Shumlin team in D.C. to seek waivers for single-payer health care

Gov. Peter Shumlin and his top health care officials were in Washington, D.C., last week to discuss waivers to federal programs that would allow Vermont to move forward with a single-payer health care program.

Traveling with Shumlin were Robin Lunge, director of health care reform; Lawrence Miller, chief of health care reform; Al Gobeille, chair of the Green Mountain Care Board; and Anya Rader-Wallack, a consultant managing a large federal grant funding health care innovations.

Robin Lunge

Robin Lunge, director of health care reform for the Shumlin administration, updates the Vermont Health Access Oversight Committee in June on the progress of setting up a health benefits exchange where Vermonters will purchase health insurance. VTD File Photo/Alan Panebaker

The government won’t grant waivers to the Affordable Care Act before 2017, but the state will continue to position itself to receive one for the next several years, Lunge said.

To proceed with single-payer, Vermont will need  a waiver from provisions of the Affordable Care Act and a renewal of its Medicaid global commitment waiver, which expires in 2016.

That waiver allows the state flexibility in how it spends federal Medicaid dollars as long as it meets the program’s basic requirements.

Vermont will also apply for what’s known as an “all-payer waiver,” which would allow the state to set reimbursement rates for Medicare. The state already sets Medicaid rates and regulates commercial rates.

The all-payer waiver could allow Vermont to reduce cost-shifting among payers, as currently happens to commercial insurance carriers when government programs underpay, Lunge told state lawmakers Tuesday at a legislative meeting.

Maryland is the only state with an all-payer waiver, which it has had since 1977.

It has used the waiver to ensure that Medicaid, Medicare and private insurance all pay roughly the same rate, according to Robert Murray, who spent nearly two decades working for Maryland as a hospital regulator and now consults for the Green Mountain Care Board.

Such a waiver could ultimately allow Vermont, if it transitions to a universal publicly financed health care program — often called single-payer — to pay the vast majority of people’s health care costs with capped payments to doctors and hospitals, though the details of such an arrangement will take years to finalize, Lunge said.

The all-payer waiver will help Vermont reform how health care services are paid for even if it never moves to single-payer, Lunge said, adding that the two are complimentary but not contingent on each other.

The Shumlin team met with U.S. Secretary of Human Services Cynthia Burwell and officials from the Centers of Medicare and Medicaid Services. Lunge and Miller also met with officials from the Treasury Department and the Office of Budget and Management.

Beyond starting preliminary negotiations on the federal waivers, Vermont officials pushed for federal funding for health services IT projects to be extended.

If Republicans gain a majority in the U.S. Senate in the November election, Lunge said she doesn’t see that having an adverse affect on Vermont’s waiver prospects.

“The most interest in a waiver is from Republican states” that want to walk back aspects of the law, Lunge said, “If anything, that might loosen up the waiver process.”

Morgan True

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11 Comments on "Shumlin team in D.C. to seek waivers for single-payer health care"

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Karen McCauliffe
2 years 2 months ago
There is good reason why Maryland is the only state that charges all payers at the same rate, as Medicare pays Maryland far more than it does the other 49 states. It is estimated that that Maryland’s hospitals have been receiving an extra $1 billion in Medicare reimbursements each year “In the late 1970s, the U.S. government agreed to a provision that gave Maryland the unique authority to set its own prices — even for Medicare. Analysts estimate that recently the state’s hospitals have been receiving an extra $1 billion in Medicare reimbursements each year. A handful of other states,… Read more »
Willem Post
1 year 11 months ago
ALL-PAYER-WAIVER Now that Single-Payer has been put on the back burner, because it would excessively upset the already-fragile, near-zero-growth Vermont economy, an ALL-PAYER-WAIVER is the fallback alternative. Maryland has had such a waiver since 1977. Its hospitals receive about $1 billion in extra Medicare/Medicaid reimbursements, which reduce cost shifting. It will be very difficult for Vermont to follow Maryland without the higher reimbursements. A handful of other states, including New York and New Jersey, tried to implement a similar system in the late 1970s and early 1980s. But unlike Maryland, they did not get the higher reimbursements written into federal… Read more »
Willem Post
1 year 11 months ago
Here is a revision of the above comment to correct spelling and enhance clarification: ALL-PAYER-WAIVER Now that Single-Payer has been put on the back burner, because it would excessively upset the already-fragile, near-zero-growth Vermont economy, an ALL-PAYER-WAIVER has become the fallback alternative. Maryland has had such a waiver since 1977. Its hospitals receive about $1 billion in extra Medicare/Medicaid reimbursements, which reduce cost shifting. It took many years to get all providers to adjust their operations, and for the state to monitor their operations to make the program functional. It would be very difficult for Vermont to follow Maryland without… Read more »
Willem Post
1 year 11 months ago
The below paragraph is added at the bottom of the above comment for clarification: People on Medicare and Medicaid would likely not be able to go to the nearby Dartmouth-Hitchcock Medical Center, because it is in New Hampshire and Vermont would not have jurisdiction to force it to comply with Vermont rules and regulations. Those people would have to go to the Rutland Regional Medical Center, etc., which would be forced to comply with Vermont rules and regulations. It is not clear, if such people could still go to a doctor of their choice, or a specialist of their choice… Read more »
John McClaughry
2 years 2 months ago
Let’s see. Assume for a wide range of billing codes the cost norm is 100. Medicaid pays 55, Medicare pays 87, and thus commercial insurance gets hit for 135. If the Feds gave VT a slug of money like MD, let’s say VT Medicare reimbursement goes up to 100 and allows commercial to drop to 120. But Medicaid is still at 55, which is the reason for the 120. To get Medicaid up to 100 and commercial down to 100, there would have to be a huge increase in Medicaid reimbursements – 40% of which are paid for by General… Read more »
Jamie Carter
2 years 2 months ago

“How many doctors will continue working for 80% of their present income?”

I’m guessing most all of them, and those that are only concerned about a dollar can go as far as I’m concerned.

If a surgeon can’t take making only $350,000 then go somewhere else, there’s always another waiting in line.

Apply to Med school, it’s not like there is a shortage of very qualified applications.

Willem Post
1 year 11 months ago

John,
See my above comment.

John Greenberg
2 years 2 months ago
John, You’re missing the uninsured, who pay vastly more than anyone who is insured. Whether it’s Medicare or private insurance, every medical bill I get shows an amount billed, an amount paid by the insurance company, an amount (if any) to be paid by me AND an amount written off by the provider. On a recent bill from a provider in Boston, for example, roughly 65% was written off by Medicare, so this can be a LOT of money. Similar amounts pertained when we had MVP coverage. When you’re uninsured, that written off amount is left to the patient to… Read more »
Mary Alice Bisbee
2 years 2 months ago

As a current Medicare recipient paying a large monthly fee to UHC to cover all my copays, the system in Vermont works well for me at present. All providers of Medicare must accept assignment in VT. Not so in other states, I guess.
Also there is literature confirming that some hospitals and providers automatically raise the cost of their services to make up for the lower Medicare payments. Whose fault is that?

David Dempsey
2 years 2 months ago

Shumlin has said he mandated that all Vermonter’s, after the phase in period, have to buy insurance from the exchange because it was needed to move forward to single payer in 2017. Unless the government officials in Washington are as inept as the Shumlin administation is, how can they justify giving Vermont a waiver to run a single payer plan that needs a working health exchange to transition to single payer. He should have brought Mark Larson with him. Maybe he could make them believe that Vermont’s exchange has been working fine since it went live last October.

Willem Post
1 year 11 months ago

David,

May be the EB-5 program can be used to implement Shumlin’s Medicare/Medicaid” fantasy cost savings due to ALL-PAYER-WAIVER. The Chinese will pay for it. All we have to do is give them green cards.

Maryland was lucky to get about $1 billion in EXTRA Medicare and Medicaid funds to make its ALL-PAYER scheme a “success”. Vermont will not be so lucky with Republicans controlling the Congress.

“Maryland made a very strategic, savvy move,” said McDonough, the Harvard professor. “Had they not locked in those higher reimbursements, there wouldn’t be value in the program.”

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