Health Care

2017 Legislative Preview: Medicaid, mental health and Vermont Health Connect

Al Gobeille
Al Gobeille will be the new secretary of human services. File photo by Andrew Kutches/VTDigger
When lawmakers begin the legislative session Wednesday, they will be dealing with many of the perennial issues that stem from the ever-rising cost of health care.

The Joint Fiscal Office projects that lower-than-expected Medicaid funding from the federal government will be a factor in an estimated $55 million to $75 million gap in the upcoming fiscal year 2018 budget.

Specifically, the Legislature will need to begin planning for long-term changes in its mental health care system because in 2021 it will start losing Medicaid as a funding source for the Vermont Psychiatric Care Hospital in Berlin, the Brattleboro Retreat and several substance abuse treatment centers.

The Legislature is also poised to play a role in deciding whether Medicaid should fund expensive prescription drugs for hepatitis C patients. The Drug Utilization Review Board has recommended the executive branch lift restrictions for certain patients.

Al Gobeille, the incoming secretary of the Agency of Human Services, said the all-payer model of health care payment does not require the Legislature to take specific action on health care reform this year. But he said the Legislature would likely want to keep taking testimony to understand the new health care deal.

Sen. Tim Ashe, D/P-Chittenden, who is expected to be the Senate president pro tempore, said the state could lose funding for its Medicaid program if President-elect Donald Trump makes good on his campaign promises — but not for another year or so.

Ashe said the Legislature would need to keep in close contact with Vermont’s congressional delegation. He said if Trump starts funding Medicaid with block grants, that would mean less Medicaid money for Vermont to take care of patients.

“I would love to say that I’m really wildly optimistic about what is going to happen with a Trump administration,” Ashe said, “and the reality … all we can see right now are storm clouds.”

Mitzi Johnson
Rep. Mitzi Johnson, D-South Hero. File photo by Erin Mansfield/VTDigger
Rep. Mitzi Johnson, D-South Hero, the presumptive new speaker of the House, said the key to balancing the Medicaid budget will be to have policy committees look deeply at Vermont’s “whole range of Medicaid services.”

Johnson said that because enrollment in Medicaid went up drastically starting in 2014 and is now slowing down, she wants to look closely at how spending per enrollee has been changing, too.

In terms of the hepatitis C drugs, she is not concerned about the impact on the budget. “We get hit with changes in drugs all the time,” she said. “There was Orkambi (for cystic fibrosis) before this.”

Mental health facilities

Ashe said he has directed the Senate Committee on Institutions and the Committee on Health and Welfare to look at whether Vermont has enough physical space for mental health patients.

“It relates both to the number of beds we have for acute mental health patients (and) dealing with the community hospitals” that right now are experiencing stress, Ashe said.

The Vermont Department of Mental Health reports that involuntary hospitalizations for adults are at a record high, and voluntary hospitalizations for children are also up. The department, still led by one of Gov. Peter Shumlin’s appointees, is advocating adding beds.

Vermont's new state psychiatric hospital with 25 beds is preparing to receive its first patients in August.
Vermont’s state psychiatric hospital in Berlin has 25 beds. VTDigger file photo
Ashe said he was one of several senators who wanted Vermont to build a large centralized facility in 2012 after the Vermont State Hospital was damaged in flooding from Tropical Storm Irene the year before. “In truth, while it might not have been able to be funded, the 50 (beds) was probably the right number,” Ashe said.

The state instead built the 25-bed Vermont Psychiatric Care Hospital in Berlin — and the feds are pulling back funding starting in 2021. In response, Sen. Jane Kitchel, D-Caledonia, the longtime chair of Senate Appropriations, said the state should be looking at its overall mental health system.

Johnson also says the House should be looking at whether the system is functioning in its current configuration. She said that’s a big part of the leadership strategy she will be instilling in her committees: to look retrospectively at programs and decide what Vermonters need in a particular moment, instead of pushing pet projects.

“There’s been a lot of changes in the last six or eight years with the closure of the state hospital, expansion of community options, and some of the step-down facilities that we have,” Johnson said, “but we’re still seeing long waits at emergency rooms in some cases, and so looking at that is really important.”

She added: “Coupling that discussion with the new global commitment waiver that puts some pretty hard parameters around what the federal government will or won’t pay for is a really important discussion. I’m quite sure we’ll be talking about our capacity for mental health treatment.”

Review of the Kuligoski decision

The Legislature will take testimony early in the session on the effects of the Vermont Supreme Court decision Kuligoski v. Brattleboro Retreat, which said the hospital could be held responsible in court for not warning caretakers about the potential danger of a patient who was discharged.

Paul Reiber
Vermont Chief Justice Paul Reiber. File photo by Erin Mansfield/VTDigger
The court said lower courts should be allowed to decide whether the hospital should have warned a patient’s parents about the risks he posed to others if he stopped taking his medication. In a dissent, the chief justice said the decision didn’t follow judicial caution and expanded physicians’ duties to warn third parties.

The Department of Mental Health has said the increase in adults being involuntarily hospitalized is in part related to the Kuligoski decision. The Vermont Medical Society, which represents doctors, wants the Legislature to pass a law “explicitly overruling” the decision.

“Some have interpreted this Supreme Court ruling to believe that many people are implicated in this duty to notify, and it’s created this type of chilling effect on mental health professionals,” Ashe said.

“I believe there will be very quickly in the session a very strong review of that court ruling with various professional groups coming in, talking about how it has impacted their thinking or not, so we can decide whether we need to make modifications as a result,” he said. “That to me is a really time-sensitive one because there’s a lot of anxiety (over the decision).”

Vermont Health Connect

Lawmakers are likely to give significant weight to the independent review they commissioned to advise the state on whether to repair or replace the embattled health care exchange.

The study, released Dec. 21, said Vermont Health Connect has “significant deficiencies” but should be fixed, not thrown out. It also reiterated some of the chronic problems the exchange has had, including poor customer service.

Johnson said she will direct the House Health Care Committee, which recommended commissioning the report during the 2016 session, to take action based on the 121-page report, which was written specifically in accordance with the committee’s language.

“The option that lets us serve the Vermonters with the policies that we think are important at an appropriate cost with decent service — that’s what I’m looking for,” Johnson said.

In the wake of the report, Gov.-elect Phil Scott, who campaigned on ditching Vermont Health Connect and possibly joining Connecticut’s exchange, has not said definitively what he would do with the exchange.

House Minority Leader Don Turner, R-Milton, said he would be “open to anything” that is “far more customer-friendly, far more affordable and sustainable.” He did not advocate moving to the federal exchange.

“I am conscious of the subsidies and how Vermonters (will be affected),” Turner said. “I just don’t see how Vermont can continue to pay for Vermont Health Connect and be able to have Vermonters provide affordable insurance.”

Ashe said his main concern is whether Trump and Congress repeal the Affordable Care Act, and if their actions would force the state to shut down Vermont Health Connect.

“If suddenly the whole need to have it in the first place (were) eliminated, it would be like the end of a nightmare without the delight of waking up and feeling good that it was just a nightmare,” Ashe said.

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  • Curtis Sinclair

    This article is misleading. The state replaced the 50 mental health beds at the Vermont State hospital with 50 beds. 25 are at the new state facility, 14 are at the Brattleboro Retreat , 6 are at Rutland Regional Medical Center and 7 are in Middlesex. If the new Vermont Psychiatric Care Hospital had been 16 beds like most advocates wanted it would not be losing any federal funding. See here:
    “The federal government is requiring that the state “phase down” the use of federal funding for “facilities that qualify as an institution of mental disease (IMD) under federal law, which is a facility primarily for mental health or substance use disorder treatment” with more than 16 beds.”

    The senate approved the 16 bed facility, then the VSEA started lobbying for more government jobs and had the number of beds increased to 25.

    • Ethan Rogati

      50 beds, for the level of mental health challenges that Vermont faces, is wildly insufficient, no matter the geographic distribution. And, as far as I know, the 50 beds are just for adults. There are many minor children needing help as well, which I don’t recall this article even beginning to discuss.

      • Curtis Sinclair

        The 50 bed statistic is misleading. There are far more than 50 psychiatric beds in the state. The University of Vermont Medical Center has psychiatric beds. CVMC has psychiatric beds. Windham Center at Springfield has a psychiatric unit. The 50 beds this article refers to are all acute ‘care’ involuntary ‘treatment’ beds – really prison cells. If involuntary ‘treatment was eliminated there would be no need for those ‘beds.

        The Ethan Allen Institute published a well though out plan for eliminating the need for a state psychiatric facility in 2007.

        • Lisa Nicholson

          Medical hospitals are able to be very choosy about who they will accept as inpatient clients and so they are not useful in addressing all of VT’s mental health needs (see one of the comments from previous articles about MH in VT about UVMC’s unwillingness to take anyone suicidal/high risk). They will refuse folks with high acuity which leaves them in the ER’s costing us thousands of dollars.
          Involuntary commitment is a very small group in VT due to the high threshold of proof of need but there is still a need for treatment availability for people with higher risk profiles.

  • Jim Christiansen

    Perhaps Mr. Ashe has figured out that drawing down dollars from a federal partner to expand state services could lead to some long term problems, especially when your financial partner is trillions in debt and run by Republicans and led by Donald Trump.

    Commence the hand wringing Mr. Ashe.

  • Dave Bellini

    Is it true that Medicaid would fund and continue to fund any size mental hospital if, it was attached to a medical hospital?? If so, why did the state build one across the parking lot from CVMC and not attach it instead?

    • Curtis Sinclair

      The VSEA would not have allowed that because it would have meant 200 fewer state employees. The idea was discussed and dismissed.back in 2012 :
      The Vermont State Employees Association said the hospitals (CVMC and FAHC) were right in trying to get more beds built but it is opposed to having them operate the facility. “It would be unprecedented to completely privatize the mental health system,” said Conor Casey, legislative director for VSEA.

      • Randy Jorgensen

        I find it hard to believe that the VSEA has something other then the State’s best interests in mind.

        • Curtis Sinclair

          That’s the attitude that is causing more and more people to vote republican. The VSEA represents a few thousand state employees, not the entire state population and especially not psychiatric patients.

      • Lisa Nicholson

        At the time these decisions were being made VT was reeling from Irene and all of the jobs lost by folks working in Waterbury and there were multiple stakeholders to satisfy and demanding needs from flooded ER’s full of folks struggling with mental health challenges.
        Privatization could mean that a for profit hospital would be driven by insurance and money and not necessarily by the needs of the people…..

        • Randy Jorgensen

          “Privatization could mean that a for profit hospital would be driven by insurance and money and not necessarily by the needs of the people…..”

          What for profit hospitals? FAHC (now UVM medical Center) AND CVMC are both NON PROFIT.

          Are you suggesting that these hospitals are being run as FOR profit entities under the cloak of non profit entities?

        • Todd Morris

          yes we know all businesses must be operate as altruistic entities to serve the people. Do you request a profit from your labor and skills? If so isn’t that just plain wrong?

          • Lisa Nicholson

            There’s nothing wrong with earning money of course but my experience of the private hospitals is that they are not driven by people’s needs but cherry pick based on insurance and liability issues. That leaves the rest of folks with needs exactly where? On our streets, filling the prisons?

  • In my humble opinion, the primary reason that the 50 acute care beds for inpatient mental health treatment appears insufficient causing persons in need of treatment to wither and decompensate in hospital ER rooms, is that the state retreated from its commitment to provide a full-range of community based mental health services including peer run programs. If the resources once promised in replacing VSH in Waterbury were maintained, we would not be seeing the spiraling increase in persons in need of treatment in acute settings. There are waiting lists at virtually all community based programs (particularly for addiction treatment) that precludes folks from getting what they need when they need it. Another example of penny wise and pound foolish!
    Then there is the whole saga of those with serious mental illness (more than one-third of all male inmates and 70% of female inmates) who are being housed in correctional facilities where they truly don’t fit and only digress.

    • Morgan W. Brown

      Exactly! Well put!