While lawmakers have spent previous years looking at ways to reform health care delivery, such reform took a back seat this year as they grappled with shortfalls in the state’s mental health system.
House Speaker Mitzi Johnson, D-South Hero, and Sentate President Pro Tempore Tim Ashe, D/P-Chittenden, had already prioritized some parts of mental health care—realigning oversight of mental health care to promote parity and overturning a controversial court decision.
But in February, shortly after the session started, mental health care took center stage. The House and Senate held a joint hearing to find out from state workers what was going on in the public part of the mental health care system, such as the Vermont Psychiatric Care Hospital in Berlin.
The hearing didn’t focus on that one hospital. Instead, doctors and nurses from several of Vermont’s community hospitals [told lawmakers] that their patients are not getting the mental health care they need, and that they were burning out at their jobs.
They testified that the ongoing situation in which psychiatric patients—including children—are held in emergency rooms while they wait for appropriate treatment has spiraled out of control.
Years ago, they said, it was rare for patients to wait in emergency rooms, but years after Tropical Storm Irene destroyed the state’s psychiatric hospital in 2011, they said that boarding psychiatric patients in emergency room has become “the de facto policy of the state of Vermont.”
Mental health care
The Senate Health and Welfare Committee responded by spearheading a big-picture mental health bill, S.133. The bill will require the Agency of Human Services to perform a deep dive into the state’s mental health system and submit an action plan for improvement to the Legislature.
The committee also advocated for millions of dollars in additional funding for workers at publicly funded mental health agencies. The committee originally sought more than $30 million for the workers, whose advocates have complained for years are burning out or moving to other jobs because of the low pay.
The money in the Senate Health and Welfare Committee’s original plan would have been used to pay workers a minimum of $15 an hour and to pay salaried mental health workers more comparably to mental health workers employed by the state, by school districts, or by hospitals.
During the budget process, the Appropriations Committee brought that number below $10 million and called for a multi-year process for increasing funding for the mental health agencies. In the final version of the budget, lawmakers approved $8.3 million in increased pay for mental health workers.
The Senate Judiciary Committee also spearheaded S.3, a bill that overturns the decision Kuligoski v. Brattleboro Retreat, a controversial case that alleged mental health providers were negligent in how much training they gave to caretakers of a schizophrenic man who eventually assaulted someone else.
The Vermont Supreme Court allowed that case to move forward just months before the legislative session started. Mental health providers interpreted the decision as putting new burdens on them. The bill would require their “duty to warn” to stay the same as it has since 1985.
Over in the lower chamber, House Speaker Mitzi Johnson, D-South Hero, decided to reassign jurisdiction of mental health oversight from the House Human Service Committee to the House Health Care Committee in order to achieve “true parity.” The committee dove right into making progress on parity between mental health issues and physical health issues.
House Health Care spearheaded H.184, which requires the Agency of Human Services to research the causes of suicide. The state already collects suicide data but does not look at the qualitative reasons that Vermonters are taking their lives.
They also approved H.230, which will allow minors to consent to mental health counseling starting Jan. 1. The House originally sought to allow lesbian, gay, bisexual, transgender, and questioning minors to get therapy. The Senate expanded the bill after learning that the majority of states across the country already allow all minors to consent to mental health treatment.
H.145 creates a commission to review how police officers are responding to people in mental health crisis. The commission will recommend public safety policies and ways to train police officers to make sure people in mental health crisis experience positive outcomes with police.
PTSD
H.197 was the most controversial mental health bill of the session. The bill was designed to require workers’ compensation insurance to cover post-traumatic stress disorder for first responders and require it to cover mental health issues obtained on the job.
Currently a Vermont Supreme Court case prohibits firefighters from getting workers’ compensation coverage for PTSD. Additionally, workers’ compensation only covers work-related mental health issues if they are associated with a physical injury.
The bill almost died in the House Commerce and Economic Development Committee, where lobbyists for insurance companies and the Vermont League of Cities and Towns testified that the bill would increase workers’ compensation premiums by an unknown amount. The Department of Labor, which regulates workers’ compensation, agreed.
Mental health advocates upped the political pressure on the committee to pass H.197. They pressed on as the bill eventually hobbled through three different committees and to the House floor, where Republicans threatened to walk out on the vote.
The bill missed procedural deadlines to get to the Senate for consideration. But Senate President Pro Tempore Tim Ashe, D/P-Chittenden, worked with senators to copy and paste the House language from H.197 into a bill that had met deadlines, S.56.
The Senate passed S.56 with the mental health language. The bill is now headed to the governor.
Hospitals, independent doctors, and ACOs
As part of the budget, the Legislature took away 20 percent of $37.4 million in annual charity care money that hospitals have been getting through Medicaid. The budget instructs the state to reduce the money across all hospitals or to take it away specifically from the University of Vermont Medical Center.
Ashe, the senate president, had targeted the money back in 2015 because Medicaid expansion meant that hospitals were not providing as much charity care to uninsured people. The Vermont Association of Hospitals and Health Systems opposed the reduction, in part because the Affordable Care Act could be repealed.
The Senate Finance Committee made a last-minute push to improve pay for independent doctors, whom commercial insurance companies pay less than academic medical centers for the same hospitals.
For the previous three years in a row, the Legislature had ordered the Green Mountain Care Board, which regulates hospital budgets and insurance prices, to reduce the pay disparities. That still hasn’t happened.
The committee added language on pay parity to another bill, H.29, which hobbled out of the Senate after intense pushback from hospitals, accountable care organizations, insurance companies, the Green Mountain Care Board, and some senators.
The House Health Care Committee abandoned H.29 because the Senate did not send it over until the day the Legislature was scheduled to adjourn. However, the Senate and House did pass language in the budget bill, H.518, requiring a fourth report from the Green Mountain Care Board by Oct. 1.
Starting July 1, accountable care organizations, which are the health care reform entities that the all-payer model is based on, will be required to hold open board meetings if they plan to make binding decisions. That bill, S.4, also started in the Senate.
The bill will affect three entities: OneCare Vermont, which is owned by the University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center, Community Health Accountable Care, which is owned by community Health Centers, and the Vermont Care Organization, which is a combination of the two.
The future of the Vermont Care Organization became unclear months later, when they considered suspending operations and then decided to rethink their purpose. OneCare originally pushed back against the bill but then pivoted and announced its support.
