Vermont 2002 Budget

With cuts and prescription drug increases. And, a .75 cigarette tax increase as well.

BENEFIT REDUCTIONS AND COST SHARING:

Drug programs:

VHAP Pharmacy – copays increased to $3 for generic and $6 for brand – Cost sharing is capped at $50 per quarter

Vscript – copays increased to $5 for generic and $10 for brand, capped at $100 per quarter

Vscript expanded – $275 deductible, $2500 cap on cost sharing, 50% co-insurance, only covers maintenance drugs.

(All three programs will be subject to an $11 million spending cap. If the cap is exceeded, programs may be closed to new enrollment.)

Pharmacy discount program – budget includes $200,000 for state match for Healthy Vermonters program that allows seniors and low income people to buy drugs at Medicaid rebate price – a savings of about 18%.

VHAP (Vermont Health Access Program) cost sharing:

Physician and other health care professionals – increase copayments from $2 to $7

Hospital Outpatient - $25 copayment per visit

Hospital Inpatient - $50 deductible

Hospital ER - $25 copayment, added a new $60 copayment if visit is inappropriate

Chiropractic – covered with 25% coinsurance (A CUT)

Vision – suspend coverage of refraction evaluations (92015), frames and lenses for one year* (A CUT)

Medicaid cost sharing:

Physician and other health professionals – no change in coverage or cost sharing

Vision – suspend coverage of refraction evaluations (92015), frames and lenses for one year.*

Dentures – full dentures only (A CUT)


http://www.vtmd.org/LEG&POL/leg-bull0215.html

The temporary freeze on coverage of glasses is for adults ONLY. That doesn't apply to children. Adult eye exams are covered, but the glasses are not. I am on one of the affected plans and got new glasses not too long ago. My eye exam was covered and I had to buy my own glasses, which were $120 for one of the pairs the plan would not have paid for anyway. Under the program, you get certain frames to choose from. I liked frames that I would have had to pay for out of pocket anyhow.

Reading through that list of changes, I don't see anything at all to complain about. Keep in mind that the poorest of seniors already get Medicaid, and their prescriptions are 100% covered. There is nothing unreasonable about those co-pays. On top of that, if you compare it to what people in other states are paying, I think you'd be hard pressed to find anyone who would complain about the costs of those living in Vermont.

And the facts are that cigarette taxes went up, benefits were cut and prescription drug costs went up. For senior citizens. If you click the link you would see the benefits have been cut under VHAP and Medicaid. And it doesn't matter whether YOU think it's reasonable, the fact is that it did happen. So even though Dean say he was just threatening the legislature to increase cigarette taxes, benefit cuts and new costs were implemented in addition.

In fact, I think the rise in the cost of prescriptions (which are still a hell of a lot cheaper than anywhere else) occured because something had to be done to encourage doctors to prescribe generics when available and for patients to ask for and accept the generics. Dean did a lot to battle this problem because it was wasting a lot of money in the program. He signed the first law of it's kind against big pharmecutical companies. In Vermont, it MUST be reported anytime a drug company gives "gifts" (aka bribes) to doctors and hospitals to get them to prescribe their more expensive medications. If the gift is over $20, it has to be reported. No one lost services or were kicked off any programs. They had to pay a couple more dollars to make sure they got coverage. Just as premiums through employer plans go up sometimes, so does public fees.

So, what seniors has Kerry provided a prescription drug benefit to? Oh yeah, that's right...none. I keep forgetting that he was too busy fighting for tax cuts, war and the desecration of US public schools and Constitutional Rights to be concerned about helping the elderly get medication.

remeber things just kept getting worse in Bush's America and also if these are the same cuts Kerry referred to. Some of them can't be since he supposedly was going to end prescription coverage entirely which didn't happen.

It was even better before the Bush economy? That is amazing.

Do you have few resources? Your state may well already have a health plan for people who don't qualify for medicaid, alot of them do. SCHIP, waivers, block grants and pass-through medicaid prescription programs are what state's use to expand their benefits.

There's two points here. First, when Dean says he was threatening cuts just to get the cigarette tax passed, he's not telling the whole truth.

More importantly, ambitious health plans have been introduced only to be cut and restructured later. This is the reason the Democrats in Congress have been against managed care and privatized solutions. They start off as an expansion of benefits, but restructure the basic way benefits are provided. Then they cut and cut until pretty soon they become so burdensome on the individual or so expensive to operate that they'll be removed altogether. The increases in Vermont's taxes and the deficit projections are evidence that there will be more problems in the future. We've already seen the problems of managed care in respect to getting needed health care or doctor's reimbursements, so proposing this as a solution to health care doesn't seem to be very logical. In addition, for low-income seniors in particular, deductibles and co-pays are one of the major reasons they don't get care as quickly as they otherwise would. The fact that this plan has already run into problems despite various tax increases will not go over well in the Presidential election.

You claim:"...when Dean says he was threatening cuts just to get the cigarette tax passed, he's not telling the whole truth."

From the VMS website: (January 2002.)

VERMONT MEDICAL SOCIETY ANNUAL CONVERSATION WITH THE GOVERNOR

Braving the first snowstorm of the winter, ten physicians from across Vermont met with Governor Howard Dean on December 17 to discuss current Vermont health care issues. Tim Thompson, MD, President-Elect of the Medical Society, opened the meeting by thanking Governor Dean for his administration’s health care accomplishments. Dr. Thompson led the meeting on behalf of VMS President Carolyn-Taylor-Olson, MD, who was unable to travel due to illness. Dr. Thompson relayed her sentiment that, given the precarious financial state of many private physician practices, the Governor’s support for increased Medicaid reimbursement to physicians is very much appreciated


MEDICAID BUDGET

Governor Dean discussed his health care priorities for the coming session with the group. First on the list was addressing the revenue shortfall and its impact on the FY 2003 Medicaid budget. The Governor strongly supports a tobacco tax increase, and last year proposed a 67-cent increase to the legislature. He will not incorporate such a proposal into his ’03 budget. Instead, the administration will propose a number of cuts in medical and prescription drug benefits, with the understanding that if the legislature chooses to avoid those cuts through an increased tobacco tax, the Governor will be supportive. Dean noted the strain placed on the Medicaid budget by increasing prescription drug expenditures, and said that although he has resisted formularies for years, it is no longer possible for Vermont to control these costs without a preferred drug list.

David Johnson, MD, an anesthesiologist from Shelburne and Chair of the VMS Physician Policy Council, asked about Federal law regarding Medicaid copayments. He wondered to what extent Vermont could impose more significant copayments for expensive benefits, including brand name prescription drugs. Dean said that Human Services Secretary Jane Kitchel is investigating Vermont’s cost-sharing options. He observed that collecting copayments is burdensome for physician practices, and said that his administration will look first to other cost-sharing measures, such as coinsurance.

(snip)

MEDICAID AND MEDICARE RATES

Dr. Thompson brought up physicians’ concerns over a potential 5.4% Medicare rate cut nationally. He explained that Vermont physicians were in a particularly vulnerable position because low Medicaid rates and large Medicaid caseloads impeded their ability to make up for a Medicare cut.

The Governor said that, while health care costs did indeed need to be controlled, it would be unfair for public payers to “beat up on” physicians through fee reductions. He noted that the tests physicians order and the drugs they prescribe are more important cost drivers than physician fees. Dean said it was more appropriate to target these expenditures for cost control, to use the patient’s pocketbook to educate the physician about cost-effective diagnostic testing and prescribing. He reaffirmed his commitment to increasing Medicaid reimbursement rates for physicians to the Medicare level, but stated that a funding source such as the tobacco tax would be needed to achieve this goal.

(snip)

TOBACCO TAX INCREASE

Drs. O’Brien and Johnson asked about the revenues raised from the cigarette tax increase. Peter Van Vranken, health policy advisor to the Governor, said a tax increase would raise approximately $500,000 per year per cent increase, with some reduction in revenue over time as smoking rates fall. Governor Dean said he hoped that the cuts his administration proposes in prescription drug benefits for seniors will spur broader interest in the tax increase. He stressed that Medical Society input on this issue could have a significant impact.

Ms. Mongan explained that VMS is putting a lot of energy behind the tobacco tax increase for the coming session. VMS is working both independently and as a member of the Coalition for a Tobacco Free Vermont. Conversations between physician constituents and members of the House Ways and Means Committee, Health and Welfare Committee, and majority leadership are already underway on this issue. Dean thanked the Medical Society for its active involvement.

He raised cigarette taxes AND cut benefits. He never mentions the fact that the tax increases weren't enough to pay for the program. The health plan deficit is expected to continue to rise. Where's the money going to come from?

You stated that he was lying. He obviously was not.

And BTW..."he" didn't do anything, the State Legislature did. You do understand how government works, right?

The legislature did it. Okay. Howard Dean is just a rubber stamp.

There's a fair chance you already have a low-income health plan in your state. Alot of them do.

but in mine I don't qualify despite a low income and even if I did it is no where near as good. No coverage for glasses or dentists for example.

Did you not read the part where it says (A CUT)? No glasses or dental. Howard Dean cut them, even though he denies making cuts. And you might not qualify in Vermont either, there's a bunch of factors involved in who qualifies.

I make considerably less than his state's cutoff for singles and I have no assests to speak of. I literally can't imagine what other factors there could be.

On edit I take the word of the lady who actually is on the program that exams are covered (they aren't here) and your own thread shows dentures are covered (they aren't here). Hence his program is better than my state's which is what I said.

The lady didn't even know her sales tax increased this month or that the cigarette tax increases and the cuts happened at the same time. I don't know her financial situation or anything else to make a judgment on why or how she qualifies for VHAP. The same goes for you, you can say anything you want. I know that there are states that have higher cut-off rates than Vermont, Missouri for instance. And as to the dentures, in checking to see the federal requirements, I just discovered a Nov 2002 change to Vermont medicaid. Dentures no longer covered. That's the problem with trying to figure out Vermont's plan, it changes so often, it's tough to figure out exactly what they cover and what they don't. http://www.dpath.state.vt.us/PED_rules/Bulletin_02_34.pdf

Vermont is ranked 6th.

http://www.unitedhealthfoundation.org/shr/book.pdf


By looking at their database there are 10-15 states that provide a modicum of decent health care.

1. NH
2. MN
3. MA
4. UT
5. CT
6. VT
7. IA
7. CO
9. ND
10. ME

By any definition, Vermont provides some of the best health care in the nation. Why attack Dean on one of his strongest issues? Go after the Death Penalty or something. You might find more sympathetic ears.

:shrug:

And note in your own health care ranking, MN is #2. But the poster below explains his problems and you can quickly see #2 doesn't mean alot. They've opened a real can of worms here, where the poorest among who used to get health care won't anymore because the co-pays, premiums and deductibles will go higher and higher. And not everybody qualifies for VHAP either. Many people only qualify for a pass-through program where they buy prescriptions at the Medicaid rate which is paid for by 18% pharmaceutical rebates. And others have a 50/50 plan, where they pay 50% of the price. It really looks like they've sacrificed quality care for the poorest people who will end up with no care because they aren't going to be able to afford all of these co-pays, deductibles and premiums.

You're talking $3 and $5 co-pays in the original post.
And capped maximums.


I hardly see this as onerous. I'm not saying that Vermonters are getting the best HC in the world. I'm saying that they're getting some of the best HC in America. And so are Minnesotans. I'm not saying it can't get a lot better, though.


The larger picture:

All the states are limited in the HC that they can provide due to budgetary concerns and how they each prioritize it. By any fair definition, Vermont does that as well, or better, than virtually all the other states. It's not a weak point for Dean. It's absurd to argue otherwise, imo, all things being relative.

The original post was actually just a basic point that cigarette taxes went up AND cuts were made as well. So when Dean says he threatened the legislature with cuts just to get the tax increase, he's not telling the whole truth. That was really ALL that post was about.

However, it does also expose the problem with Dean running on this platform next year. Vermont health care is projected to run huge deficits, despite tax increases. If the plan won't cover the few people in Vermont, it's not going to be able to be expanded to the entire country. And, he's proposing to repeal all the tax cuts in order to provide this deficit-ridden plan. It's a real problem.

And as to the larger picture, this Medicaid waiver program is a step backwards. As you can see in the Minnesota plan and as you know just by the way insurance works, the co-pays, premiums and deductibles will continue to rise. We had a federal mandate on what Medicaid had to provide and it looks like we've lost that for the lowest income adults in order to get a program that low income adults aren't going to be able to afford to participate in anyway. That's really the big, big picture.

As to the big, big picture: The reason why HC is heading towards deficits is Chimponomics. That problem will be solved once a Dem is in office. Dean has said that he would sign a single-payer bill the instant it hit his desk. But we all know that that isn't going to happen. One step at a time.

If you actually have a reference to Dean preferring single payer, I'd be very interested in that. I have never seen that. One of the complaints against going to this Medicaid plan in the first place was downturn in the economy and reduced revenues which would allow the kinds of cuts that wouldn't have been allowed before. Nobody really could have projected 'Chimponomics' and the radical departure from an economic plan that was working, I would agree.

Clinton gave Dean a waiver so he could do things differently. People in Vermont qualify for programs who would never qualify in any other state. Name one other state where a family can earn $50,000 a year and still qualify for a state health care program.

My wife and I made about $47,000 combined a couple years ago, but I could not get medical coverage with her employer because she worked for a small company (5 employees), and I was self-employed and had a pre-existing condition.

I was able to qualify for MinnesotaCare (the "insurer of last resort" for people with moderate incomes but with P-ECs) and got on that. However, the premiums were about $200/mo, and didn't offer much prescription coverage (my monthly prescription bill comes to $325 w/o insurance). I was making maybe $800/mo before taxes AT BEST at the time. That $200+prescriptions was a lot of money.

Healthcare is an issue that's way too important to be left up to the states. This country needs to join the rest of the industrialized world and institute a National SINGLE-PAYER system, that covers EVERYBODY for EVERYTHING.

Trying to fix the current system is like putting a band-aid on a melanoma. You're only covering up the problem, NOT fixing it.

after Dean's 'draconian' cuts. It seems that is just a wee bit better.

Up in #22, you'll see Minnesota is ranked second. But you've explained the problem exactly. This new approach to Medicaid allows increased burdens on low-income people where even people who formerly had good health coverage now have so many personal expenditure that it does them no good. Vermont may have lower co-pays, premiums and deductibles now, but as the deficit in the program increases, they'll have to cut benefits or increase personal expenditures, just like Minnesota. Then we'll have more people not getting health care because they can't afford their own required contributions.

The premium is $50 a month or less. Medications are very cheap and there might not even be a co-pay for most services. The costs vary depending on your ability to pay. Those with the highest need have no cost for anything at all. The sliding scale changes based on your ability to pay. About 20 minutes from where I live there is also a free medical and dental clinic. They provide free services for anyone who doesn't have insurance and they provide medication as well, all free. It doesn't matter what your income is for these services, either.

The programs in Vermont are nothing like the programs anywhere else because of that waiver Clinton gave Dean. The base Medicaid and Medicare is the same, but Dean extended the programs with that waiver and the eligibility is different as a result. Some people here claim that it's just Medicaid, but that's not true. Although Medicaid services are the core, the qualifications are different and the coverage is expanded in some areas.

With that $50,000 income. The actual cost of co-pays and medication are extrememly low, too. Vermont's programs are the best in the country.

than my dad's private plan for which he pays a pretty good premium and worked several years. Plus, he is eligable for Medicare. Not bad at all.

You can't say this is better when you don't know how much the premiums are for this plan or what it even offers. These are just the cuts. If the plan didn't offer home health care at all, for example, you wouldn't know that just by looking at the 2002 cuts.

which is way, way, way better than his. He also has no vision or dental coverage whatsoever (fortunately he also doesn't need it). I know it covers home health care due to the several threads about that here. If you really need a citation I will dig up Nick's thread.

Again, there is no vision or dental coverage. And whether home health is covered depends on which plan you're talking about. They aren't all the same.

You neglected to include the following footnote:

* Because physician services are required to be covered, ophthalmologists and optometrists who bill under ophthalmologists rather than independently, may continue to bill for refraction evaluations

It looks like this is if the opthalmologist is serving patients who are still in the fee for service Medicaid plan. The managed care people would have the plan that states specifically what is covered and not covered, meaning no vision.

Please read my response to the Minnesota person about the problem with handling low-income health care with managed care. Give me a minute to post it.

Unless on that line you did something you didn't do anywhere else and that is list what was cut instead of what the benefit actually was. From what I understood your post to mean there used to be more dental coverage but now only dentures are covered. That is still more than what Ohio does and I do know since I live here.

I don't know what line you're talking about. The original post which is about the legislative action in 2002 leaves denture coverage. But an action after that took away the denture coverage in 11/2002. That's what this Medicaid waiver block grant stuff is doing. Allowing us to go backwards on Medicaid coverage, letting States decide more and more what they cover and what they don't. That's what we had years ago. I don't think that was Howard Dean's intention, but when you can't guarantee what will happen with future Governor's, it was a very risky thing to implement.

It isn't my fault that I figured your post described the current program and if Dean didn't make the cut then my point still stands. The program Dean left in Vermont is better than my dad's private plan.

The 2002 legislature implemented "Benefit Reductions and Cost Sharing". That seems pretty straight forward to me.

And what I'm trying to say is that the program is already running into budget problems and that is expected to continue. He's proposing repealing all the tax cuts (I guess) to give the U.S. a program with very large projected deficits. He's already had to raise taxes and cut benefits in Vermont at least once (I believe more, the programs change all the time). Other states who have waiver programs have had to suspend enrollment, raise individual contributions, or make other changes as well. It's a pattern that raises serious questions. This is an election problem, like it or not.

do you talk about cutting dental completely. If it is there I honestly don't see it. Reread your first post and look at what you wrote under dental and look at the rest of the post.

You can find dental care, and it's available, but it is a bit harder to find a dentist who will take Medicaid patients. It's not impossible and you usually have to drive a little further for the appointments. There is also at least one free dental clinic in the state that will provide dental care (including cosmetic dentistry) free of charge for those who need it and can't otherwise get the care. This isn't that big of an area, so I'm guessing there are similar clinics in other areas of the state as well.

my dad's insurance provides.

The only real "sore spot" in Vermont's system is the dental part of it. That's not even an issue with the actual program so much as it is a lack of dentists in the state. There just aren't a lot of dentists, so many of them take the patients with the best dental plans just because they can fill up their appointments without a problem. If there were more dentists in the state the competition for patients would be tougher and the picture would be much different. Basically, you have to usually go to a fairly large town to find a dentist because there are more there and the level of competition is higher. I'm guessing this would be a problem about anywhere that is rural for anyone with a less than stellar denatl plan. This isn't something limited to Medicaid, either. There are other plans some dentists won't accept for the same reason...they don't have to.

Bush, is wiping out health care throughout America and leading us down the road to fascism and you're attacking Dean because he wasn't liberal enough for you on healthcare?

That is yet another reason why I support Dean. His priorities are in order, unlike other candidates' priorities.

This is managed care, similar to the Medicare proposals. That's why Democrats fight it, because once you open the door, there's no telling where it will end. Howard's program is fine for now, but look at that Minnesota post. Managed care can quickly lead to a sitution where no benefits are secured and costs rise to the point of being unaffordable as well. Public health coverage would then be withering on the vine, from being unused. But everybody could point to fancy names and say we have medical coverage in America.

For instance, he saw that too many people and doctors were opting for the more expensive medications when cheaper medications would have been just as good. Because Dean is a doctor, it's easier for him to spot things like this. That is why he made it more expensive for people to buy these other drugs, to discourage it from being done. He also made it law that any gifts from drug companies to doctors, hospitals (etc) valued over $20 MUST be reported. This exposes those bribes. One of the biggest areas of wasted money is the processing of paperwork. Dean wants to make simpler, universal forms that would drastically reduce the paper monster and the costs associated with it. Dean has an insiders understanding of what the problems are better than anyone else in this area. Regarding Medicare, Dean has some great ideas on how to fix it so that more people get help while spending less money. As it stands now, Medicare will sooner pay over $165 a day for someone to be in a nursing home when the person would be happier and do just fine at home with a little extra support with things. Some people don't need full services, but it's an "all or nothing" situation. If we simply change the eligibility requirements to allow for partial services in appropriate cases and allowing home care easier, it will make things so much better for seniors and the disabled. Dean's complaints about Medicare are because he has been very frustrated with the rules, not the services. He religiously testifies on behalf of the elderly and disabled before Congress to urge them to ease the eligibility rules and allow for home care easier. Dean has always been a real champion for health care for all. In fact, it was his number one priority here in Vermont, even before balancing the budget. That was number two. He was able to do both, though. And for the enviornment...his lobbying for a bike path was what got him involved in politics in the first place. He's also pretty militant about recycling. The criticism to Dean on these issues have been very unfair and inaccurate.