one of the things that i learned while being a representative in mongolia was that there are so many topics and so much knowledge and so many experts across the state that this program that is an effort to bring some of that expertise right to richmond here locally and today we have as a goal for the program to share the knowledge about health care reform with two people who are very knowledgeable about this topic and i'm on the first introduction of senator claire air she was raised and educated in a champla welfare committee and as vice chair of the government operations committee of the senate she has been an out of sync county senator since two thousand and three and she is married to a physician both she and her husband are health care providers so she has the experience and knowledge of being a provider as well as it from the provider point of view from the billing and administrative point of view in the practice the consumer point of view and the policy point of view when she was first elected claire said she actually opposed any changes to health care in the health care system and through the year is that with learning and getting more information has actually changed her view on that so i'm interested to have her talk with us about that our second guest is robin mont she is the director of health care reform an agency of administration previously it actually right now she coordinates and oversees all of the state's health care reform efforts and prior to that she was working as an attorney for the department for my department of banking insurance security and health care administration other wise known as fish got robin has also served the health and human services committees of the legislature as a nonpartisan attorney drafting bills and has been very much in the planning process for health care reform outside of vermont she worked for the center on budget and policy priorities in washington d c as a senior policy analyst and her areas of expertise include federal and state public benefit programs health care and health care reform and international trade policy and right now robin is the liaison to the newly created green mountain health care board so welcome so happy to have you here in richmond and what i want to do is just to give you the overview that we're going to talk about four different topics today first the kind of broad brush about what is health care the second i want to bring in the questions that individuals have been asking me about you know i'm on medicare and how does that affect mayor i don't have insurance and how does that affect me so i have a discussion about that third the timeline and sort of construct for cost for this project to you know where are we at currently where is the development of the knowledge about how much it will cost people and then the fourth category will be kind of the impact or the decision making of individuals about their personal health care decisions and how that plays into the discussion about how much health care reform so to start with and i think we're going to ask robin about just the overview for h access to high quality health services to ensure that our health care system as a whole is sustainable because we know that health care expenses are breaking the bank here in vermont as well as nationally third to ensure that we improve the health of vermonters which really is a collaborative effort between individuals and their providers and force to ensure that we pay for health care in a transparent and fair way so that's that's what we're shooting to do there's a multi stage process that's underway the first main step that vermonters will see will be the called the vermont health benefit exchange and the vermont health benefit exchange is an online web site as well as a call center and other forms of in person assistance where people can shop for health insurance and it will connect them to health coverage and that will be for individuals who don't have coverage through their employers and also for small businesses and that starts in january twenty fourth teen that's the step one the second step the longer term plan is to move towards a universal system where all vermonters will have coverage regardless of whether their employer offers coverage so they'll have coverage as vermonters and that that transition to a program called green mountain care will take place after we're able to get some federal permissions and move so it really did not have a huge impact on the state of vermont because we had moved forward and had started planning for the health benefit exchange because of the tight time frame we felt like a lot of what we were building in that model would be helpful in our longer term goal to so why waste any time just move forward and get moving and the supreme court upheld that part of the law the supreme court did strike down one part of the affordable care act that's the name of the federal law  that was passed by congress in two thousand and ten and that was what for many states would have been a medicaid expansion up to what a certain income level many fake do not provide health coverage to their citizens  in less you're very very very very very very poor at like seven thousand dollars a year income or less in vermont we have moved towards universal coverage over the past twenty years through medicaid expansion so we already cover everyone under the medicaid expansion so for us we've already done it so i had no impact because so i am approached by many individuals a lot of people here in richmond businesses right here in town that are really interested in how it's going to impact them and i thought that would be the a really wise use of our time to just talk about let's take an individual scenario and say what would it mean for someone who owns a small business who has a few employees who does not now offer health insurance perhaps really so for small businesses with fifty employees or less in two thousand and fourteen when the health benefit exchange comes on line their employees will be able to shop for insurance through that exchange as could the small business itself but if i'm not offering insurance today it's probably because i i as a business owner can't afford that cost and we know that many small business owners struggle to offer insurance for their employees and often the coverage that they're able to offer are really high deductible plans five thousand six thousand dollars deductibles we even have some plans with twenty five thousand dollars and there's one with a hundred thousand dollars deductible so in twenty fourteen the small business owner can assess their options and make a choice as to whether or not they want to start providing for their employees they probably won't make that choice if they're not doing it today because of the cost factor and if you're an employee the benefit for you is that you can go in you can look at apples to apples comparisons of different insurance coverage is from different insurance companies and pick the one that's best for you and your family the other cool thing about the exchange is that it comes with some federal tax credits which will be paid on a month to month basis so that it will in effect make your premium less so if you're under about ninety two thousand a year for a family of four you could be eligible for some assistance in paying for the cost of insurance so that's really good news for miners and what about  large business owners so the blue cross blue shield providers they have the kettle black women their employers are all happy with that plan what will it mean to so in twenty four again the expander the federal law the exchanges only open to employers of a certain size and vermont had a choice of between one hundred employees or less or fifty and vermont chose fifty employees or less because that's how things are today so large employers nothing would change for them  twenty four teams if you have a business with one hundred employees or less then you would come into the exchange in twenty sixteen but not before that so no immediate change in terms of coverage for large employers and how about further out like yeah so after we move to a universal system called green mountain care then employers still whether they're large or small always have the choice of whether they want to offer different coverage or not but for their employees they would know that they have green mountain care and because green mountain care will be a publicly financed system a lot of people i think will choose to go that route so again employers still have the choice that's a protection under federal law that they get to choose if they offer coverage but they could choose that their employees could be covered by agreement care and the employer could offer some supplemental benefits for example so the employer can of which can have the choice but do they not have a choice whether or not to provide consumption under federal law employers have the choice to provide or not provide health insurance that's that's true today and it's true until federal law changes which is not expected anytime soon if ever doesn't really a very popular question in the house and county anyway we have an older population but they shouldn't experience any effect i'll still have medicare the program will still work just the way it does now if we have it in the insurance and when we get to universal care in twenty sixteen or twenty seventeen we expected was it would be the same everybody would be paying for the program and they would have to medicare so the concept and the length of people use language the the word single payer and i prefer to think of like a single system because really the reason is it true it's not really a single payer because medicare will still have medicare if you're going on and how technical you want to be about the terminology most people think of switzerland as having a single payer system but they actually have several different insurance pools but they have one administrative system so i think whether you call it single payer or single administrative system i think the concept is we move towards a system for paying for health care in a simplified streamlined way so that we save on administrative costs because of course if you have a computer system in your house and i have one at my house and claire has one of her house we've now paid three times for three systems if we had one shared system it would be less expensive and streamlined and what does it what about people who some people have insurance in my family you know my one son has like a poor h s a which is all his employer can do and another has a cadillac premium program which comes from an employer and then my daughter who's a farmer has no insurance because she's heard the she has an employer that provides so if people are happy with their insurance or are not happy with their insurance if they have insurance already will they have an option for something else like in the exchange that there are three different scenarios and  thousand in the dream care program the green mountain care program they would all be eligible for a really good program that's that's one of the four or five or six conditions under which will move to universal care the plans are really good the they're comparable to what state employees have right now so they would all be eligible for that and they would all pay for that but the payments would likely be lower they'd be paying it through their taxes or you know we haven't got that one yet but everybody will be everyone will be insured everyone will have it because everybody's paying the cost should be less and because we're doing these administrative change in the way we run the internes programs and pay for health care the car should be less there's this an element of cost savings  you know that thanks from the person's perspective but the other initiative that the green care board is working on is they're really focused on cost and cost containment in the system as a whole and think about how many times have you gone to see your primary care doctor they've ordered a test that they needed to diagnose you reviewed and said you really need to go to a specialist so you go to the specialist specialist and get the tests and then they redo the test say now you've just done to test for one problem and all of that is redundant so we need to improve the way things work so that it is easy for providers to work together and to be able to share that kind of testing and other types of here because right now they get paid for services they provide they don't really nobody pays them to look at you as a whole person and say what do you need to be healthy and if we can shift the way our higher cost less necessary care to really important primary care and in specialty care and i just looked at one of the fears that people have about this whole way of doing business saving money and how we do business that physicians and health care providers nurses people who might clinics would be paid less and that somehow we would be able to attract health care providers and that is one of the five or six basic tenets that we have and that is that we must pay good wages to those people to attract them to get them to come here and cause him to stay here and in canada for example they already make more than most doctors make of them on here to get their salaries are are are very good so it wouldn't be heading the way we're paying when becoming necessarily reimbursement for doctors who would be changing how we pay them and what we pay for it would be for keeping them healthy as opposed to dealing with them that when they have a strep throat that sort of thing so it is a blueprint to create advance practice primary care medical which basically is a fancy way of saying paying doctors to be able to look at the whole per se they connect the patients to community health teams to help with some of the needs and prevention that will keep them healthier but which primary care docs don't necessarily have the time in their schedules to provide so one example i have high cholesterol and the way i manage that cholesterol is through diet and exercise and so for me it was very important to be able to talk with a nutritionist because you know i know how eat healthy but i don't necessarily know how to be healthy for high cholesterol you know so it's and you can say well you lower fat and that's sounds simple but when you actually try to do it day to day you don't even realize so having this kind of support services to educate you is the patient so that you know what you need to do to keep yourself healthy is really important  blueprint is moving in that the whole idea is to provide a system three hundred sixty degree system that takes care of the person as a whole from top to bottom getting where they need to be doing what they need to do having them take more responsibility for their own care and follow up on a plan and report in how they're doing it really it it is producing very good results we need a little bit longer to look at the money aspect of it but it's producing very good results  so what about this whole question of the cost like there's a cost side a lot of levels there's the system cost and then there's cause that we were trying to duplicate procedures how is it just from a high level how is that from a health care reform working to decrease the cost so a lot of the focus on cost containment is that the green mountain care board and they're doing that in a number of ways first of all they have now final authority over insurance rate increases so if the insurance company comes in to the government and says i want to increase my rights that needs to go to the board and they have a broader  the way insurance rates you still look so for example used to be what the government looked at with an insurance rate is how what did the insurance company's bottom line look like was that a reasonable request what the board can now do is look at it from an affordability perspective and a broader based health care reform perspective and not just that at the soleus solvency levels so that could be one way to put more pressure on the system to keep costs down so that's just one example they  also work on other regulatory mechanisms to look at the system as a whole as well as looking at new ways to pay providers they have a couple of it's going right now with them in different areas of the state to experiment experiment with paying for total care for raavan lines or there but it was a take to keep us healthy on average and let the caretakers make that work because the expense of if you're paying for each procedure on the big incentive in the current system is for physicians to do more to make more money rather than to be really focused on the field that's also the incentive from the consumer's point of view and in some respects you only go if you're sick you only go if your throat hurts or you have a high c very whereas you might be more inclined to go to figure out how to be right for high cholesterol absolutely and i think the other thing that is prevalent in our nation really is that we think at least here in our country we think of going to the doctor we want something facts and if you want something facts doing more is better right but what we actually know from the data is that in the areas with really high utilization of health services the outcomes are worse so we know that both from something called the dartmouth at west which looks at medicare spending nationally and you can go in there and plug in your local hospital and see how that hospital spending compares to other places and how the outcomes compare so i think part of what we as a need to do as a community is start thinking and understanding more about how more is not better than health care in fact it's often worse for you that is that is one of the key piece that we've written into the health care bill that has to be based on real evidence so you know a lot of times we're all sure we know how it works and this always works we keep doing the same thing but if you stand back and look at the bigger milestones coming up and all this goes through them chronologically it are that for green mountain care the long term plan we the administration have a two financing plans actually due to the legislature in january of two thousand and thirteen and the the one that i think has gotten the most press is the financing plan for the single care system which will come into place later later on when the sixt twenty seven and the purpose what that financing plan will look at is what should the benefit package look like they're all first the legislative parameters around that so it's not a free wheeling analysis it's fairly contained but looking at it what kind of dentals and vision and what do you do about long term care and then looking at what kind of contributions should people have individually looking at how we would pay for it for a public system so which kinds of taxes they make the most and probably will have more than one scenario there they will look at that would make sense and also then what's the economic effect on vermont as a whole from different scenarios so it's legislation sets up a process before we move to the big change in the system in twenty six years twenty seven and that is that this financing plan has to come in and the financing plan would have some sort of financing would have to be passed to some point by the legislature and then the green mountain care board also has an analysis that they would do five or six factors i think it is to ensure that the plan is a good plan that it's fair that vermont will legislature's goal and then there's also another check in the system which is that the joint fiscal office which is the model nonpartisan money office that work for the legislature they look at the assumptions that the board makes to make sure that  legislature understands whether those were valid assumption so it's not a done deal there are several steps left to go and i think it's just important to allay people's fear of change that you know we're taking a really slow thoughtful process for the last question we were wanting to touch on this this whole idea of how an individual personal choices and our individual responsibility for our own health and how that actually impacts the whole system or is that an appropriate discussion to be having in health care reform like do i exercise my good being with my eating or i think it is for for a lot of reasons i think we've done depending on how old you are the culture has been that you had your healthy health as a default position you don't have to do much about that and you go to the doctor when you're sick and now we understand that there are ways of there are a lot of environmental factors but there are ways things that we should do to stay healthy and in the new system looking at the blueprint for how and howard pay doctors and everybody paying into the system i think that individuals will have a have more of an investment in the system because everybody pays and everybody's covered but also the way it's designed is that people with high cholesterol would not have to hope they can figure it out on them on their own how exactly they should adapt their eating habits they'll be able be calling out and say let's let's sit down and write down everything ate yesterday let's see this for another or you know where are you usually lunch those kinds of things to help people maintain health and the data shows that that's money wise it's a very effective way to prevent illness homeless is more expensive now so i think personal responsibility is going to become is going to be a must because the patients will be part of the team that's part of the product  if you look at the population health issues in vermont today obesity is right out there and obesity is not something you can go to the doctor and get a pill to fix it requires hard daily choices on an individual basis and a  lot of support and a lot of support a lot of support it's not easy i think the other piece of information that i think is sometimes helpful on this topic is if you look at the evidence around health and what are the terminus of health what makes people healthy  there's a pie chart there in the literature which shows that ten percent of your health is the health care system you get access fifteen percent is your environment and you i think another fifteen percent is your socio economic circumstances were you born rich or poor something you don't really have control over forty percent is your behavior and thirty percent of your genes so while a big chunk of that are things that you