Fiscal Fitness: How States Cope

Vermont shares its results, one year after moving toward universal coverage

About 12,000 of the estimated 65,000 uninsured Vermonters now have health insurance who didn't before, as a result of a universal coverage program launched in October 2007. Here are steps that were taken to achieve this:

The 2006 Health Care Affordability Act was passed with the goal of controlling rising health care costs with better management of chronic conditions, and also by making health care affordable and accessible for all Vermonters.

As part of this health care reform, a new comprehensive health insurance plan called Catamount Health was established, including subsidies for all uninsured Vermonters not eligible for existing Medicaid programs up to 300% of the federal poverty level (FPL). State-subsidized premiums are between $60 and $185 per month, depending on household income.

Offered by two private insurers, Catamount Health Plans are available at full cost for $393 a month.

Vermonters must be uninsured for 12 months, although the waiting period is waived for certain circumstances, including if the person lost his or her health insurance because of loss of a job or reduced hours, divorce, death of a spouse, graduation from college, or no longer being eligible on their parents' plan.

"The statute that created this in 2006 defined the benefits package in terms of cost sharing and the services that needed to be covered, so it's very comprehensive and affordable," says Susan Besio, PhD, director of health care reform implementation for the Vermont Agency of Administration.

The program is a public/private partnership. Catamount Health Plans are offered by Blue Cross Blue Shield of Vermont and MVP Health Care in cooperation with the state. The plans provide comprehensive benefits—doctor visits, checkups and screenings, hospital visits, emergency care, chronic disease care, and prescription medicines.

Another part of the new program is providing premium assistance to uninsured Vermonters who are eligible for the Catamount Health Premium Assistance Program or the Vermont Health Access Program (VHAP) to enroll in their employer-sponsored insurance.

"If their employer's plan offers comprehensive and affordable coverage—and we've got specific criteria for those characteristics—and it is more cost-effective for the state, we give them premium assistance to enroll in their employer's plan rather than the Catamount Health Plan or VHAP, our Medicaid expansion program for adults up to 185% FPL," says Dr. Besio.

Before the program was implemented, a statewide household insurance survey was done in 2005.

The survey was conducted to get detailed state-specific information about the insurance status of Vermonters and, if they were uninsured, to find out why. The survey revealed that about half of Vermont's uninsured were eligible for existing Medicaid programs or Medicaid expansion programs, but were not enrolled.

As such, the state decided to create an umbrella marketing name for all of the Medicaid, Catamount Health, and premium assistance programs called Green Mountain Care. It is a comprehensive family of low-cost and free health coverage programs for uninsured Vermonters.

Other Green Mountain Care programs include traditional Medicaid programs, the Dr. Dynasaur program for uninsured kids up to 300% FPL, Vermont Health Access Plan for childless adults to 150% FPL and caretakers with dependents to 185% FPL, and several prescription assistance programs.

"A big effort has been made to re-brand those programs, along with Catamount Health, into the Green Mountain care brand," says Dr. Besio. People are encouraged to call a toll-free number or visit the web site to find out which programs they are eligible for.

A major marketing blitz was done when the program was launched, including television, radio, newspaper and Internet advertisements, and will be done again this fall.

In addition, advocates and outreach workers promote the Green Mountain Care programs through one-on-one outreach to uninsured Vermonters, distribution of materials, and statewide meetings with organizations that serve the uninsured.

"We continue to have consistent enrollment every month. It's decreasing a little bit but not a lot, which is very encouraging," reports Dr. Besio.

She says their 2006 goal was to have 96% of Vermont's approximately 60,000 uninsured covered by 2010.

"We have a significant way to go to reach that goal. We have to get another roughly 20,000 Vermonters enrolled in some kind of insurance," says Dr. Besio. "But we are really pleased that with a brand-new startup of a coverage program, that we are seeing such interest in enrollment in the first 10 months."

Lessons learned

Dr. Besio says Vermont has learned a lot about how to implement premium assistance programs. "For example, it is important to ensure that the program rules allow a seamless transition between the state-subsidized programs when someone's household income changes, so they don't go without health care coverage," she says. "It also is very helpful to work closely with the private carriers who are offering the Catamount Health Plans."

A key part of the program's success is having a single toll-free number for people to call and find out what they are eligible for, and a single web site with a screening tool and eligibility information. The state used an already existing toll-free number for the VAHP program but added additional staffing, up to 40 at any one time, to handle all the Green Mountain Care calls.

Since October 2007, there has been an average of about 200 calls per day about the new Catamount Health and premium assistance programs. "We also are working very closely with external stakeholders and advocates, who themselves have gone out and accessed foundation funding to support our outreach efforts," Dr. Besio reports. "Significant resources were needed to implement these new programs."

The programs are funded partly through an assessment on employers who don't offer insurance to their employees. Other funding sources included an increase in tobacco taxes, some state general funds and some federal matching funds.

While some states have developed more narrow expansion programs in an effort to cover their uninsured, those in Vermont, Massachusetts and Maine were the first and the most expansive.

But whether other states will model this program remains to be seen. Dr. Besio says it depends largely on how much federal support states receive.

"Given the economic environment right now that states are struggling with, I don't think there will be a lot of expansion programs," she says. "However, with a change in the federal administration with more support for state's efforts, they very well could, if and when the national economy turns around. In the meantime, Vermont, like every other state, is struggling to make ends meet. Only time will tell if it can maintain the premium assistance programs like they exist today."

Contact Dr. Besio at (802) 828-1354 or