Recent critical editorials about Vermont’s health reform plan are welcome. Perhaps they will spur the Vermonters affected, particularly small business owners and their employees, to take a closer look at the real opportunities available to them as we implement the federal and state health reform laws.Small business owners and their employees are the primary beneficiaries of premium subsidy provisions of the federal health reform law, the Affordable Care Act, known as the ACA. These benefits will be available to businesses and individuals purchasing insurance through the federally required health insurances exchange. Here are some examples:

• Tax credits of up to 35 percent of a small employer’s contribution to employees’ premiums between now and 2013 and of up to 50 percent of the contribution in 2014 and 2015.

• Free choice for small employers regarding whether or not to offer insurance to employees. No penalty if they decide to drop coverage.

• Tax credits for individuals and families who purchase insurance that will limit the impact of premiums. For a family of four earning $50,000 per year, monthly premium would be limited to $282, about one-half of what many families now pay. These credits will be available on a sliding scale to families earning up to $92,000 per year.

• Cost-sharing for families earning up to $57,636 per year to help pay for out-of-pocket expenses like deductibles and co-pays.

Some commentators have ignored these facts and focused on the ACA requirement that all states implement new insurance rules that reduce variation in rates. This requirement will eliminate a giant loophole in Vermont’s current law that allows certain businesses to band together to form “associations” and escape the normal insurance rate setting laws.

Our analysis of this change shows that it will level the health insurance rate playing field for Vermont small businesses and their employees. Leveling the playing field means that there will be a one-time adjustment producing some winners and some losers. This will happen in 2014, when the tax credit and premium subsidy provisions listed above kick in to soften the impact on those who have benefited for more than 20 years from Vermont’s “association” loophole.

We are not “proposing” this change, as some commentators have said. It is a requirement of federal law that everyone in the small group market be treated alike and that costs be spread fairly. And as already noted, this is a one-time change. Some small employers, even some of those in associations, have seen annual premium increases for several years in a row greater than the elimination of the so-called association exemption will cause. And some small employers will see premium decreases as a result of giving fair treatment to all.

All of these changes are part of a transition to a more cost-effective, less complicated and fairer system. And when health care reform is fully implemented, we are willing to be held accountable for its level of success.

But we do need the help of all Vermonters in explaining and striving to understand the long path toward changing a health care system that threatens to bankrupt our state. Creating a successful health insurance exchange that complies with federal law is an absolutely essential step on that journey. But it is only one step.

Gov. Shumlin has proposed additional reforms that will have a more dramatic effect in the future. He has proposed that health care coverage be fully divorced from employment, so that employers no longer have to worry about insurance details and all Vermonters know they will have coverage regardless of their employment or income status. He has proposed significant changes in health care payment and delivery so that we can contain health care cost growth. And he has proposed investments in improving the health of Vermonters so that we assure access to good primary and preventive care and avoid illness. The Green Mountain Care Board is working to implement these reforms.

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On Jan. 30 Gov. Peter Shumlin appeared before a chamber of commerce legislative breakfast in St. Johnsbury. During the question period he reported how his good friend Quebec Premier Jean Charest had told him that many companies had asked him about locating a plant in Vermont, New Hampshire, Maine or Quebec, and Charest had gotten all of them to choose Quebec because of Quebec’s single payer health care system. There are some who will be skeptical of this report.

Later I had the chance to ask a question: “Governor, since you mentioned Quebec, can you tell us how your Green Mountain Care will differ in any material respect from the Quebec single payer system?”

His reply was this: “In Quebec health care providers work for the government. They will stay private in Vermont. Vermonters will have universal access.”

In the first place, Canadian Medicare is more universal than Green Mountain Care will be. It covers all Canadians except those in the armed forces or in prison. To distinguish Green Mountain Care as being more universal is, frankly, ridiculous.

The other part of Shumlin’s answer is more troubling. He actually believes that Canadian health care providers are employed by the government. That’s true in the United Kingdom’s National Health Service, but it is unarguably false with respect to Quebec. Shumlin’s Green Mountain Care will operate exactly like Quebec Medicare, right down to the controlling board, government definition of essential benefits, setting compensation rates for providers, writing all the checks to pay private providers, and setting a global budget in the name of cost containment.

I am shocked that Gov. Shumlin is so totally ignorant about the system just 50 miles north of Montpelier, while he is trying to impose exactly that system on Vermonters.

VTDigger

February 6, 2012
Contact: Mike Kanarick
802.324.4296

Gov. Shumlin Endorses Weinberger for Burlington Mayor

Burlington, VT – Today, Gov. Peter Shumlin endorsed Miro Weinberger for Burlington mayor. During a press conference at Main Street Landing’s Union Station, Gov. Shumlin stated:

“Miro Weinberger knows how to get tough things done. And he does it with his unassuming, extraordinarily bright, talented ability to bring people from all walks of life together to face challenges and to turn them into successes. That’s what Vermont’s largest city needs the most right now – leadership that will take troubled times and turn them back to good times.

“Miro will be the kind of leader that Peter Clavelle was, as the mayor of this city, one that found creative ways to enhance everything from housing, to job opportunities, to public infrastructure. That’s what this city needs now. So Miro, I can’t tell you what a pleasure it is to endorse your candidacy, to tell you that I’m willing to do whatever it takes to help you win.”

In response to Gov. Shumlin’s endorsement, Weinberger stated:

“I am excited and honored to have Gov. Shumlin standing with me today.”

Weinberger spoke of his admiration for Gov. Shumlin’s leadership of Vermont through difficult economic times and two major natural disasters, and stated:

“The next mayor of Burlington will need to lead in a very similar way – putting our finances back in order during difficult economic times – while at the same time moving forward on important priorities to make this city more affordable and livable, to add to the vibrancy of the downtown, the waterfront, and commercial corridors throughout the city, keeping our schools strong and keeping our community united as we become an increasingly diverse city.”

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The decision came after business owners testified last week to House and Senate health care committees, many of whom expressed concern that the administration’s original proposal would increase the cost of doing business in Vermont by disallowing high-deductible plans for employees.

At a press conference, Gov. Peter Shumlin told reporters that the exchange is merely one part of his signature health care reform effort.

“We feel strongly that the exchange is not the answer to all of Vermont’s health care problems,” Shumlin said. “If we just passed the exchange, we would not contain costs adequately and be able to provide universal access.”

The exchange, he said, should provide maximum flexibility and ensure that patients have many of the same insurance options they have now.

The federal government requires states to set up electronic marketplaces for individuals and small groups to purchase health insurance by 2014.

The federal health care reform law sets basic requirements for an exchange, but states have authority to decide matters such as essential benefits insurance companies in the exchange must cover. In 2016, all businesses with 100 or fewer employees must purchase insurance through these exchanges. For 2014 and 2015, states can decide whether to include businesses with 100 or fewer or 50 or fewer employees.

The administration’s original proposal, embodied in House Bill 559, included larger employers and allowed only plans rated “silver” and above by the federal government. The bill also requires these companies to buy insurance in the exchange — a requirement that would remain for smaller businesses and individuals under the governor’s proposal.

Plans are rated by the value of health care benefits they covered compared to what individuals end up paying. Bronze is the lowest level plan under federal law.

While the exchange has been pitched as a stepping stone to a universal health care system that the state could implement in 2017 with a federal waiver, Shumlin emphasized Monday it is not the fix for all of the state’s health care problems.

What the exchange will do, Shumlin said, is allow businesses and individuals to access huge tax subsidies. It also allows the state to draw down millions of dollars in federal funding for things like technology to coordinate health care providers and reduce administrative costs.

“The exchange is helpful to Vermont to bring us federal dollars to achieve our single payer goal,” Shumlin said. “The exchange itself is not the panacea to all our problems and challenges in Vermont. It is a helpful tool but by no means a solution to Vermont’s challenges.”

The exchange will help Vermonters save millions of dollars they spend on insurance brokers who help employers choose insurance plans and help insurance companies assess risks, Shumlin said.

Speaker of the House Shap Smith told reporters Monday the choice to propose bronze plans and exclude larger businesses was a “very hard decision.”

“I don’t think businesses speak with one voice on this issue,” Smith said.

Opposing views in the business community

Reactions to the governor’s announcement resonated that message.

Betsy Bishop, president of the Vermont Chamber of Commerce, gave legislative testimony last week advocating for inclusion of a “bronze” plan, excluding businesses with 50 to 100 employees and allowing an off-exchange market.

Bishop praised the governor and the Speaker of the House for a proposal that would allow more choice for businesses.

“By allowing bronze plans, those employers being forced into exchange will have a greater choice of what to purchase,” Bishop said.

The Chamber has worked with Sens. Hinda Miller and Vince Illuzzi to introduce legislation that would limit the exchange to smaller employers, include bronze plans and make the exchange voluntary by allowing an outside market for individuals and small groups.

“We’re still hoping to see some movement along making the exchange voluntary,” Bishop said.

Allowing this separate market would allow more options for employers in 2014, Bishop said. If the exchange provided attractive, cost-effective options, people would choose it over other plans, she said.

Meanwhile, Vermont Businesses for Social Responsibility expressed disappointment in the governor’s announcement.

Andrea Cohen, the organization’s executive director, said the group has a preference for including the larger businesses in the exchange and restricting it to higher level plans.

These will both create a more vibrant exchange and provide higher quality plans for Vermonters, she said.

Vermont Businesses for Social Responsibility’s end goal, she said, is decoupling health insurance from employment, and the exchange does not do that. It can be a means to an end, however.

“We just want to see good progress,” she said.

Cohen said businesses that don’t offer health care are more competitive because they save money on labor costs, while companies that offer insurance pick up the tab not only for their own employees but also higher premiums for the uninsured.

Cassandra Gekas, a health care advocate for the Vermont Public Interest Research Group, said including high-deductible “bronze” plans in the exchange would increase the number of underinsured Vermonters.

People with high-deductible plans are more likely to forgo preventive and primary care, which can lead to catastrophic illnesses and increased costs for the system as a whole, Gekas said.

Dr. Deb Richter has been advocating for a publicly finance universal health care system for years. She said the governor’s proposal was “not a catastrophic decision, but it’s not a good trend.”

High deductible plans appeal to healthy people and result in insurance companies cherry-picking healthy individuals, she said.

Patients insured with high-deductible plans cannot afford to get sick, Richter said. When people cannot afford to pay their medical bills, hospitals are forced to increase costs to make up for that undercompensation. This costs are then shifted to other payers.

Under the “bronze” plan, an insurer has to pay for 60 percent of the cost of care. In theory, if a patient had a catastrophic illness and incurred $100,000 in medical bills, his or her liability would be $40,000. Out-of-pocket limits would, however, cap an individual’s personal costs to a little under $6,000 or slightly less than $12,000 for a family under the federal law.

Darcie Johnston of Vermonters for Health Care Freedom, a group that opposes the state’s health care reform effort, said provisions of H.559 still in place remain problematic for businesses.

Prohibiting individuals and businesses with 50 or fewer employees from purchasing insurance outside the exchange will limit competition and increase costs, she said.

“I think it’s critical for people to buy insurance off the exchange,” she said. “If the exchange has merit, it will stand on its own.”

VTDigger

Vermont AG William Sorrell, right, said his office lacked the evidence needed to bring criminal charges against Vermont Yankee Officials. At left is Asst. Attorney Gen. John Treadwell. VTD/Josh Larkin

Entergy Corp. filed a motion with the U.S. District Court on Friday to recover $4.6 million in legal fees for its lawsuit against the state.

The Louisiana company prevailed in federal court on Jan. 20 when Judge J. Garvan Murtha struck down two state laws that required Entergy to seek approval from the Legislature to continue operating Vermont Yankee Nuclear Power Plant past its 40-year anniversary and to store high level nuclear waste at the plant site.

The state has 30 days to appeal the decision.

Entergy says it is entitled to an award of attorneys’ fees because it also prevailed on its claim under the Commerce Clause.

Chanel Lagarde, spokesman for Entergy, said in a written statement that “the law allows for the prevailing party to seek recovery of attorney’s fees.”

“We believe this is the appropriate next step for our company in this case where we were compelled to challenge several Vermont state laws that we believed were unconstitutional and were in fact found to be unconstitutional,” Lagarde said.

Download the motion Entergy Attorney Claims 2-3-12.

Vermont Attorney General Bill Sorrell said he expected Entergy to request attorneys’ fees.

“I was certain it would be all of seven figures, I just didn’t know how far into seven figures it would be,” Sorrell said. “It’s a little higher than I thought.”

Sorrell said “they threw a lot of legal horsepower at us, they went into the record extensively and they charged New York City rates.”

Entergy hired Kathleen Sullivan, the dean of Stanford Law School, to litigate the case. Sullivan was on the short list of candidates for Obama’s recent Supreme Court appointment, and she has been described as “one of the most trusted advocates before the United States Supreme Court.” Sullivan unearthed a detailed record in which she said lawmakers made references to safety as justification for a decision to deny Entergy a permit to continue operating the 40-year-old nuclear plant for an additional 20 years. States can’t regulate the safety of a plant under federal law; safety is the purview of the Nuclear Regulatory Commission.

The state can challenge the amount of the fee, Sorrell said. “This is a long way from over,” he said.

Sorrell said his office can question whether the lawyers’ hourly rates and the amount of time they spent on the case was reasonable. Entergy can’t claim relief for any legal work related to the questions about the reliability of the nuclear plant, he said.

It’s not unusual for litigants to go through a mediation process and retain experts to review attorneys’ fees, according to Sorrell.

“It’s not that they get to say this is what you give us,” Sorrell said. “There’s a lot of lawyering to be done on a request of this magnitude.”

Sorrell pointed to the prescription datamining case as an example of how the state has negotiated with other litigants. The state lost the case against IMS, a drug datamining company last summer in proceedings before the U.S. Supreme Court. The attorney general said he couldn’t reveal how much IMS is requesting for attorneys’ fees, but he said the state is negotiating with the company to reach a settlement. The state has already settled with one of the litigants in the case, Pharma, an advocacy group affiliated with IMS for about $1.75 million.

Will Entergy’s $4.6 million request affect Sorrell’s decision to appeal? “Not really,” he said.

“Some have speculated that we would be intimidated by the amount not to go further with an appeal,” Sorrell said. “Others have said it reinforces the reasonableness of an appeal because if the decision is overturned we don’t pay a dime. We’ll look at the appeal on its own merits.”

Cheryl Hanna, a professor at Vermont Law School and an expert on constitutional law and the U.S. Supreme Court, said the judge ruled that the state of Vermont violated Entergy’s constitutional rights and that entitles Entergy to legal fees.

“As a general rule, we allow that,” Hanna said. “We want to give incentives to enforce constitutional rights even when there is no money involved.”

Vermont doesn’t have to pay damages, she said, but “we allow for requests for attorneys’ fees so that lawyers will take these (constitutional rights) cases.” Hanna said fees are requested for a wide range of cases whether the litigants are inmates or multi-million dollar corporations.

Hanna says it will be up to court to decide how much to award.

“Unless the state prevails on all counts, we will probably end up paying for Entergy’s lawyers,” she said. “We don’t get a discount rate because we’re in Vermont. The court will force us to pay New York rates.”

Last year, the Shumlin administration pushed for a “billback” provision that requires Entergy to pay the state’s legal fees. Sorrell advised the Legislature to move ahead with the change in statute, which would make Entergy Corp. liable for the state’s legal expenses, including responses to public records requests and the preparation of litigation in the case.

Whether the court would honor this provision, in light of the judge’s dismissal of the state’s authority in matters of pre-emption, is an open question.

Editor’s note: This story was updated 5:40 a.m. and again at 6:25 a.m. Feb. 4.

VTDigger

“This is a historic moment,” said Rep. Ann Pugh, D-S. Burlington, as she spelled out to House lawmakers details of the sweeping bill drafted to respond to the loss of the 54-bed state hospital in Waterbury, which was flooded and closed by Tropical Storm Irene.

By a 124-3 vote, legislators agreed with Pugh, chairwoman of the House Human Services Committee, that it was time to seize “this tremendous opportunity growing out of the crisis Irene gave us.”

“We’ve been talking about transforming the mental health system in Vermont ever since I’ve been a legislator,” said Pugh, noting the state’s extensive and futile effort in the past decade to plan and fund a replacement for the antiquated buildings that comprise the state hospital.

Lawmakers have been working feverishly for weeks with the administration of Gov. Peter Shumlin to draft legislation that addresses the mental health treatment crisis caused when the acute-care state hospital beds were removed from the system.

The governor launched the process in December when he declared patients would never go back to the Waterbury facility and set out a plan to trim acute-care beds, arguing for a comprehensive proposal that stresses treating mental illnesses in a spectrum of community settings instead.

Lawmakers in the House tweaked Shumlin’s plan and together with Mental Health Commissioner Patrick Flood filled in innumerable blanks on funding to come up with the consensus bill that won backing Thursday.

Flood said Thursday that the pricetag for the proposed system is around $174 million, roughly $20 million more than the fiscal 2012 mental health budget. However whether there is any actual cost increase to the state is unclear because of the complexities of extensive federal Medicaid reimbursements.

The one major dispute over the bill involved the size of Shumlin’s proposed new state hospital in central Vermont, which lawmakers decided needed to be bigger than the 16 acute-care beds proposed. The bill, H.630, proposes a 25-bed facility instead. Those beds are paired with a six-bed facility at Rutland Regional Medical Center and 14 beds at the Brattleboro Retreat.

The bill also calls for a secure five-bed acute-care facility for patients under department of corrections control.

Rep. Alice Emmons, chairwoman of the House Institutions and Corrections Committee, told House lawmakers her panel struggled with the complexities of deciding the right size for the new state-run hospital since Vermont doesn’t know how much FEMA and insurance money will be available for the $25 million facility. But she also said because the hospital won’t be built for “anywhere from two to three years,” stakeholders in mental health will have to time to make sure the 25-bed hospital is right-sized for the needs of Vermonters.

Pugh noted more than 70 individuals from psychiatrists and clinicians to mental health experts and consumers came before her panel, some urging no state hospital beds at all and others as many as 100.

“We spent over a month trying to weigh those different perspectives,” she said. Her committee eventually concluded by a 9-1 vote last Friday that a 25-bed facility was needed in the northern part of the state and formed the best “backstop” to meet the needs of Vermonters and provide a professional “staff to promote recovery.”

“We were not able to receive sufficient data that a 16-bed facility could do that,” she said.

The overhaul bill includes a range of other beds outside of the acute-care facilities: four short-term crisis beds designed to avert hospitalization, a five-bed voluntary non-coercive residence with peer support; and one 15-bed and two eight-bed facilities around the state providing for intensive recovery.

A wide variety of peer services provided by those who have had experience in the mental health system, crisis intervention teams, housing subsidies and mobile support teams are also provided in the bill. The community services, housing and the four-bed and five-bed beds facility are estimated to cost $8 million annually.

The bill that reached the floor included a provision to ensure that the 240 state hospital workers, who were dispersed to work at facilities around the state, will have extended and preferential rights for jobs when the new state hospital is built. Emmons said those provisions were agreed to by the Vermont State Employees Union and the administration.

Rep. Thomas Koch, R-Barre Town, rose to support the bill, humorously saying he felt like a member of the audience throwing flowers on the ice at the national skating championships. Noting he had “become extremely frustrated by the lack of progress” during the last nine years in reforming mental health, he praised the committees that slogged through the complex process and found consensus.

While he had his own concerns about letting private institutions handle some of the former state hospital patients, he said lawmakers should be “extremely proud” of the bill.

“There’s been a lot of inaction, a lot of talk. We’ve done more in the last five months than we had done in the last eight and a half years,” he said.

The bill will have its final reading Friday and upon passage move over to the Senate for that body’s review.

Rep. Pugh was elated with the large margin for passage.

“I think a vote of 124-3 is incredible,” she said, especially considering how “controversial” replacement of the state hospital has been in the past.

Asked what is likely to happen in the Senate, she said she didn’t know and was just going to let the process work.

Emmons had the same response, calling the vote “terrific.”

“Now we’ll see where it goes,” she said.

VTDigger

Contact
Ann Curran at (802) 655-8059, acurran@vpt.org
or Jeff Vande Griek at (802) 655-8062, jeffv@vpt.org

Gov. Peter Shumlin will take questions from a studio audience in a statewide televised forum on Thursday, Feb. 9, at 8 p.m. on Vermont Public Television and on vpt.org.

Host Kristin Carlson will also invite viewers to participate at 1-866-424-LIVE or connect@vpt.org during the hour-long program.

People interested in being part of the audience at the VPT studio in Colchester should call

1-800-639-3351 or email engage@vpt.org by Feb. 7.

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COTS Executive Director Rita Markley speaking to reporters during Gov. Shumlin's weekly press conference. VTD/Josh Larkin

Gov. Peter Shumlin and his administration are taking steps to prevent more homeless Vermonters from freezing to death.

Three people have died of exposure this winter because they didn’t have access to shelter.

The governor said the state will waive eligibility requirements for homeless Vermonters seeking shelter during dangerously cold weather so that “every homeless person knows that when it’s cold they have a place to go.”

“It’s tragic that any state allows anyone to freeze outside,” Shumlin told reporters at a press conference in the governor’s ceremonial office. “Our goal is simple: Move homeless people from shelters and motels to permanent housing.”

About 4,000 Vermonters sought shelter at some point last year.

The Shumlin administration has also launched a rental subsidy program and authorized 100 housing vouchers to move people in motels and shelters into permanent housing.

The programs will cost $1.5 million. The money will come from General Assistance funds. In addition, some of the funding from the recently announced New Emergency Solutions Grant from the Department of Housing and Urban Development (HUD) will be put toward affordable housing projects for homeless Vermonters.

The governor also signed an executive order re-establishing the Vermont Council on Homelessness. He named Angus Chaney as the chair of the council and director of housing, a new position in the Agency of Human Services, to coordinate homelessness prevention efforts between AHS and the Agency of Commerce and Community Development. Chaney has served as the community services program administrator for the Office of Economic Opportunity.

Chaney said housing is “key to any of the services we provide.”

“The goal is fairly simple: It’s to end homelessness,” Chaney said. “The solution is not rocket science. It’s affordable housing. You’re going to see some exciting changes in the next year in terms of the way we view this issue. It can’t be viewed through the lens of a single grant program or single division of government.”

It’s important, he said, for the state and nonprofit groups that help the homeless to come together to “re-energize our efforts,” to address what he called a 30-year crisis.

“It would be easy to let ourselves slide a little bit and start to accept this level of homelessness in Vermont,” Chaney said. “I would encourage you all not to accept that.”

Gov. Shumlin has appointed Angus Chaney as the director of housing for the Agency of Human Services. VTD/Josh Larkin

Rita Markley, executive director of the Committee on Temporary Shelter, said in a down economy “it’s so easy to just focus on the crisis and to do a short-term fix.”

She lauded the governor for addressing the immediate needs of homeless Vermonters and moving ahead with changes to programs that will have long-term impact and “break the fall” for Vermonters who are on the verge of becoming homeless. She said the new director of housing at AHS will “navigate many of the cumbersome systems currently in place to create a coherent homeless prevention strategy.”

The new flexible guidelines for emergency assistance, she said, will ensure “that no Vermonter on the coldest nights is left without a place to turn.”

“These flexible guidelines are going to mean that when shelters are full, or there isn’t room, that they’ll get emergency assistance, perhaps through an overflow motel for people who might not otherwise be eligible,” Markley said.

Markley said the state subsidies will help keep people in their homes during difficult times, “when their job changes or their family income plummets or something happens we will keep them in homes.”

Over the last four years, COTS has run a similar homeless prevention and rehousing program she said that costs about $800 per household that has prevented 816 families subject to eviction and foreclosure from “sleeping in their cars, in shelters or doubled up in places that aren’t good for kids or families.”

VTDigger

A big contingent of Vermont State Hospital staffers wore T-shirts to Tuesday's hearing on Vermont's mental health system. Above, Kathy Bushey, left, and Priscilla DeGumbia outside the hearing room. VTD/Andrew Nemethy

MONTPELIER – Two distinct themes emerged in Vermont’s debate on how to rebuild the state’s shattered mental health system.

One is that Vermont’s effort to strengthen and broaden community mental health treatment and peer services is laudable, essential, workable and long overdue.

The other is that Vermont’s proposal for replacing the acute-care mental health beds lost when Tropical Storm Irene flooded the Vermont State Hospital is ill-advised, insufficient, inadequate for care, geographically unbalanced and will stress the entire system.

That, in general, is what emerged from morning legislative testimony in the House Human Services Committee and from an emotional, standing room only afternoon hearing that packed one of the largest rooms in the Vermont Statehouse with more than 80 people from around Vermont.

Take psychiatrist Terry Rabinowitz of Fletcher Allen Health Care in Burlington, who said the state’s plan for acute mental health care falls short and marginalizes the state’s most vulnerable population. He called it “not only a disservice but a dishonor.”

“Do we Vermonters want to do this to our most vulnerable population? I think not,” he said.

There’s no shortage of moving parts as Vermont attempts to rebuild its mental health system after Irene wiped out use of the Waterbury state hospital’s 54 beds and the experienced staff who had expertise in treating the most acutely ill patients.

Gov. Peter Shumlin has proposed spreading out 36 acute care beds to replace the state hospital, using three facilities: 14 at the Brattleboro Retreat, six at the Rutland Regional Medical Center, and a new 16-bed facility expandable to 25 beds to be located near Central Vermont Medical Center.

The plan also calls for expanding community services, from emergency intervention, housing, crisis beds, services provided by peers (people who have been in the mental health system and can relate to patients) and intensive local mental health outpatient and residential services. Administration officials contend those services will preempt the need for more acute care beds.

Criticism of the acute care part of the plan has been building as discussion continues in the Legislature and on Tuesday it turned into a crescendo.

In the morning, Dr. Peter Thomashow, medical director of Central Vermont Medical Center, and James Tautfest, a psychiatric nurse who heads the 14-bed psychiatric unit, added their voices to those of other key medical professionals in the state who say the governor’s plan doesn’t provide enough acute- care beds for the mental health system.

In testimony to the House Human Services Committee, Dr. Tomashow said the state needs a 30 to 40 acute care bed facility in central Vermont, much more than the 16-bed facility proposed. He said he strongly supported the governor’s overall plan, but he and Tautfest said the state desperately needs the intensive care “safety net” that the former state hospital beds provided for assaultive and dangerous or self-harmful patients.

His comments mirrored those of the state hospital director and head of Fletcher Allen’s psychiatric unit, who have already advocated a similar number or even more beds. Tomashow said the governor’s plan simply underestimates the difficulty of the patients who were sent to the state hospital, many involuntarily. Professionals in the wards and emergency rooms see things differently, he said.

“We’re talking about the most difficult population in psychiatry,” he said.

He also said the governor’s plan does not provide enough acute care in northern Vermont where the biggest population is, and suggested that an uptick in acute care needs from aging baby boomers means even more beds may be needed in the future.

Tautfest suggested the state consider reopening – only temporarily – a ward at the state hospital to ease the crunch that has existed since Irene, which forced regional and community hospitals to treat patients who would have ended up at Waterbury and has flooded emergency rooms with “very sick” people.

More than 40 people, many of them also nurses, doctors and mental health professionals, as well as relatives and patients, testified along the same lines in short yet emotionally packed 2-minute statements in the late afternoon.

“I do believe that we need a state hospital in one central location, not for or five little bitty ones located around the state,” said Nancy Colby, a Chittenden County resident who said she had 25 years of personal experience with mental illness. She said having several small acute-care facilities would duplicate services and not be as effective as one larger facility.

“We worked with people no one else was able to treat,” said Kristy McLaughlin, a social worker at the Vermont State Hospital. “A decentralized system will not be making us better,” she said, warning that the state’s plan would “demolish” the mental health equivalent of an excellent intensive care unit if the governor’s plan goes through.

Dr. Ruth Grant of Waltham, who said her 20-something son had schizophrenia, said the state needed a “no-reject” acute care full-service facility in the northern part of the state and more beds than proposed. She urged the panel to listen to the opinions of the front-line care providers who were saying the governor’s plan falls short.

Jack McCullough, a legal aid lawyer with long experience in mental health judicial proceedings, agreed that community treatment is the ideal, but when it came to acute beds, he said “my judgment is that scattering beds around the state is not an efficient way to provide care.” And he said the governor’s plan is a “dramatic shift of resources down to southern Vermont” to private facilities, which raises legal issues the state needs to address.

The rights of patients when it comes to involuntary admissions and medication was also a concern to Ann Klein, a nurse at the state hospital. She said staff there were well-trained and kept up-to-date on involuntary procedures ordered by the courts. “We’re the most vulnerable patients’ protectors,” she said, but if the acute care is split into three places, two of which are not state run but private, “there will be no continuum of care.”

Many testified to the benefits of the community care proposals and urged lawmakers to make sure funding is sustained for the long term, noting drastic cutbacks in recent years.

Roxi Smith urged more support for organizations such as Another Way in Montpelier, which provides peer support and has helped her overcome “a lot of my own fears.”

“Peer support works,” she said. “Only people who have had mental illness can understand it,” she said.

Josh Sawyer, 43, of Montpelier choked up as he told lawmakers he had been at the state hospital twice and how Another Way had helped him and now he was on its board of directors.

“I ask you to continue funding for these programs,” he said.

Marla Simpson of Randolph provided a patient’s stark perspective, explaining she was one of the last to be evacuated from the state hospital when Irene hit. She called involuntary hospitalization, seclusion and restraint the same as “psychological rape,” but at the same time she praised the “outstanding” staff at the shuttered state hospital and said a 16-bed northern facility was not enough either for the acute care needs or to maintain expert well-trained staff.

Erica Smith of East Montpelier, a psychiatric nurse for 15 years who worked at the state hospital and now is in community mental health, said community treatment can have “wonderful” results for some people. But she cautioned that people misunderstand the high level of illness that afflicts some patients and some just do not do well in community programs and need intensive care.

“I am very fearful 16 beds is not enough and people are not going to survive in the community with this many beds,” she said.

That was also the message from Allison Hall, a psychiatrist at Fletcher Allen in Burlington. Hall said while she has been on call duty she has seen the hospital struggle to deal with patient emergencies since the state hospital closed. Fletcher Allen, along with the Brattleboro Retreat and Rutland Regional Medical Center and others, has had to take on many added patients in crisis with the state hospital’s closing.

She said she was “very concerned” that the governor’s acute care plans would be inadequate to treat the patients she has been seeing, she said. And she said state hospital staff, who are assisting around the state since the closure, are far better trained and able to de-escalate difficult situations.

“I strongly feel breaking up a strong team and scattering them around Vermont is unwise,” she said.

A physician’s assistant questioned why the state is even considering anything but building a new central state hospital, noting if a “top flight emergency room” had been wiped out in a flood, no one would even question rebuilding it. Mental health patients’ suffering is just as real, he said, and they deserve a top-flight hospital, too. Another psychiatrist made the same analogy, saying the governor’s acute care proposal “falls far short of the current and future needs of the state, ” noting it was tantamount to replacing a specialized cardiac care unit with a community health center.

Alexandra Forbes raised another problem with spreading acute care around to several community facilities. Speaking for the Vermont Psychological Association, she said one centralized facility with several units would provide the best clinical treatment and staff. She added that transferring people among three facilities means transporting them by sheriff in shackles, which is traumatic and humiliating.

“Truly it is embarrassing that the state is not committed to what we really need, a state-of-the-art facility,” she said. “The state should make that commitment.”

Several people lamented that the dispute over beds has overshadowed the larger issue of the positive transformation that the state is undergoing. Others said the state needs to go slow and make sure it gets it right.

Becky Moore, a state hospital social worker, said the rush to come up with a solution to the state’s crisis worried her and reminded her of the saying, “Marry at haste, repent at leisure.” She said an unfortunate “fallout” of the hospital’s closing was that different parts of the system felt they were being pitted against each other.

“It’s a false dichotomy or trichotomy, or whatever, because were all part of the same continuum,” she said. “I implore all of you as you make this decision, as you decide the future or mental health in our state, remember, we need all the parts of the mental health system.”

Mental Health Commissioner Patrick Flood, who sat in on the hearing, has said he finds the testimony in support of community services “very affirming” about the state’s direction. But he insisted despite the criticism Tuesday that the state’s proposal for acute-care replacement beds is “on the right path” and at this point said there was no plan to change it.

He also said the idea of reopening a ward at the state hospital even temporarily to handle some patients is “just not feasible” for a host of reasons.

Correction: Alexandra Forbes spoke for the Vermont Psychological Association; her affiliation was incorrect in an earlier version of this story.

VTDigger

Welcome to the world of Super Intendents and mandated school consolidation.

According to Gov. Shumlin we should be changing our for-now semi-autonomous state Department of Education into a wholly owned subsidary of the governor’s office (as in a governor-directed agency). And Shumlin has announced support for a proposal from state Sen. Kevin Mullin , R-Rutland, to reduce the number of supervisory unions to 16 with the further mandate that all school districts (except interstate) will become a part of one or another of these super supervisory unions.

Act 153 of 2010 has some interesting mandates regarding consolidation, and you need look no further then section 9 (page 16) to find the most obvious. It is this section that forces local school districts to surrender their responsibilities and authorities in almost every major decision-making area and turn these responsibilities and authorities over to the appropriate supervisory union board.

The trend is blatant: mandated consolidation of Vermont’s schools along with the resulting loss of local and democratic input and control. And this trend is being followed in a religious fashion … based entirely on blind faith and “but of course” discussions. The public discussion and exchange of evidence regarding end game costs and student outcomes has been nil.

The Williamstown school board is working with local legislators to introduce either legislation or an amendment to any educational bill that comes out of the House or Senate committee process. The board has voted unanimously in public session to support a legislative proposal that is intended to assure consolidations are a process that comes from the local level and not some top-down mandate; school districts are freed to pursue innovative and efficacious programs to improve student outcomes and reflect on the bottom line; and the state does not have to pay out any bribe money that will negate any possible savings.

The Williamstown proposal creates a process for school districts (as opposed to supervisory districts) to enter into inter-district agreements for the purpose of “consolidating or sharing school district operations or assets,” specifies that no extra state funds will be required for these agreements although small planning grants may be requested, and affirms that it is the state policy that “school consolidations of any type should be the result of local community action.”

The path forward according to Shumlin and friends is obvious: Consolidate control over the day-to-day operations of the schools, consolidate the public political input by reducing the number of publically elected officials with oversight capacity, and dis-empower the local school boards. The final step of their dream becomes trivial after that: Do away with those pesky local school boards forever.

Do you want to give up your local schools? I don’t. Do you want super-powered Super Intendents or would you rather have supporting superintendents? I’ll take the latter thank you.

VTDigger