VERMONT’S HEALTH REFORM HISTORY AND THE ROLE OF THE GREEN MOUNTAIN CARE BOARD
Vermont’s current health reform plan builds on more than two decades of work to expand health insurance coverage and improve health care delivery in the state. In May 2011, Governor Peter Shumlin signed into law Act 48, comprehensive health reform legislation that aspires to create a health care system in which all residents receive coverage from a single source, with all coverage offered equitably and health care costs contained by systemic change in the way providers of care are compensated for their services. The legislation had three components:
- It created a Health Benefit Exchange, as required by the federal Affordable Care Act. The Exchange, which is housed within Vermont’s Medicaid agency, will be responsible beginning in 2014 for:
- Enrolling Vermonters who purchase health insurance on their own or through a small employer in coverage;
- Assuring that Vermonters who are eligible receive new federal tax credits to reduce the cost of their health insurance; and
- Coordinating between public and private programs to reduce gaps in coverage.
- It created the Green Mountain Care Board (GMCB), which has explicit responsibility for controlling the rate of growth in health care costs and “improving the health of Vermonters” through a variety of regulatory and planning tools.
- It laid out the broad outlines of a single payer system in Vermont, but required additional detailed planning for how such a system would operate, and how it would be financed. This detailed planning is the responsibility of the Governor’s Director of Health Reform and the Secretary of Administration, the state’s chief financial officer.
In 2007, the Vermont legislature, with the participation of Vermont’s three largest commercial payers and Medicaid, authorized pilots to test an Integrated Health Services Model, called the Blueprint for Health (Blueprint). The Blueprint model includes a primary care practice that meets NCQA medical home standards and a community health team that augments the practice with connections to other medical and social services. In 2011, Medicare selected Vermont as a participant in its Multi-Payer Advanced Primary Care Practice Demonstration initiative, and agreed to participate in the Blueprint project. The project now includes 79 practice sites serving approximately 360,000 patients, more than half of the state’s population. By October 2013, the Blueprint will expand statewide.
The GMCB has a clear charge to expand health care payment and delivery system reforms, building on the Blueprint. Act 48 directs the GMCB to implement policies that move away from a fee-for-service payment system to one that is based on quality and value, to include all payers in payment reform and to reduce or eliminate cost-shifting between the public and private sectors. Toward that end the GMCB has the authority to approve hospital budgets, major health care capital investments, health insurer rate increases and all-payer rates for all providers (with permission from the federal government to include Medicare).
The GMCB also has responsibility for approving the state’s health care workforce plan, its health information technology plan and minimum benefit requirements for both the health benefit exchange and the single payer plan. More generally, the GMCB has a responsibility to improve the health of Vermont’s population in implementing all of its duties. The GMCB’s scope of authority is unprecedented in the U.S. However, it is tempered by an understanding across stakeholders that regulatory interventions and efforts to better plan health care spending, resource allocation and population health improvement will succeed only if coupled with active public engagement.
Taken together, Vermont’s previous health reforms and the reforms included in Act 48 are intended to assure that:
- All Vermonters have health insurance coverage;
- Health care delivery is efficient and high quality;
- The system emphasizes health improvement;
- Costs are sustainable; and
- We move in a deliberate manner toward de-linking health insurance coverage from employment and publicly financing coverage.