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VT Digger

Legislature, insurers look to cover federal health subsidy cut

In the wake of President Donald Trump’s cutoff of federal funding for a health insurance subsidy in October, state officials, insurers and lawmakers are considering a plan to ease the impact on Vermonters.

Lawmakers anticipate moving quickly to allow reworking of some health care plans, as the insurance rate-setting process for next year is set to kick off within weeks.

A Trump executive order in October ended federal funding for a subsidy, part of the Affordable Care Act, aimed at stabilizing insurance premiums and keeping costs manageable for consumers.

However, a mandate in federal law continues to require insurers to offer a silver-level health plan at reduced cost to people whose income is up to 250 percent of the federal poverty level. Without federal dollars, insurance companies are left to bear the cost of that benefit themselves, which is expected to drive up premiums for all health plans.

Now, key players in Vermont’s health insurance sector are backing a proposal meant to prevent across-the-board increases because of Trump’s action.

The proposal would take advantage of a different federal subsidy — the premium tax credit — to make up for the loss of cost-sharing funding.

Under this scenario, premiums would increase only on silver-level health plans sold on Vermont Health Connect. Blue Cross Blue Shield puts that increase at 10 percent. Customers would be shielded from paying the higher rates themselves.

For most consumers, the premium tax credit would cover the rate increase, according to the plan’s architects. The credit is available for people with incomes up to 400 percent of the federal poverty level. Based on the 2017 federal poverty level, the credit is available for individuals with an income up to $48,240; for a family of four, the cutoff is $98,400.

People who buy silver plans through Vermont Health Connect but aren’t eligible for the tax credit — there are about 2,195 such customers now — would pay the full cost of the higher premium if they purchased their plan through the exchange.

But to help keep costs down for those people, the insurance companies would develop a similar plan with lower premiums that would be available directly from the companies. Lawmakers’ authorization is required for the insurance companies to develop parallel silver-level plans to offer outside Vermont Health Connect.

Only Vermont, North Dakota and Washington, D.C., did not make changes in the wake of the October executive order. According to Blue Cross Blue Shield, 37 states implemented a plan similar to the one lawmakers and health care officials are considering in Vermont.

Blue Cross Blue Shield initially drew up the plan, which has been endorsed by the state’s other major insurance company, regulators, advocates and other key stakeholders.

“We fully support it,” Susan Gretkowski of MVP Health Care told the House Health Care Committee on Wednesday. “We do feel it is the best way to protect each group of people in the silver level.” [...]

Chief Health Care Advocate Mike Fisher, of Vermont Legal Aid, also supports the plan.

“It will avoid many Vermonters seeing increased premiums,” he said.

It’s important for people to be aware of available subsidies, Fisher said.

He encouraged people to pay close attention to the amount they must contribute to their insurance plan when they are enrolling through Vermont Health Connect. Though the total costs may be high, their contributions will be much lower, he said.

“The sticker shock of the total premium scares people, understandably,” Fisher said. “It’s really important that people look at what their family contribution requirement is, and that will be unchanged.”

He and others emphasized the need for a campaign to raise public awareness of the change. [...]

Seven Days

When the Bedbugs Bite, Vermont Officials Are Ill-Equipped to Respond

As Chester's health officer, Leslie Thorsen is responsible for enforcing Vermont's rental housing code, meant to protect tenants from inadequate plumbing and heating, contaminated water, rodent infestations, and other health-threatening conditions.

Thorsen, an operating room nurse, does all this in her spare time, for just $1,000 a year. And when she responds to a tenant's complaint, there is little she can do if a landlord refuses to correct a problem.

"The [most] you can do is write a health order," Thorsen said, referring to a legal document that negligent landlords have been known to ignore.

Enforcement of Vermont's rental housing codes depends almost entirely on people such as Thorsen — low-paid or volunteer town health officers with minimal training and a limited ability to remedy substandard housing.

In a report set to be released this week, Vermont Legal Aid concludes that this system fails to protect tenants, essentially trapping them in unsafe homes. The report tells the stories of Vermont renters living with broken furnaces, sparking electrical outlets, cough-inducing mold and leaking toilets.

"I think it's fair to say that the governmental response has been inadequate," said Jack McCullough, a longtime attorney with the nonprofit law office.

Legal Aid's report calls for creating a landlord registry to allow more oversight of rental units, professionalizing the health officer force and increasing penalties for violating the rental housing health code.

Enforcing minimum housing standards is particularly important because of Vermont's aging housing stock — 43 percent of rentals were built before 1950, according to the Vermont Housing Finance Agency — and a dearth of affordable housing statewide, said Maryellen Griffin, a lawyer with Legal Aid.

Under the state's rental housing health code, landlords are legally required to provide necessities such as a sink, a flush toilet, a working sewage system, a source of heat, and a structure that is weather-tight and rodent-free. (Fire safety regulations are separately enforced by the state Department of Public Safety.)

Vermont law "would seem to put tenants in a good position to have reliable and well-maintained housing," McCullough said. "The problem is that actually getting those rights enforced has been tremendously difficult." [...]

Some health officers limit what they'll endure in service to their towns. Edgerly said he's declined to inspect a tenant's complaint about bedbugs: "I'm not going into a bedbug situation — no way."

That sort of attitude frustrates tenants.

"Our clients will make complaints to town health officers and it doesn't really go anywhere," Legal Aid lawyer Sandy Partiz said.

"We know that people are radically underreporting problems because they don't believe in the system," Griffin said. [...]

Legal Aid, which plans to advocate for some of these changes during the legislative session, says steps such as investing in a better-paid, more professional force of town health officers will save the state money in the long run. "Something that might have cost a landlord a few hundred dollars to fix, like a mold problem, can end up costing thousands of dollars in health care expenses to treat a tenant's resulting respiratory illness," the report says. [...]

VLA Press Release | January 11, 2018

Many Vermont Tenants Stuck in Unsafe and Unhealthy Housing

Despite regulations intended to protect them from substandard housing conditions, many Vermont tenants still live in unsafe and unhealthy homes. Today, Vermont Legal Aid released a report, Renters at Risk: The Cost of Substandard Housing, to examine the problem and call for policy solutions to address substandard housing. The report was the result of data analysis and interviews with tenants, advocates, and public officials.

Our key findings are as follows:

1. Tenants who suffer from the various impacts of unsafe and unhealthy housing conditions experience increased health care usage, mental health problems, disruption to school and work, and homelessness.

2. The most common problems tenants face are pests and plumbing problems.

3. Threat of eviction and lack of affordable housing options often prevent tenants from reporting rental housing health code violations.

4. Town health officers are commonly unpaid volunteers without the time or experience necessary to address health code violations.

5. We can and should make changes to our code enforcement system.

In our report, the voices of nine tenants in the struggle for healthy housing reveal the long-lasting impacts of substandard housing. It is clear that their experiences with inadequate housing conditions are not isolated instances – many other renters throughout Vermont suffer serious problems in their rented homes. For example, Amberly, a tenant in Rutland, had to live with a severe rat infestation (see attached photo). It appeared that they were coming into her home from the outside through the basement. Amberly set traps and did what she could, but had to live with rats -- in her home, in her kitchen, chewing on her possessions – for months before she could move out. Amberly developed hives and other medical issues in addition to handling the plain stress of a rat infesation, all while trying to juggle work and raising two small children.

“This kind of situation is too common, and it is not just a problem for tenants,” according to Maryellen Griffin, one of the attorneys at Vermont Legal Aid who worked with lead author Tessa Horan on the report. “These problems also hurt good landlords, towns, and taxpayers. The medical costs, the downward pressure on property values, the risk that the rats will continue to multiply and migrate to other buildings, not to mention the human suffering – these are problems for all of us. Allowing our housing stock to continue to degrade threatens the health of our residents as well as the tax base and the viability and vibrancy of our towns.”

We are proposing legislation to address this issue using three strategies:

1. Strengthen Town Health Officers’ authority to issue orders and enforce them, and make it unlawful to re-rent an apartment if the landlord has not complied with the orders.

2. Direct the Department of Health to provide more coordinated support to Town Health Officers.

3. Create a statewide database of rental housing to collect better data about the problem.

As Jonathan Bond from Vermont Tenants Inc. said in the report, “If we’re going to have a really basic health code, I would like to see the basic health code being enforced, and right now it’s just not being enforced.”

To read our full report and list of recommendations to address the impacts of substandard housing on Vermont tenants, visit our website at http://www.vtlegalaid.org/renters-at-risk.

University of Vermont Medical Center Settles Deaf Access Cases

Patients who are Deaf or hard of hearing will receive better services at the University of Vermont Medical Center (UVMMC) because of settlements reached with Vermont Legal Aid, the Vermont Human Rights Commission, and the U.S. Department of Justice. The agreements settle multiple cases brought by Vermont Legal Aid at the Vermont Human Rights Commission and the U.S. Department of Justice for UVMMC’s failure to provide adequate Deaf interpretation services to patients and family members at the hospital.

The cases were brought by Vermont Legal Aid because UVMMC had not provided adequate sign language interpretation services in multiple cases over the past four years. “Credit goes to our clients for demanding their rights to equal access in order to make positive change for all Deaf patients,” said Barbara Prine, Staff Attorney with the Disability Law Project of Vermont Legal Aid. “We also thank UVMMC for agreeing to robust improvements in its system for Deaf access.

Under the global settlement agreements, UVMMC must improve policies on Deaf access, train staff on how to provide accommodations, and set standards for working with in-person and remote interpretation. The agreement also includes grievance procedures. The Vermont Human Rights Commission will monitor compliance with the settlement agreement over the next two and a half years.

“This comprehensive agreement covers best practices for serving individuals who are Deaf or hard of hearing in hospital settings and also provides for an extended period of monitoring to ensure that these much needed changes are effectuated,” said Karen Richards, Executive Director of the Human Rights Commission. “The HRC appreciates the UVMMC’s cooperation in reaching a settlement that will improve services to their Deaf and hard of hearing patients and family members.”

“We strive to provide all of our patients with the highest quality of care, but unfortunately we did not meet that goal in these cases,” said Eileen Whalen, RN, MHA, president and chief operating officer of the University of Vermont Medical Center. “We have taken many steps to strengthen our interpreter services including hiring an Interpreter Services Coordinator, educating staff on the resources we have and how to use them, and upgrading our remote interpretation technology. We’ll continue to seek out opportunities to strengthen our services and policies regarding the treatment of Deaf patients, and maintain the involvement of our patient and family advisors who have provided valuable guidance in this area.”

“I’m glad that Deaf patients stood up together for our rights. I’m also glad that the hospital has agreed to improve its policies and procedures so that the Deaf community will have equal access to medical treatment,” said George Lareau, one of the complainants.

Vermont Health Connect Open Enrollment Starts Wednesday

Open enrollment starts Wednesday for Vermonters who want to sign up for a health insurance plan for next year through the state's online exchange or existing subscribers who want to change to a different plan.

The annual enrollment period runs from Wednesday to Dec. 15.

Officials tell Vermont Public Radio that Vermont Health Connect's technical problems have largely been fixed and operations have improved dramatically in the past year.

Open enrollment comes as President Donald Trump has done away with federal subsidies to health insurance companies used to reduce out-of-pocket expenses to low- to moderate-income Vermonters.

Mike Fisher, chief health care advocate for Vermont Legal Aid, says the benefits will still be available and it's up to the insurance companies to figure out how to fund them.

VT Digger | September 27, 2017

Legal advocates warn against Burlington crackdown

BURLINGTON — The American Civil Liberties Union of Vermont and Vermont Legal Aid are warning city officials that an ordinance criminalizing “quality of life” violations could result in legal challenges.

The City Council approved a resolution on Aug. 28 that calls on its Ordinance Committee to draft a new ordinance that “creates a criminal penalty for repeat offenders” for civil infractions including public intoxication, public urination or littering.

The letter from the two legal groups says that instead of criminalizing minor violations, the city should expend more resources to address the “root causes” of such behavior, which they say are poverty, homelessness, substance abuse and mental illness.

“Our goal was really to tell the city, the choice should be clear, we can either take the easy route to criminalizing petty code violations, or we can actually make the city a safer better place,” said ACLU Staff Attorney Jay Diaz, who has been a vocal critic of the proposed ordinance.

The City Council passed a second ordinance calling on its Public Safety Committee to review existing safety net services in Burlington and work with social service providers to improve their delivery, but supporters of the new criminal penalty maintain it has a role as well.

Burlington Police Chief Brandon del Pozo has argued the ordinance will create accountability for people who currently ignore the civil tickets they are issued, accruing thousands of dollars in unpaid fines in some cases.

It will also give officers a way to remove people who are intoxicated and causing a disturbance from downtown before their behavior turns violent, the chief has said. Police say the new ordinance is needed because of several recent incidents of violence in or near City Hall Park.

Councilor Kurt Wright, R-Ward 4, who sponsored the resolution calling for the new ordinance, said he was spurred by the frustrations of downtown business owners, some of whom have said aggressive panhandling and catcalling are upsetting employees and customers.

Both Wright and del Pozo have suggested that police and judges, when making decision about whether to arrest someone or what penalties to impose, will be able to delineate scoff-laws from people with substance abuse or mental health problems.

The problem, according to the ACLU and Legal Aid, is the act of being arrested and brought before a judge can have negative consequences for people living in poverty.

“Regardless of whether they are released on conditions, on bail, on a plea, after probation revocation, or after dismissal, low-income people commonly lose their jobs, miss rent payments, miss car payments, lose their property which may be left in the open, and lose contact with medical and other service providers—all from even a night or two behind bars,” the letter states.

Should the city move forward with an ordinance criminalizing low-level civil offenses, the ACLU and Legal Aid write that they will “work with impacted individuals to oppose and challenge it.”

The letter highlights a number of different grounds for potential legal challenges to such an ordinance including state laws prohibiting the criminalization of alcohol consumption, provisions against debtors prisons in the Vermont Constitution, and possible violations of the U.S. Constitution.

The ordinance could also run afoul of federal anti-discrimination laws, the letter states, because it’s likely to have a disproportionate impact on people of color and people with disabilities.

So far, the Ordinance Committee has not taken any steps to draft the ordinance called for in the August 28 resolution, said City Councilor Chip Mason, D-Ward 5, the committee’s chair.

An Ordinance Committee meeting scheduled for Wednesday was canceled, and the committee members are still working to find a time for their next meeting.

To read the full letter from the ACLU and Legal Aid, click here.

VT Digger | September 20, 2017

Phantom rule could leave special needs kids, parents in limbo

State officials thought they’d had a rule in place since 2013 requiring school officials to respond within 15 days when a parent requests that a child be evaluated for special education services.

Now it turns out the rule was never filed properly with the Vermont Secretary of State’s office. Some parent advocates saying that means families have no recourse when school officials drag their feet.

Because some of the rules passed by the Vermont Board of Education are not the same as those posted on the Secretary of State’s website a new rule-making process must take place in order for the 15-day standard to go in effect, officials said.

The state Board of Education and Agency of Education say they are swamped with implementing Vermont’s Act 46 school district consolidation law, and don’t have time to deal the special education rules.

Now they’re asking local school districts to meet the 15-day response time as a “best practice.” But parent advocates say that gives them less power to challenge inaction by schools.

“The difference between best practice and a rule is that a rule is a procedural safeguard for parents’ rights,” said Karen Price, the family support director with Vermont Family Network.

With a rules violation, parents could enter a formal complaint process, Price said. When looking to cure a deviation from best practice, “a parent is relying on the good faith on the part of the school,” she said.

When a parent suspects their child may need special education services, the first step is to ask for an evaluation to see if the child is eligible. Price said that before the state board added the 15-day rule there was no defined timeline for schools to respond to parents’ requests.

“It has been a long-standing problem that parents that suspect their child has a disability and they make a request then never hear back,” Price said. “It happened a lot.”

Price said she knows of one parent who has since learned she cannot file an administrative complaint based on the 15-day rule.

“Now that it’s no longer a rule, she has no right to complain,” she said.

One parent in the Franklin-Northwest district said she had planned to file a formal complaint after becoming frustrated about the school’s lackluster response to her request for a special education evaluation for her child.

“I was going to lodge a complaint about the 15-day rule, but now I’m stuck with not knowing if it makes sense because the rules are changing,” said the parent, who asked for anonymity because being publicly identified could harm her own employment situation. She said she had been notified of the change to the rule by staff at Vermont Legal Aid.

“I believed the information I was finding online was correct. I’m really disappointed that they could make this type of mistake,” she said, adding that guidance is not good enough.

“If a child needs special services, it can’t wait. It needs to be addressed as soon as possible. In the meantime, while we are waiting, a child is suffering,” she said.

The agency has strongly advised school districts to use the 15-day rule until officials have a chance to update it, according to an agency memo released in August.

Haley Jones, spokesperson for the agency, said school districts have been using the 15-day rule since 2013 and everyone is used to it. “We have not heard that anyone intends not to continue to use it,” she added.

In 2013, the state Board of Education made a number of changes to the special education rules, mostly to bring them into compliance with new federal laws. Most of the changes did show up in the official rules posted by the Secretary of State’s office, but a few did not.

“This is the kind of thing that happens when you are short-handed and the state board also has no staff,” said William Mathis, vice chair of the board.

Recent years have been marked by increasing responsibilities for the state board and Agency of Education, including the implementation of the Act 46 school district consolidation law, without long-promised increases in staff, officials said.

The federal government requires schools to respond to parents within 60 days and the state has remained in compliance.

Mathis said the state board added the 15-day rule because members wanted to be more responsive and responsible to parents.

“But through a huge foul-up and a lack of staff to check and double check the work, it didn’t happen,” he said, adding that it will be put back in when the state board goes through the rules process again.

But that is little comfort to Vermont families, said Price. “It is the Agency of Education’s job to have these regulations be correct and protect parents’ rights. As a parents rights organization this is not a response we are happy with – they are short of people? Short of time? They can’t get to this? It isn’t right for parents of children with disabilities for this to remain unfixed.”

Mathis said he isn’t sure when they can start it up since the board and the agency have to deal first with Act 46 and the private school rules series 2200. “It is a matter of the workload for the Agency and for the board. We don’t have any staff.”

VT Digger | August 10, 2017

UPDATED: Blue Cross will get to raise premiums 9.2 percent

Health care regulators will let Blue Cross Blue Shield of Vermont raise insurance premiums on Vermont Health Connect by 9.2 percent.

The allowed increase is nearly a third less than the 12.7 percent the company originally requested in May. That was the most the company had asked to increase prices since Vermont Health Connect started offering plans in 2014.

The board said the company withheld important information during the regulatory process about the “financial stability” of the company. Once the board got a fuller picture, it said, there was room to cut back the increase for calendar year 2018.

The approved rate increase represents a balancing act, according to the board. “In issuing this decision and order, we first acknowledge the tension between two of our standards for review,” the board wrote in its unanimous decision issued Thursday.

“On the one hand, there is an undeniable need for health insurance coverage that is affordable for all Vermonters. On the other, we cannot reasonably expect our insurers to continue to voluntarily participate in the health benefit exchange if it imperils their financial stability.”

“If health insurance is not affordable, access to it will be restricted; if it is no longer financially viable for an insurer to remain in the marketplace, however, access will also be restricted,” the board wrote. “Our decision today seeks to strike a balance and achieve the leanest rates feasible, while protecting the insurer’s financial health.”

The board’s actuaries had said, upon review as part of the regulatory process, that the premiums should go up 12.6 percent — slightly less than the original request. Blue Cross then agreed with the board’s actuaries and reduced its request to 12.6 percent.

The Office of the Health Care Advocate brought in an actuary who argued that the company was using “conservatism” in its math, and that the increase should be just 8.7 percent.

In the end, the board largely went with the calculations by Blue Cross and its own actuaries. However, the board told the company to decrease the amount of premiums that go into its reserve funds to 0.5 percent, from 2 percent, because it has requested $10.3 million from the state to cover unpaid premiums in calendar year 2016. [...]

Mike Fisher, the chief health care advocate for Vermont Legal Aid, said he supports the reduction in how much Blue Cross can send to reserve funds. “I think that Blue Cross has a number of levers that they can use in the course of a year to manage expenditures,” he said.

The Office of the Health Care Advocate at Vermont Legal Aid had argued that Blue Cross should put 0.8 percent of premiums into reserves — which is slightly higher than what the board ordered.

Fisher said the board’s decision “definitely moved in the right direction, but, “at the same time, I can’t celebrate a 9.2 percent rate increase when I’m so aware that average-income Vermonters with real health care challenges have a real crisis in their ability to afford the care they need.” [...]

Seven Days | August 16, 2017

Nurse Shortage Puts Vermont Parents on the Hook for Kids' Care

Natalie Briggs spent the first six months of her life in hospitals. Born at 30 weeks with an extra chromosome, she couldn't breathe or swallow on her own. She was deaf. Doctors predicted she'd be permanently confined to a hospital bed.

Now nearly 8 years old, Natalie has short brown hair and a big grin. She is walking, learning sign language and living at home with her parents in Shelburne, although she still breathes through a tube in her throat. Another tube delivers food and water directly to her stomach.

"She has to have eyes on her 24 hours a day to maintain her airway, monitor her for seizures," explained her mother, Amelia Briggs.

Amelia and her husband, Will, rely on nurses to help care for their daughter. The state determined that the family needed 112 hours of home nursing a week — and that Medicaid, the federal insurance program for those with low incomes and disabilities, should pay for it.

But the young couple says they receive only 70 hours of care a week. They take turns monitoring their daughter at night, each picking up a four-hour shift. On July 26, Amelia was on duty from 3 a.m. to 10 p.m., while Will, a software engineer, worked.

The Briggs' plight isn't unique.

For the last 20 years, the United States has suffered a nursing shortage, a problem that's expected to worsen as baby boomers age. The crisis is especially acute for home health agencies that provide nurses for families such as the Briggs, because they compete for employees with higher-paying hospitals and doctors' offices. [...]

"The problem is that we're not compensating home health nurses at a rate that allows there to be enough of them to meet the needs of these kids with high needs, and so there's a shortage of nursing, particularly in the home and particularly nights and weekends," said Barbara Prine, an attorney with Vermont Legal Aid's Disability Law Project. "What that creates for these families who are dealing with really medically complicated kids is a tremendous amount of stress." [...]

In the meantime, families continue to pick up the slack.

"The consequence of not having someone alert, ready to take care of the kids, is really dire," said Prine of Vermont Legal Aid. "Part of the problem is we have this expectation that parents can go above and beyond. These parents are going above and beyond night after night, week after week, month after month, year after year, and that is a huge toll on them and their families."

The issue is not just about providing relief for overextended parents. "They are saving Vermont money by keeping these kids home," Prine noted. [...]

Have you been charged for a mammography screening?

Thousands of Vermonters follow their doctors’ advice and get an annual mammogram screenings. About 10 percent the time, they will get called back for an additional views. Being told that you have to come back for more views can be stressful, but most of the time, it should not lead to additional cost for Vermonters.

In 2013, the Vermont Legislature passed a law requiring mammography, including call-back screening, to be covered without copayments or deductible charges. This means even if you are still in your deductible, your screening mammogram will be covered.

The law, however, has not been fully implemented. Women are paying hundreds of dollars for screenings that should be covered in full. Other women are avoiding mammography screens out of fear that they will be called back and have to pay. At the office of the Health Care Advocate (HCA), we hear stories of women being charged anywhere between $300 and $500 for screenings that should be covered at no cost.

The HCA is working with Vermont’s insurance companies and health care providers to implement the law and make sure that Vermonters are not charged for their screening mammograms in order to comply with the law.

The HCA takes our role in protecting Vermonters from inappropriate health care charges seriously. Last year our advocacy for individual Vermonters saved over $320,000 in medical or insurance charges.

If you have been called back for an additional mammography screen and were charged, we want to hear from you.

The Vermont Legislature wanted mammograms to be covered without cost sharing for a good reason. Early diagnosis of breast cancer is key to improving outcomes and saving money. It is hard enough for Vermonters to get timely screenings without worrying about how they will pay for them.

Contact the Office of the Health Care Advocate at 1-800-917-7787, hca@vtlegalaid.org, or vt.lawhelp.org/health. Our office provides free help to all Vermonters who have questions about and problems with health insurance and health care.

Mike Fisher, Rutland

Chief Health Care Advocate, Vermont Legal Aid