Highlight on Vermont: Implementing the ACA on the Road to a Single Payer System

Implementing the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) has been a priority in Vermont as it has been elsewhere. The launch of the state’s Health Insurance Exchange  was fraught with problems. Perhaps one reason why Vermont’s health insurance exchange roll-out was ineffective is that the state used CGI Group to build its system, the same contractor who developed the sites for HealthCare.gov and the state health benefits exchanges in CaliforniaHawaii and Massachusetts, all of which had problematic launches.  As recently as the first week of February, individuals who had enrolled online could not enter changes to their information, such as family status, or income, online. All small business enrollments must go directly through the insurers for the remainder of the open enrollment period. In addition, the site still cannot accept premium payments. The state has suspended payments under the contract and withheld $5.1 million from CGI.

Enrollment through the Marketplace

Vermont has enrolled a higher percentage of its uninsured residents in health plans than any other state. Estimates of the number of uninsured residents as of December 31, 2012, range from 43,000 to 47,900.  According to HHS figures, the state Marketplace has found 19,583 people eligible for a qualified health plan (QHP); 54 percent have been found eligible for financial assistance. Vermont Health Connect released its own enrollment figures on February 12, 2014, showing that 14,462 people who have been found eligible for QHPs have also been found eligible for the advance payment of premium assistance and/or cost sharing reduction.  Vermont is one of five states that have released the number of paid enrollees; 13,514 enrollees in QHPs had paid their first month’s premium as of February 10, 2014. About 13,000 people have enrolled in Medicaid through the Marketplace as of February 10, 2014.

Other Recent Developments

On February 13, 2014, it was reported that there had been breaches of seven individuals’ privacy rights connected with the Marketplace between December 16, 2013, and January 24, 2014. Two similar breaches occurred in the fall. In general,the breaches appears to involve human error rather than failures of technology. For example, a worker inadvertently placed two invoices in one envelope, so that the addressee received another person’s invoice in addition to their own. In another instance, a worker entered information from a paper application into the account of another enrollee who had signed up through a broker. The broker accessed the account and sent the invoice to his client before realizing that the two enrollees were different. Four people who accessed their accounts online saw that scanned  checks  from other enrollees with similar names had been posted to their accounts by the payment processor. In one instance, the enrollee’s Green Mountain Medicaid card was mailed to a former address because of a “data reconciliation” problem.

The state’s largest health care provider, Fletcher Allen Health Care in Burlington, told the press that it had experienced few problems with patients who obtained their coverage through the Marketplace since the plans became effective January 1, 2014. Although the number of patients enrolled in Marketplace plans is small, Shannon Lonergan, director or registration,  said there were fewer problems than she had expected. There are always many patients whose health insurance changes at the beginning of the year. However, an executive at Blue Cross said that the company was still getting enrollment information for people whose coverage was effective January 1, 2014.

Vermont’s Long-Term Plans for Health Care Reform

For the last several years, the state has been implementing efforts to improve residents’ health and the quality of care in conjunction with payment reforms through its Blueprint for Health. Like the federal government, Vermont has created and expanded medical homes and accountable care organizations and focused on evidence-based practices.  In 2011, the legislature passed Act 48, the purpose of which is to establish a single payer system in which all residents are covered without regard to their employment status. The system will be called Green Mountain Care. A  Board of Directors will establish the benefits.

The projected launch date is 2017. It will be necessary for the state to get a waiver from HHS of the federal statutory requirements under Medicaid and the ACA. However, the funding for the program has not been finalized. The projected costs are disputed. Initially, the estimated cost was $1.6 billion. A recent report by Avalere Health concluded that the cost would be between $1.9 and $2.2 billion. The Green Mountain Care Board is developing proposals to present to the General Assembly.