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Aiming Higher for Health System Performance: Vermont

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Aiming Higher for Health System Performance: Vermont AIMING HIGHER FOR HEALTH SYSTEM PERFORMANCE A Profile of Seven States That Perform Well on the Commonwealth Fund’s 2009 State Scorecard: Vermont OCTOBER 2009 THE COMMONWEAL T H FUND The Commonwealth Fund, among the first private foundations including low-income people, the uninsured, minority Americans, started by a woman philanthropist—Anna M. Harkness—was estab- young children, and elderly adults. The Fund carries out this mandate by supporting independent lished in 1918 with the broad charge to enhance the common good. research on health care issues and making grants to improve health The mission of The Commonwealth Fund is to promote a high care practice and policy. An international program in health policy is performing health care system that achieves better access, improved designed to stimulate innovative policies and practices in the United quality, and greater efficiency, particularly for society’s most vulnerable, States and other industrialized countries. Aiming Higher for Health System Performance: A Profile of Seven States That Perform Well on the Commonwealth Fund’s 2009 State Scorecard: Vermont GRE G MOODY AND SHARON SILOW -CARROLL HEALTH MANA G E M ENT Ass O C IATE S OC TOBER 2009 To download the complete report containing all seven state profiles, click here. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become avail- able, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1329. VERMONT : A BLUEPRINT TO CONTROL COSTS major health reform effort in 1994 failed in part A ND EXP A ND CO V ER A GE because of the inability of political leaders to recon- Vermont ranks at the top of The Commonwealth cile the goal of covering the uninsured and the goal Fund’s State Scorecard on Health System Performance, of containing costs for the insured.4 A decade later, 2009. It is the only state that ranks in the top the debate again focused largely on how to finance quartile of states across all five dimensions of perfor- coverage for the uninsured. In 2005, the General mance measured by the State Scorecard. The state is a Assembly proposed a new payroll tax to support uni- leader in integrating public health principles into the versal coverage, but some residents who already had health care delivery system, and has one of the most health insurance (90 percent of the population was innovative models of prevention and care coordina- insured at the time) were convinced that they would tion in the country. The goal of these activities is to pay even more for health care and receive less, and shift the focus of health care from only treating ill- Gov. Douglas ultimately vetoed the bill.5 ness to a system that prioritizes prevention, supports Although universal coverage did not pass in healthy environments and lifestyles, and improves 2005, legislation was enacted to fund a new legisla- access to preventive and primary care. The scorecard tive Commission on Health Care Reform. The indicates the strategy is working—Vermont contin- Commission was cochaired by Senate health chair ues to improve its already-high rankings in preven- Jim Leddy and his counterpart in the House, John tion and treatment, and other measures of healthy Tracy. Both Democrats, Sen. Leddy and Rep. Tracy lives, and to hold the line on cost (Table 3). held hearings throughout the state, authored princi- Since 2003, Vermont’s health system perfor- ples for reform with the Vermont Business mance has been driven by a “Blueprint for Health,” Roundtable, and developed a new reform bill, which initiated by Gov. Jim Douglas (R) and the health the Governor signed in January 2006. The final legis- commissioner at the time, Paul Jarris, M.D., to cut lation struck a balance between controlling costs and costs and improve care by preventing chronic diseases expanding coverage. It funded the Governor’s and getting better treatment to people who have Blueprint priorities to modernize how care is deliv- them. Vermont’s majority-Democrat legislature ered and create a statewide health information tech- endorsed and funded the Republican Governor’s nology system—and it created a new public–private Blueprint in 2006, and created a new public–private health plan called Catamount Health to cover unin- insurance expansion called Catamount Health. In a sured Vermonters. remarkable burst of reform activity from 2006 to 2008, the legislature approved and the Governor Coverage signed 11 health reform bills with over 60 specific Census data used in the State Scorecard indicate that initiatives to increase access, improve quality, and 86.5 percent of Vermont’s nonelderly adults had health contain the cost of health care in Vermont.3 insurance in 2007–08 and 93.4 percent of children were insured. However, according to the Vermont Setting the Stage for High Performance Household Health Insurance Survey, since 2005 insur- Vermont has a long history of political debate on the ance rates for Vermont children have increased dramati- tension between health coverage and cost control. A cally (2.0 percentage points) to 97.1 percent in 2008.6 4 Since 1997, the Vermont Department of Medicaid, Dr. Dynasaur, and the Vermont Banking, Insurance, Securities, and Health Care Health Access Plan Administration (BISHCA) has conducted periodic Vermont has significant experience using Medicaid household health insurance surveys to monitor the waiver authority to expand coverage for the unin- health insurance coverage status of Vermont residents sured. The state was working to enact universal and related demographic, employment, and economic health insurance coverage early in the 1990s and, characteristics. Vermont’s state-sponsored surveys although the broader effort achieved less than univer- include a more robust sampling approach than the sal coverage, Medicaid was expanded in an effort to federal Census Bureau’s Current Population Survey cover most children. Today, the Dr. Dynasaur pro- and are tailored to specifically address health insur- gram provides Medicaid coverage to all children with ance issues. Early surveys supported efforts to target household income under 300 percent of the federal Medicaid outreach, and data from the 2005 survey poverty level, to pregnant women under 200 percent provided data on the uninsured that was used to of poverty, and to parents and caretakers under 185 8 develop health care coverage reforms enacted in percent of poverty. The Vermont Health Access Plan 2006. Three years into reform, the state reports (VHAP) provides coverage for adults who have been 13,771 fewer Vermonters are uninsured, about 23 uninsured for at least 12 months and are not other- percent of the previously uninsured population wise eligible for Medicaid or Dr. Dynasaur, up to (Table 4). More than half of the gain in insurance 150 percent of poverty. The 2006 health reform coverage since 2005 was achieved through the expanded Medicaid benefits to include a new Medicaid program. There were also significant gains Chronic Care Management Program (CCMP) and to in military health insurance coverage and a modest create new Medicaid reimbursement incentives to gain in private coverage.7 improve care for people with chronic conditions. Table 3. State Scorecard on Health System Performance: Vermont Number of 2009 Overall and Dimension Rankings Indicators in: Number of Indicators That Revised 2007 Top Quartile of Improved by Scorecard 2009 Scorecard States Top 5 States 5% or More OVERALL 2 1 22 8 14 Access 12 13 1 0 0 Prevention & Treatment 6 3 10 3 9 Avoidable Hospital Use 9 11 7 3 1 & Costs of Care Equity 2 2 * * * Healthy Lives 10 8 4 2 4 Note: Data were available to rank Vermont on all 38 State Scorecard indicators in 2009. Trend data were available for 35 indicators. * The equity dimension was ranked based on gaps between the most vulnerable group and the U.S. national average for selected indicators; thus, it is not included in indicator counts. Source: The Commonwealth Fund, Oct. 2009. 5 Employer Sponsored Insurance Premium Assistance enrolls the individual in the Catamount Health Adults currently enrolled in the Medicaid VHAP Assistance Program. program and new VHAP applicants who have ade- quate access to employer-sponsored insurance (ESI) Catamount Health are required to enroll in their ESI plan, if it meets Catamount Health is a public–private health insur- state minimum requirements. The state provides sub- ance program that offers a lower-cost comprehensive 9 sidies to ensure that that the individual’s out-of- health insurance product to uninsured residents. pocket obligations are no more than premiums and Catamount Health is modeled after a preferred pro- cost-sharing under VHAP. The state also offers sup- vider organization plan with a $250 in-network plemental benefits or “wraparound” coverage to deductible and $800 out-of-pocket maximum for ensure VHAP-eligible enrollees continue to receive individual coverage. Plans are required to include the full scope of benefits available under VHAP. coverage and waive cost-sharing for chronic care The ESI Premium Assistance Program also makes management programs and preventive care, including health coverage more affordable for uninsured low- immunizations, screening, counseling, treatment, and income residents who are not eligible for Medicaid or medication. Mental health coverage is subject to the VHAP. For uninsured people with incomes under state’s mental health parity law, which has been in 300 percent of poverty who have access to ESI cover- place since 1997 and continues to be one of the most age, the state provides a subsidy of premiums or cost- progressive in the country. Catamount Health pro- sharing amounts based on the household income of vider rates are established in law and are lower than the eligible individual.
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