Gov. Phil Scott's administration is taking a firm stance against a legislative effort to create a universal primary health care system.
The administration is opposed to S.53 in part because publicly financed primary care would require new taxes. But that's only one of several problems, said Michael Costa, deputy commissioner of the Department of Vermont Health Access.
Costa also says universal primary care doesn't directly address the high cost of health care, which is the administration's top reform priority. And he's concerned about possible conflicts with the state's ongoing efforts to switch to a new system of payment for medical providers.
"How much reform can you responsibly manage?" Costa asked. "I think to take on a totally separate, second statewide reform effort will put both projects at risk, for uncertain benefit."
There has been a strong push for universal, publicly financed primary care during the 2018 legislative session.
Supporters packed the House chamber for a January hearing on the matter. And in early March, the Senate Health and Welfare Committee approved a version of S.53 proposing that the state work toward a publicly financed primary care system with no patient cost-sharing.
The Senate eventually approved a weakened version of that bill that has no commitment to taxpayer financing.
S.53 is now in the House, where the Health Care Committee last week heard from consistent universal primary care supporters like Vermont Businesses for Social Responsibility; Dr. Allan Ramsay, a former Green Mountain Care Board member; and Dr. Susan Leigh Deppe, representing the Vermont Psychiatric Association.
Deppe made an argument heard often in this year's debate: Increasing access to primary care will decrease the cost of health care in the long run by focusing resources on preventive care and early interventions.
"This isn't about money or taxes," Deppe said. "This is an investment and we're already spending the money. We need to think of it that way."
Costa told the committee that the Scott administration supports investing in primary care. He also expressed support for the goal of "everybody having health insurance," pointing to the administration's backing of a state individual mandate bill earlier this session.
But he doesn't think the current push for universal primary care is the way to reach that goal.
Financial concerns play a role in the administration's position. If a new primary care system is publicly financed, it will rely heavily on revenue from some still-unspecified tax.
"I think the governor has been very clear on his position on new taxes and fees, and so it's hard to see a situation where the administration would ever support that aspect of universal primary care," Costa said.
Costa, who was involved in the previous administration's ill-fated effort to enact a single-payer health care system, also pointed to a potential flaw in the taxpayer-financing model.
"Until you get the cost of care under control, it is very hard to move dollars into a publicly financed system," Costa said. "To the extent that the expense of that system grows more rapidly than your tax base, you're going to have a real sustainability problem."
That ties in with one of Costa's other objections: The administration wants to tackle cost and quality of care issues first, he said, before prioritizing universal coverage.
"The problem we're trying to solve is that we pay too much for health care, and we do not have high-quality, well-coordinated care," Costa said.
From an operational standpoint, Costa also is questioning how creation of a universal primary care system might conflict with the state's implementation of an all-payer model, which seeks to move Vermont away from the fee-for-service model of health care provider payment.
"We're engaged in a multiyear effort to determine whether (all payer) has merit and whether it will succeed," Costa said, adding that universal primary care is "a totally different project."
Green Mountain Care Board Chairman Kevin Mullin echoed those concerns, though he said neither he nor the board is taking a position on S.53.
"The one thing I want to make crystal-clear is that we can't take our focus off the implementation of the all-payer model," Mullin said.
"I don't think there's a true conflict between (universal primary care and all payer), but I do think there could be complications," he added.
Care board officials also warned lawmakers that, under the version of S.53 approved by the Senate, the board would need significant financial support and additional personnel to undertake study and planning work.
A new estimate says the cost of that work over a two-year period could range from $590,000 to $770,000.
The House Health Care Committee is scheduled to hear more testimony on S.53 this week.
Some committee members had sharp questions for Costa.
Rep. Brian Cina, P-Burlington, referenced the fact that the administration has proposed eliminating\ a cost-sharing reduction that lowers expenses for income-qualified residents on certain Vermont Health Connect plans.
What's the difference, Cina asked, between "raising someone's taxes to cover their health care and removing their cost subsidies or removing other public assistance, which ultimately increases a fee that a person's going to have to pay?"
Costa sought to differentiate the two issues, saying the proposed subsidy cut is a budgeting decision.
"It's not that we didn't think that those folks could use help paying for health care expenses it's that we're making the best of difficult alternatives given limited public funds," he said.