When it came to health care, the 2013-2014 legislative session was driven mainly by issues that originated outside the Statehouse.
Tracking the progress of Vermont Health Connect, the state's federally mandated online insurance marketplace -- which got off to a rocky start and continues to have technical limitations -- was a priority for the House Health Care Committee.
In addition, Gov. Peter Shumlin chose not to set an agenda for health care with proposed legislation and instead called on lawmakers to use this session as a learning and planning period to prepare for the next biennium when Vermont is likely to pass laws that define what services the state's planned universal health care program will cover and how to pay for them.
Though Sen. Peter Galbraith, D-Windham, kicked off the session with a financing proposal for Green Mountain Care, as the program is known, it gained little traction because lawmakers anticipated that discussion would be driven by a financing plan the governor was expected to deliver in the spring.
When it became clear that the governor didn't intend to present the administration's financing proposal this year, Sen. Tim Ashe, D/P-Chittenden and several of his colleagues looked to fill the void with legislation aimed at achieving the goals Shumlin laid out at the start of the session.
The Senate-passed bill would have called on the administration to report a wide array of information to the Legislature aimed at helping lawmakers consider a financing proposal and design a benefits package. It also would have put dates in statute for the administration to hire third-party contractors to build and administer aspects of Green Mountain Care, all of which the administration resisted.
Portions of the Senate bill meant to guide lawmakers in designing a benefits package for Green Mountain Care that single-payer advocates saw as problematic were later struck when the House Health Care Committee took up the bill.
The bill grew substantially in the House, where a separate bill relating to the long-term health effects of childhood trauma was attached to it along with sections regulating and banning certain practices by pharmacy benefit managers and urgent care centers.
In the last week of the session, it looked as though the House and Senate might not reconcile the two bills, but a compromise was reached that removed several sections the chambers could not agree on and watered down others.
A provision that would have frozen the administration's planning and implementation budget for Green Mountain Care if it did not provide a financing plan before Jan. 15, did not make the cut. The deadline for contracting out elements of Green Mountain Care was converted to a study and report.
Several other studies on aspects of Green Mountain Care and Vermont's current health care system will be presented next year.
Using some nimble legislative maneuvering, the pared-down bill was passed and awaits Shumlin's signature.
Health care items in the budget and tax bills
A provision of the health care bill relating to the employer assessment -- a penalty on businesses that don't offer health insurance to their employees or don't offer insurance that's affordable -- was struck in negotiations and later became a sticking point in tax bill negotiations between the House and Senate.
It's unclear what lasting impact the changes will have, because administration officials and legislative fiscal analysts have suggested that the employer assessment might not make sense in the tax structure that will be used to pay for Green Mountain Care.The compromise in the tax bill requires employers to pay the penalty for their employees who are on Medicaid and requires that an increase in the assessment be re-indexed each year. The Senate had wanted a tiered increase based on the number of employees at a company.
Earlier in the session, the House Appropriations Committee balked at the Medicaid rate increase in Shumlin's proposed budget, reducing it from 2 percent to .75 percent. Low Medicaid reimbursement rates, which don't cover provider costs, drive what is known as the "cost shift," in which providers transfer the cost of treating Medicaid beneficiaries to people with private insurance. In budget negotiations the Senate took up the administration's call for a 2 percent increase, and a compromise of 1.6 percent was ultimately reached.
Increasing the Medicaid reimbursement rate is seen as an important show of good faith to the provider community that the state will be a responsible partner in a single-payer system.
Other health care legislation
Lawmakers passed a bill that changes timing elements in the judicial review process for holding and medicating people with severe mental illness when they refuse treatment.
Supporters say the changes will improve current law and give patients appropriate treatment in a timely manner, while opponents say it will tax court and legal aid resources and lead to more coercion in the mental health system.
Several other bills relating to health care passed this session, including one that was aimed at protecting doctors that choose to prescribe long-term antibiotics to treat lingering symptoms of Lyme disease from censure by the Board of Medical Practice.
Another will require the Agency of Human Services to cover telemonitoring services for certain conditions and classes of Medicaid beneficiaries.
Telemonitoring in a home health context means placing devices in the patient's home to take vital signs and relay the information back to the home health agency. When readings are outside parameters set by a physician, a nurse is sent to the patient's home. By monitoring patients in their homes remotely it's hoped that hospital admissions can be reduced, helping to lower medical costs for individuals and providers.
Legislation also requires that vision benefits offered through health plans compensate optometrists and ophthalmologists equally for those services that both are able to provide, and prevents health plans from excluding optometrists for services that are within their scope of practice.
A bill that would have created a mid-level dental practitioner position in Vermont was blocked by opposition from dentists, and a counterproposal from dentists to increase access to oral care failed as well.
It's likely the advocates for a licensed dental practitioner position, which is often compared to a physician's assistant, will be back next year.
Vermont has the oldest dentists in the country, according to the Department of Health, and many practices say they aren't able to treat Medicaid beneficiaries because of low reimbursement rates.
That could be an even more acute problem now that there 55,000 Vermonters newly covered by Medicaid.