals or in other positions in state government.
State hospital workers testified in hearings that the Shumlin administration’s human resources department gave them the option of taking jobs with lower pay in the private sector or state government.
Conor Casey, a lobbyist for VSEA, said the Senate vote was “very difficult for our members.”
“When the governor makes such a bad decision, we look to the Legislature to intervene,” Casey said. “We thought the Illuzzi amendment was a very reasonable proposal. It allowed people to continue to do the jobs they loved.
“We know the Legislature can’t rescind reductions in force from the executive branch, so these are the only proposals we can make,” Casey said. “The governor talks about Vermont strong; this decision was Vermont weak.”
The Labor Caucus met on Wednesday afternoon to pass a resolution honoring the “heroes of Tropical Storm Irene,” the state workers with the Vermont State Hospital who worked long hours far from home to ensure that patients received good care at regional facilities.
The stage is now set for contentious conference committee negotiations, which will likely take place after the next week’s Town Meeting Day break. Though the House and Senate bills are nearly identical, the House overwhelmingly supported a 25-bed facility on Feb. 2 (story here), and debate over that issue will likely be intense.
The Senate plan does not include an option to expand the 16-bed facility to 25 beds if more capacity is deemed necessary at a later date.
Such an expansion clause, as proposed by Benning, could be the compromise pressure point in conference committee negotiations. When asked if the administration, which has been adamant about a 16-bed solution, would consider a provision that would allow for an expansion of the facility from 16 beds to 25 beds, Jeb Spaulding, secretary of the Agency of Administration, didn’t rule out the possibility. He said: “We’d prefer not.”
Editor’s note: This story was updated at 6:15 a.m.