Vermont’s ‘OneCare’ All-Payer System Beset by Problems

Published January 8, 2019

On November 9, Vermont Legal Aid’s Office of the Health Care Advocate sent a letter to members of the Green Mountain Care Board, the organization charged with overseeing health care administration in the state, expressing concerns over the program and a lack of transparency on the part of OneCare’s administrators.

“OneCare has not provided the Board with adequate information to exercise meaningful oversight,” the letter said.

The concerns are related to the agreement between Vermont’s OneCare program and the federal Centers for Medicare and Medicaid Services. The pact runs from 2017 to 2022 and was characterized as a way to provide better-quality, lower-cost health care.

Failure of Oversight Claimed

In 2011, the Green Mountain Care Board was created to run as an independent oversight entity responsible for supervising the development and implementation of the state’s all-payer model, evaluating its effectiveness, and regulating the health care payment and delivery system changes it would implement. The board’s regulatory authority gives it oversight of payment and delivery system reforms, provider rate-setting, approval of health information technology and workforce plans, hospital and accountable care organization budget approval, insurer rate approval, certificate of need issuance, and oversight of the state’s allpayer claims database.

Four insurance programs—Medicare, Medicaid, Blue Cross and Blue Shield of Vermont, and the University of Vermont Medical Center’s selffunded employee insurance plan—are slated to be part of OneCare in 2019. Critics of the program have said the allpayer system has failed to meet target growth goals and the Green Mountain Care Board has failed to produce accurate data about the program.

‘Not Actually Doing Anything’

Meg Hansen, executive director of Vermonters for Health Care Freedom, says the state administrators in charge of OneCare have not released records on the program’s performance.

“We’ve submitted requests to the Department of Vermont Health Access and the Green Mountain Board, and no one has records,” Hansen said. “The next legislative session, in 2019, we are going to ally with legislators in the House to force them to reveal the data.

“If the login reports show that no one’s actually using [the program], it means this model doesn’t work and we should just end it,” Hansen said. “It’s like a small hedge fund with an incrementally increasing budget, but it’s not actually doing anything in terms of improving patient care and saving money.”

Government Dominance

Robert Roper, president of the Ethan Allen Institute, says Vermont is suffering from a lack of health care innovation because the market is undermined by one-size-fits-all government programs.

. “OneCare and all-payer have a future in Vermont because there are no other ideas on the table at this point—at least none that would be politically acceptable to our moderate Republican governor and our very liberal legislature,” Roper said. “So far, I have not seen enough public interest in or dissatisfaction with the issue to cause a political shift. I don’t think many people outside of the ‘Montpelier bubble’ even know what this is enough to be dissatisfied with it at this point.

“If Green Mountain Care Board members go ahead and vote [in favor of] OneCare, I don’t see why the federal government should continue to honor this agreement, because it was meant to be a mutual agreement,” Roper said. “They should cancel it.”

Single-Payer to All-Payer

Hansen says the state turned to OneCare after lawmakers failed to find a way to fund the state’s planned single-payer system.

“Vermont tried to do the singlepayer model … under Democrat Gov. Peter Shumlin,” Hansen said. “He made it the hallmark of his administration. In 2011, the Green Mountain Care Board—five bureaucrats that now determine all regulations for Vermont—was created to oversee and regulate the entire process. But the whole thing collapsed. It failed. They ran the numbers: There was a 150 percent increase in income tax on Vermonters and it still wasn’t enough [money].”

Under the Radar

Roper says the introduction of the allpayer model flew under the radar and is an avenue to get the state back to single-payer for everybody.

“Unlike the single-payer initiative, which was launched, hyped, and followed by the press like the space race, all-payer happened pretty much entirely under the radar,” Roper said. “All of a sudden, it was just there, and it’s really just a back-door approach to single-payer. As with most government programs, it is run by bureaucrats who know little to nothing about the businesses of whatever service they are administering—in this case, the very complicated business of health care. As such, the program is destined to be inefficient and expensive and provide poor service.”

High-Demand Demographic

Roper says Vermont’s large elderly population makes expensive programs like all-payer easier to sell. “Vermont has the second-oldest demographic out of all the states in the nation,” Roper said. “Only Maine has an older population. The older you get, generally the more health care you need.”