Vermont health officials have a challenging task explaining to consumers the details and benefits of the state health insurance exchange without being able to say much about how insurance and healthcare will or will not change in 2017, when Governor wants to transition to a single payer system.
Until that plan is unveiled, probably sometime in 2016, officials at the state insurance exchange, Vermont Health Connect, are introducing the new marketplace as part of the Affordable Care Act's new essential benefits and subsidies, and as part of a progressive tradition in Vermont going back to the 1990s and 2000s with the enactment of guaranteed insurance access for consumers and community rating that bars premium variation based on age (going even further than the federal 3 to 1 ratio between young and old).
Vermont Health Connect officials have been holding public forums, explaining some of the current consumer healthcare problems in the state -- about 30 percent of Vermonters told the health department in surveys they've put off a doctor's visit or medication refill because of cost concerns -- while answering questions about eligibility, subsidies, taxes and business owners' coverage options.
In early April, about 30 Vermonters gathered at the Burlington High School for a forum about the future of health insurance. It wasn't a huge audience, in the state's largest city, with a population of roughly 42,000, but it did bring out a fairly broad cross-section of consumers who will be enrolling in the exchange:
A younger middle-age man asked, "How do they count your subsidies, is it like a magical formula?" (Close: it's the modified adjusted gross income, or MAGI, calculation that appears on an individual's 1040 income tax return form.)
A semi-retired couple in their mid-fifties was wondering how their savings and assets would factor into premium support eligibility? (Assets and savings are not factored into MAGI unless they are generating investment income, so the couple would qualify for some support if their income is below 400 percent of the federal poverty level, or $62,050 for a two-person household.)
And a small business owner said she was trying to figure out if she'd be able to offer coverage through the exchange comparable to what she offers workers now. (Possibly, depending on whether the current coverage meets qualified health plan requirements.)
Lindsey Tucker, deputy commissioner at the Department of Health Access, which manages Vermont Health Connect, has been explaining insurance and healthcare policy to consumers and working at the intersection of state and federal policy for a while. Before moving to Vermont in late 2011, Tucker worked as a policy manager at the nonprofit Health Care For All in Massachusetts, tracking consumer protection and access policies in the implementation of Massachusetts' 2006 health reform law and, more recently, on the early stages of the commonwealth's cost containment initiatives.
"Massachusetts is now, through their payment reform law, doing a lot of the work that we are doing here," Tucker said in an interview. "One of the challenges with the Massachusetts reform -- which is not at all true for us here -- is the federal financing was not available. We have a real opportunity here to use federal funds to create the exchange and give us a really robust and new IT system. We have the benefit of working on coverage while we're working on cost, instead of doing it sequentially."
Tucker likes to say the exchange is going to be a "road, not a detour," to the single payer system in 2017 -- although she and other health officials can't offer many details on the end destination. The design of the single payer plans, and the federal innovation waiver application for it, is the responsibility of Governor Peter Shumlin's health reform office, which will submit plans to the Green Mountain Care Board for approval, rejection or modification.
Tucker also said that few people at public forums really ask about single payer. But she does have a general vision for the journey.
"We are looking at a future where by the virtue of being a resident of Vermont you would have access to that insurance," Tucker said. "It wouldn't preclude you from purchasing something else or from purchasing a supplemental plan, but you would have access to a comprehensive benefit package because you are a Vermonter."
From the consumer experience at least, would it be sort of like the ACA's would-have-been public option, as it was vaguely conceptualized? "Yeah, a little bit," she said.
"We're looking to a future state where there's one claims system and one administrative system. The state would hold the risk for all of its residents, so there would not be a private insurance company that would be an insurer in the way that we understand insurance companies today" -- although, she noted, Vermont's large employers, whose health plans are "grandfathered" into the current market under the ACA and are covered by the federal Employee Retirement Income and Security Act, would likely still be able to keep their current insurance and may not be all that affected.
An estimated 100,000 Vermonters will be purchasing insurance through Vermont Health Connect in the first year and an additional 125,000 could conceivably gain coverage through Medicaid.
In between now and 2017, Vermont Health Connect -- like other state exchanges and CMS -- have considerable work to do ensuring the exchange IT runs smoothly and that consumers are able to understand qualified health plan benefits, cost sharing and the modified adjustment gross income tax information that will determine premium assistance.
"It is certainly complex," Tucker said. "And we do want to make sure that we have call centers, navigators, brokers, all of those channels available, and also that we're partnering with local libraries and local unemployment centers, so that wherever folks go for help, somebody will be able to give it to them."