Vermont Comprehensive Reform
Vermont Comprehensive Reform
Vermont Comprehensive Reform
MARCH 4, 2009
October 2009
for Health Policy, Planning and Research, University of New England, ^Columbia University Mailman School
of Public Health, ~Market Decisions, Inc., *Policy Integrity, LLC
Summary
Universal health care legislation, passed in Vermont in 2006, has met its goal of significantly
increasing the number of insured Vermonters and aims to further impact care through improving
quality and containing costs.
The percentage of uninsured Vermonters has decreased significantly since 2006, and enrollment in
both public insurance programs and private insurance has increased.
Vermonters have learned that health care reform will be an ongoing process, requiring a great deal
of stakeholder collaboration.
Vermonts public insurance programs are not likely to be sustainable in the long term without both
federal assistance and system-level improvements.
Vermonts passage and implementation of comprehensive health reform is often overshadowed by the
efforts of Massachusetts, but preliminary evaluation findings on health reform in Vermont offer a number of
lessons to other states. This report presents the interim results of a two-year comprehensive evaluation
examining the impact of health care reform in Vermont as initiated by the 2006 Health Care Affordability
Acts. The evaluation addresses three key dimensions of Vermonts comprehensive health reform, including
(1) health coverage affordability, (2) health services access (especially access to primary health care), and
(3) reform sustainability. This first-year report includes findings from key informant interviews, analyses of
affordability, initial findings from enrollment data, baseline data on fringe benefits, and preliminary
analyses of sustainability.
State Health Access Reform Evaluation, a national program of the Robert Wood Johnson Foundation
Center for Health Policy, Planning, and Research University of New England, Portland, Maine 04103 www.chppr.org (207-221-4560)
HISTORY OF REFORM
The State of Vermont has a long history with health care reform. Recent efforts have included Medicaid expansions
beyond the traditional income limits, including expansions in 1989 to cover uninsured children and an expansion in
1995 to cover low-income, uninsured adults. Despite the success of these programs, a survey conducted in 2005 found
that approximately 10% of Vermonts population remained uninsured and per capita health care costs were rising
faster than the US rate.i Faced with this information, Vermonts policymakers agreed that the state could not provide
better access to health insurance without extensive health care reform.
In May 2006, the legislature passed and the Governor signed Acts 190 and 191, the Health Care Affordability Acts
(HCAA) for Vermonters. Implementation of the HCAA began in early 2007. Lawmakers have continued to modify the
Act since its initial passage in order to address implementation issues as they have arisen.
In considering reform, legislators had the following overarching goals:
1. To achieve universal access to affordable health insurance for all Vermonters
2. To improve quality of care and contain costs through health care system reform
3. To promote healthy behavior and disease prevention across the lifespan
These goals were interrelated: access to health insurance would increase the use of preventative services; lower health
care costs would make insurance premiums more affordable; and promotion of healthy behavior and preventive
services would help keep health care costs in check. Each component would play an essential role in ensuring
successful reform.
The 2006 HCAA was designed with these reform goals in mind. To achieve the first goal, the HCAA created two public
health insurance programs intended to provide access to affordable insurance to the states uninsured:
The Catamount Health Insurance Program (Catamount Health) is a subsidized health insurance program
intended to provide affordable health insurance coverage to those who are not covered through their
employer but who exceed the income limitations for current state and federal Medicaid programs. Catamount
Health is available to all Vermonters and can be purchased at full cost or at a reduced cost with state premium
assistance according to a sliding income-based scale.
Under the Employer-Sponsored Health Insurance (ESI) Premium Assistance Program, the State
provides financial assistance to certain uninsured employees to help them take advantage of insurance offered
by their employer. The ESI Premium Assistance Program is designed to lower the state costs of expanding
health insurance coverage by subsidizing enrollment of individuals into their employers health plan when
such enrollment is cheaper than VHAP or Catamount Health.
Blueprint for Health (which is currently being implemented) is an initiative that was created to address the second and
third goals of the HCAA, focusing on the prevention and management of chronic conditions to improve quality of care
and reduce health care costs.ii The program is intended to help primary care providers operate their practices as
advanced medical homes that offer coordinated care supported by local services, health information technology tools,
and provider reimbursement mechanisms.iii The 2006 HCAA also required the Office of Vermont Health Access (OVHA)
to develop a chronic care management program with similar standards for new Catamount enrollees and Vermonters
enrolled in other state health programs.
period, insurance coverage in Vermont increased more rapidly than in other New England states, with most of the
increase in Vermonts coverage coming through increases in public coverage.1,2
Figure 1
160,000
140,000
120,000
100,000
Catamount
VHAP ESI
80,000
VHAP
60,000
Traditional Medicaid
40,000
20,000
0
Enrollment in both public insurance programs and private insurance has increased in
Vermont
Enrollment in the new Catamount Health program increased sharply and steadily during the initial months. By April
2009, a total of 8,758 people were enrolled in Catamount Health. Most Catamount enrollees receive premium
assistance. Only 13.9% of enrollees have family incomes above 300% FPL and do not receive premium assistance.
Vermont Health Access Program (VHAP) but may not have known about the program (or may have thought they were
ineligible) appears to have been particularly effective, as enrollment in traditional Medicaid increased by 5.5%, while
enrollment in VHAP increased by 21.0%.
more cost-effective and high-quality health care system, regardless of future health insurance reforms. Reductions in
health spending as a result of the implementation of Blueprint (not a part of this evaluation) may improve
sustainability over time.
CONCLUSION
The first year of evaluation of Vermonts 2006 health reform has focused on process evaluation in order to glean
insight into the operation of Catamount Health and into the experiences of those working with Catamount and other
aspects of the reforms. The percentage of Vermonters without health insurance has decreased significantly since
reform began, and insurance coverage in Vermont has increased more rapidly than in other New England states. Most
of the increase in Vermonts coverage is a result of increased public coverageenrollment in Catamount Health has
increased sharply and steadily during the programs initial months. Most key informants were generally satisfied with
enrollment levels to date, but still perceive barriers to enrollment. Outreach campaigns have been implemented to
combat some of these barriers, and are perceived to be effective in educating the public about reform programs.
However, health reform does not appear to be fiscally sustainable in the long-term. Despite this, key stakeholders are
optimistic about the future of health reform programs. Implementation of these programs has been viewed as an
ongoing experiment, allowing for mid-course corrections to program procedures and enrollment projections.
Next steps
In the future, analysis will continue to focus on potential change to the structure of the health reform programs
themselves and on potential changes to the costs and financing of these programs. Most informants believe that these
programs will be around indefinitely but will be adjusted on an ongoing basis as challenges present themselves. In the
second year of evaluation, we will expand our analysis with an additional year of survey data, health utilization and
cost data on Catamount covered populations, and with improved analytical models . It is also important to examine an
area not yet exploredthe impact of the reforms on access to care. These analyses will provide a more accurate
picture of program use and sustainability and in turn permit a more informed policy discussion of mechanisms to
address sustainability.
The full report, Achieving Universal Health Coverage through Comprehensive Health Reform: The Vermont
Experience (Year 1 Interim Report), can be found at
http://www.shadac.org/files/shadac/publications/VT_Interim_Report.pdf.
NOTES
i
2005 Vermont Household Health Insurance Survey: Final, August 2006 Report; available at:
http://www.bishca.state.vt.us/HcaDiv/Data_Reports/healthinsurmarket/2005_VHHIS_Final_080706.pdf and National Health Expenditure Data,
Health Expenditures by State, Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, released February
2007; available at http://www.cms.hhs.gov/NationalHealthExpendData/05_NationalHealthAccountsStateHealthAccountsResidence.asp#TopOfPage.
Conis, Elena. Vermonts Blueprint Chronic Care Initiative. Health Policy Monitor, November 2008. Available at:
http://www.hpm.org/survey/us/a12/1.
ii
iii Vermont Blueprint for Health, 2007 Annual Report, produced by Vermont Department of Health, Agency of Administration, January, 2008.
Available at: http://healthvermont.gov/prevent/blueprint/documents/BlueprintAnnualReport0208.pdf.
Coordinate evaluations of state reform efforts in a way that establishes a body of evidence to inform state and
national policy makers on the mechanisms required for successful health reform.
Identify and address gaps in research on state health reform activities from a state and national policy
perspective.
Disseminate findings in a manner that is meaningful and user-friendly for state and national policy makers,
state agencies, and researchers alike.
CONTACTING SHARE
The State Health Access Reform Evaluation (SHARE) is a Robert Wood Johnson Foundation (RWJF) program that aims
to provide evidence to state policy makers on specific mechanisms that contribute to successful state health reform
efforts. The program operates out of the State Health Access Data Assistance Center (SHADAC), an RWJF-funded
research center in the Division of Health Policy and Management, School of Public Health, University of Minnesota.
Information is available at www.statereformevaluation.org.
State Health Access Data Assistance Center
2221 University Avenue, Suite 345
Minneapolis, MN 55414
Phone (612) 624-4802