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Vermont Employers Health Alliance lists the waivers needed for VT single payer to pass

Their argument is that not all the waivers are HCR-related, and so the VT bill is unlikely to pass. Do we have anybody expert enough to say whether this list is accurate?

NOTE The Vermont Employers Health Alliance has been around a long time; they're a lobbying and educational group for the state of VT. There's not a lot of detail on their blog -- the profile of the poster reads "Policy Analyst." If the VEHA have a web site, I can't find it tonight. Their managing director, Craig Fuller, of Burlington, VT, is an R; a VP of Keller & Fuller, a public relations firm. The previous president of the Vermont Employers Health Alliance was Fuller's boss, Jeanne Keller, a registered VT lobbyist for health care and health insurance. Plus, Fuller and Keller are married.

I wonder who's funding them? Maybe BRS? Or is the money from out-of-state?

Maybe somebody who understands PR could find out:

Jeanne Keller
Keller & Fuller
P.O. Box 943
Burlington, VT 05402
Phone: (802) 864-6787
Fax: N/A
Email: jkeller@keller-fuller.com

UPDATE Interestingly, K&F donated to the Python Foundation, a worthy cause in the open source software world. But why is a PR firm doing that?

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Submitted by hipparchia on

a lot of these organizations are made up of small businesses [and it looks like veha is one of these groups], and a lot of small businesses are independent insurance brokers. most of these brokers/small businesses tyopically sell all kinds of insurance -- life, health, auto, home, etc -- so they wouldn't necessarily go out of business if single payer passed, but they would lose some business and probably cut some employees.

eta:

"Since our alliance is made up primarily of small employers--indeed 95 percent of Vermont's 17,000 businesses employ fewer than 25 people--one of our main tasks is to try and coordinate group purchasing," says Jeanne Keller, the alliance's executive director.

and:

**The Vermont Insurance Agents Association is a voluntary, professional association of approximately 130 independent insurance agencies throughout Vermont. Founded in 1906, the association now maintains its executive offices in Montpelier, Vermont.**

130 insurance agencies out of 17,000 businesses is ~1%. it would be interesting to know if the membership of veha is also ~1% insurance agencies....

Submitted by hipparchia on

essentially, he's correct [though he left off the indian health service, and the vha, for just a couple of examples]. there's a whole host of federal and federal/state programs that pay for, or help pay for medical care. and of course, there's the private health insurance industry, which [as you note] appears to have a friend in jeanne keller and keller&fuller.

so yes, if a state were going to establish a pure single payer system and be THE ONLY payer for ALL health care inside its borders, it would have to integrate or get waivers for all those items.

but that particular post seems to be all about deploying the scare tactic look how difficult this is going to be! look how many obstacles there are to overcome! we should all just give up now and stick with the status quo! and so he has broken out his list into as many items as possible to make the task look more formidable than it has to be.

for instance: his items 3 and 4, medicaid and schip, are both state/federal programs, with the federall govt setting some baselines but otherwise giving the states money and allowing them to decide how to spend it, including being able administer schip and medicaid as totally separate programs, partially separate programs, or one combined-and-expanded medicaid program.

Like Medicaid, SCHIP is a partnership between federal and state governments. The programs are run by the individual states according to requirements set by the federal Centers for Medicare and Medicaid Services. States may design their SCHIP programs as an independent program separate from Medicaid (separate child health programs), use SCHIP funds to expand their Medicaid program (SCHIP Medicaid expansion programs), or combine these approaches (SCHIP combination programs). States receive enhanced federal funds for their SCHIP programs at a rate above the regular Medicaid match.

then there's his item 5: Many other health programs codified in the Social Security Act, such as Maternal and Child Health Block Grant programs. (http://www.law.cornell.edu/uscode/42/usc...) if you follow his cornell.edu link, you see it's the entire social security / medicare / medicaid / unemployment law, which is divided into 21 subchapters. surprise, surprise, but about half of these subchapters are provisions for grants to states to augment not just paying for medical care for various populations, but also public health programs in general. the maternal and child health block grants, for instance:

The Maternal and Child Health Block Grant to States is a public health program that reaches across economic lines to improve the health of all mothers and children. A partnership between HRSA and State maternal and health programs, State Title V programs use block grant funding to build capacity and ssytems, conduct public education and outreach, train providers and support services for children with special healthcare needs, newborn screening and genetic services, lead poisoning and injury prevention, and health and safety promotion in child care settings.

massachusetts includes, among other things, domestic violece against women and children as one of the top priorities in their program. so his item 5 is sort of spurious, since he's partially conflating paying for medical care with paying for broader public health intiatives.

i could go through and talk about each item on his list, but that would be a very long comment.

Submitted by lambert on

... I saw on Hsiao and single payer in VT (although, interestingly, as "15 waivers," and not 14; I don't know where the mutatation came from).

And it took me two days to track it down. So this PR firm is very good at what it does.

Submitted by hipparchia on

i guess that would be the 4 [a-d] needed in ppaca + the other 11 he listed. i saw the '14 waivers' come up a lot in a quick google search on veha, but i didn't spend any time trying to track down where the number 14 came from.

Submitted by hipparchia on

don mccanne [pnhp] preliminsry analysis here

hsiao's statement here [pdf]

the full proposal here [pdf]

essentially, the vt proposal seems to boil down to leaving the federal [ie medicare] and federal/state [ie medicaid] plans in place, and rolling private insurance into either a state- or state+private-managed plan. this would sorta make vermont's a 2-payer plan: with the state and the federal govts being the 2 payers.

if you're going to be the very first state in a nation of 50 states to roll out a plan, it's probably not a bad idea to keep the federal and federl+state plans in place, since there's no telling [at this point] which way the rest of the states are likely to go. this way, when the entire nation goes to some form of single payer [like canada did], vermont's now-hybrid plan can [maybe] more easily be shifted to any one of the other forms [but that's just a guess on my part].

incidentally, canada's medicare is mostly like an expanded, improved, very generous form of our medicaid: the federal govt sets a baseline for the care that MUST be provided, then gives the states [provinces] money and permission to provide more generous benefits on top of the federally-mandated ones, should they so desire. our medicaid program is set up a lot like that, except that it's incredibly stingy at the federal level, and some states stick with that stinginess while others add more benefits.

eta: vt chapter of pnhp press release here

Submitted by JeanneKeller on

Hello. I was checking on what Spokeo had on me, and a link to this page appeared. So, I just thought I'd check in and say hello and clarify a few things, because you do appear to be curious about me.

Let me apologize ahead of time if I have inadvertently not followed the rules for this blog and site, which I've carefully read but may not have fully understood. I recognize this entry is probably too long, but I'm a policy analyst - it's hard to elucidate complicated stuff in bits and bytes

I live in Burlington, Vermont and have been working on health care reform in Vermont for nearly 30 years, starting at the Vermont PIRG, and then as Insurance Administrator for Mayor Bernie Sanders. My husband and I started Keller & Fuller, Inc. in 1998 and have done a limited amount of "PR" work since that time - for example, I helped kick off the Vermont Forum on Sprawl, creating their communication plan and assisting them in rolling out results of their polling, research, and I did some PR work for Women Helping Battered Women, also. But the larger part of my work is what's called "policy analysis," which basically means reviewing bills, regulations and public programs to evaluate what they mean, do and the likely outcomes, and making suggestions on how to improve them. I've done this kind of work for the Vermont State Employee Health Plan, the League of Cities and Towns Health Trust, the Vermont Department of Health, among other institutional groups, and lately for BRS (an association of small businesses who group purchase their health insurance).

For the past twenty years, I have participated on just about every advisory council that BISHCA has put together for public reporting, and have usually been the only consumer advocate on those panels. I've pushed especially hard in the last ten years for total transparency on costs, quality and safety. I've lobbied for and worked on drafting regulations for the Patient Safety and Surveillance Program , Hospital Report Cards, Health Insurer Transparency and with Ken Libertoff of Vermont Association for Mental Health, drafted and lobbied in favor of Vermont's Mental Health Parity Law..

As for the topic of this thread --- the necessary waivers of federal law that may be required to have a single payer --- Dr. Hsiao included in his report a detailed analysis of several key waivers that would be needed to implement a single payer. He came to this conclusion without any lobbying from me, I can assure you. Even the Physicians for a National Health Program admits that the major challenge facing a single state is getting Congressional approvals to waiver several federal laws. That's why they are lobbying for a national health program.

My intention in pointing out the impossibility of developing a single payer in Vermont is not, as some have asserted here, as a scare tactic, or a pro-insurance industry position. It is to remind everyone that Dr. Hsiao's estimates of savings are based on a pure single payer (see link above to his report), that would require waivers of at least ERISA, Medicaid and Medicare. Without getting those waivers, we don't get the savings, and therefore the financial model won't work. It's also important to understand that Dr. Hsiao, when directly asked about this, said his proposal is "All or Nothing," not a menu from which the state can pick and choose. (Because the press didn't ask Hsiao this important question and weren't at the meeting where he was asked, the only link I can provide is this one: http://employershealthalliance.wordpress.... When this quote was used in testimony in the legislature, no one from the Shumlin administration disputed it, although their bill, H. 202, does not track Hsiao's "all or nothing" dictum, and is less than a pure single payer they continue to quote the full "savings" Hsiao asserts.) (Two minutes into the recorded NPR story I've linked, Gov. Shumlin claims $500 million in savings, Hsiao's estimate for a pure single payer.)

I have stated repeatedly to legislators, the Shumlin administration and the public, we are, effectively, wasting valuable time and resources on building a single payer that we'll never get Rep. John Boehner to allow, because ">the Republican leadership is so totally opposed to strong government involvement in health care delivery and financing. Instead, we should throw all of the resources we currently have at our disposal (Certificate of Need, hospital budget controls, Medicaid payment reforms, insurance payment reforms) at payment reform and putting health care delivery system on a budget with fixed growth limits. Yes, that would be easier to do with a single payer, but as Dr. Hsiao, PNHP agree with me, one state realistically cannot do a single payer in the current political climate, given all the waivers Congress (e.g. including the Republicans with their control of the House and filibuster in the Senate) would never allow.

PS: "Why would a PR firm donate to Python?" someone on this thread queried. Yes, I donate to Python and I use Paypal to donate to the writers of any open-source software I use (AGV, SlimTimer, etc.) First, I'm not a PR firm, as I've explained. I do it because it's the right thing to do. This very question demonstrates, IMHO, that pulling random data together about a person may not really tell you very much about what they believe and why they believe it. So if you want to know why I said what I said, and why I think what I think, I really welcome you asking me. I'd be happy to engage. My email address and blog are very public. Cheers.

Submitted by hipparchia on

[long is good, and the rules here are lenient]

brava to you for your long involvement in some very important issues.

My intention in pointing out the impossibility of developing a single payer in Vermont is not, as some have asserted here, as a scare tactic, or a pro-insurance industry position.

that's not immediately obvious from your writing.

I have stated repeatedly to legislators, the Shumlin administration and the public , we are, effectively, wasting valuable time and resources on building a single payer that we'll never get Rep. John Boehner to allow

i partly agree with you, in that (1) i don't think a state-by-state approach is the way to go to get to a national single payer plan, and (2) the "single payer" plan that was eventually signed into law in vermont isn't going to work as advertised [mostly becuse it got hijacked and isn't really a single payer plan].

while i agree with you that working with the tools already in place is probably a good thing, i'm suspicious of some of the ones you mention. certificate of need and hospital budget controls are probably good, but ... when people speak of 'medicaid payment reform' they too often mean 'privatized managed care' and when they speak of 'insurance payment reform' they too often mean 'let the market decide' or 'high deductible plans' - none of which has a good track record of providing needed care.

and while i applaud efforts toward improving patient safety and mental health parity, measures of 'quality' are dubious at best and price transparency isn't much help to most patients. not to mention that after poking around the price transparency portion of the website i noticed that rutland has the highest surgical costs and the lowest physician costs, and that fletcher allen has the highest physician costs, moderate or mixed surgical costs, and the best track record for surgical treatment of abdominal aortic aneurysm. after that my head was hurting too much to go on.

and while a few people can and will shop around, most people want to go to a doctor and hospital near where they live, which they could do if we had medicare for all national single payer. hard to tell, from what i can see, if you and/or vt employers health alliance are actively opposed to that or not.