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Healthcare Update

by Tom Huebner, President & CEO, Rutland Regional Medical Center

As president and CEO of Vermont's largest community hospital, I am Tom Huebnerfortunate to be involved with, and included often, in conversations relating to policy and regulatory matters on healthcare. I know healthcare and policy issues can be confusing, as well as overwhelming, so when there is information I think the community should know about, I will share it here.

An informed community is a healthy community.

A Percentage of Worry — March 2, 2018

The Green Mountain Care Board (GMCB) has not yet sent out their guidelines for the 2019 budget but there has been some talk of very low thresholds. This means that the GMCB would limit our hospital’s net revenue growth to perhaps as low as 2.36%. That means that revenues, despite patient volume, can only go up the 2.36% and that, accordingly, expenses can only go up that much as well. In my view this would be very, very, very difficult to achieve. Hospitals are finding costs, including labor costs, increasing more rapidly and certainly more than the 2.36% being discussed by the GMCB. In addition, there is increased demand for services here at Rutland Regional and we are seeing market shifts to our hospital all the time. None of these realities are reflected in this proposed 2.36% target. In years gone by, the target has been 3% with 4/10th of a percent available for investment into healthcare reform. Though this was a tough standard, Rutland Regional worked hard to achieve it. We are trying to make the case that this standard should not change and, if in fact it did, it would weaken our healthcare system considerably and negatively affect the programs and services we provide to our community. We have made this point to the GMCB several times now, as has the Vermont Association of Hospitals and Healthcare Systems, and I continue to hope that they are listening. I cannot stress enough how very important it is that the target goal is not diminished. I am convinced that Rutland Regional would have to consider whether we could continue all of our programs for all of our patients if the GMCB imposed this lower limit. We want to improve healthcare and health outcomes for our patients and our community and the lowering of the target in this way would make it very difficult for us to do that. Stay tuned

Loss of Individual Mandate Concerns Officials — January 6, 2018

Republished with permission from the Rutland Herald

Loss of Individual Mandate Concerns Officials

By Patrick McArdle

Vermont health care experts say they will watch the Legislature this session, ready to provide any expertise, as the state responds to the latest changes on the federal level.

The recent passage of tax reform legislation has raised concerns about health insurance because it includes a repeal of the federal individual mandate that was part of the Affordable Care Act.

Thomas Huebner, president and CEO of Rutland Regional Medical Center and board member of the Vermont Association of Hospitals and Health Systems, said Vermonters might not see a difference in health insurance costs right away.

But he said the loss is “not helpful to sustaining a healthy insurance marketplace.”

This is a change that I think will not have an immediate impact, but over time could significantly weaken the health care system,” Huebner said.

Under the mandate, Americans were required to have a minimum level of health insurance or pay a tax penalty. Huebner said that was important for encouraging younger, healthy people to have health insurance.

There’s a value, I think, in everybody having health insurance in case they have an accident, bad things happen, but beyond that, having young, healthy people in the insurance pools keeps the cost down for everybody else,” he said.

Without healthy people in the insurance pool, those buying health insurance are those who expect to need it to cover medical costs, leaving a system that could be paying out more than it takes in, resulting in higher premiums.

Huebner said that makes affordability difficult, especially for people in Vermont Health Connect, the state health care exchange.

Then, of course, you get to a point where that’s not sustainable and the whole thing has the potential for crumbling,” he said.

Huebner said he hopes he’s wrong and healthy, younger Vermonters will still buy and retain health insurance.

The issue is one the Legislature is expected to take on during their current session. But Huebner, also a member of the American Hospitals Association, said no legislators have asked him for suggestions.

They’re just beginning to wrap their heads around it,” he said. “We have not had a chance to talk about it yet, but people like the hospital association and Blue Cross/Blue Shield of Vermont and people like me will provide input into that process.”

Huebner added: “I am hopeful that Vermont will find creative ways to continue to be able to encourage people to buy insurance. I do believe it’s in all of Vermonters’ best interests to do so.”

Kevin Mullin, chairman of the Green Mountain Care Board and a former Republican state senator who represented Rutland County, said the board decided Tuesday to compile a report – working with representatives from the insurance companies, the hospitals, medical societies and the Vermont Department of Financial Regulation – on the cost increase caused by the loss of the individual mandate.

The Congressional Budget Office said it could be as high as 10 percent,” he said. “I don’t think that after that discussion Tuesday that anybody in Vermont believes it will be a 10 percent impact, but we’re trying to get firm ranges of numbers.”

Mullin said the report, which could take a week to a month to finish, would attempt to provide valid estimates on how many Vermonters might lose health insurance and how insurance rates could be affected.

I’m sure that’s the type of information the legislators are going to want to know,” he said.

Mullin said he expects Vermont might not bear the brunt of the changes.

Going into the individual mandate, we had more people covered than a lot of other states. I suspect that Vermont will be less impacted,” he said.

Huebner encouraged Vermonters to stay involved and aware of proposed changes, although he said the state’s national delegation is already very supportive of the positions of many state and national medical organizations.

Mullin said he has been a supporter of an individual mandate since the Legislature was discussing Catamount Health in 2006.

I support it because, people in Vermont, if they go to a hospital, they’re not going to be denied care,” he said. “I don’t think that it’s fair for anybody to be a free rider on the system.”

A Legislative Breakfast — December 7, 2017

This past Tuesday I welcomed over a dozen legislators representing our Rutland delegation for a conversation about the hospital, about healthcare in general and, more specifically, about mental healthcare. There are changes needed to our mental health system and I urged our delegation to take appropriate legislative action in the year ahead. We talked about how we need to bolster the community aspects of our mental health system. Currently, patients wait in our Emergency Department for way too long for an acute psychiatric bed. The reason for the wait is not that there are too few psychiatric hospital beds. The problem is our inability to discharge patients from the inpatient Psych unit to community resources. The length of stay for patients in the Psych unit is far, far too long. This is true for every psych unit in Vermont. The reason we can’t discharge on a timely basis is that there’s no place to send people who need further care at a subacute level. Some patients need intensive outpatient services, some need supervised residential or perhaps secure residential services. There are a variety of community services that are missing in order to move these patients toward services that can help them further. The overarching message to our delegation was that we will never get over the mental health crisis until these issues are rectified. I must say that our local delegation was very receptive and I am hopeful that there might be some action on this very critical piece of healthcare in the legislative session ahead.

Taxes & Healthcare — November 27, 2017

There are some troubling components in the proposed tax bill that is before Congress right now. There are really two areas of concern that will have some impacts on hospitals including Rutland Regional Medical Center. The first concern is the ongoing debate about whether Congress should eliminate the individual mandate for health insurance. ­Americans in general don’t like to be told what to do, and certainly there are days I feel like that, but the mandate is a penalty if you don’t get health insurance and it is vitally important in stabilizing the health insurance marketplaces. Who decides to not get health insurance? The young healthy people who think they don’t need it. The problem is that if all the young healthy people leave the Exchange, it drives up premiums for everybody else.

The second impact of the tax bill would make it much more difficult for non-profit hospitals to borrow money at low costs in order to do facility campaigns. This change in the tax law would have dramatic effects on hospitals over time. We use tax exempt financing to pay for large buildings that help us provide the services a community needs and requires. If this tax exemption were to go away, it would increase the cost of building projects, making it more difficult to realize. The American Hospital Association is actively communicating these concerns, among others, to lawmakers and hopefully, we will win this battle as well. We should know by Christmas whether we’ve been successful.

It is YOUR Healthcare — November 13, 2017

We have been encourage everyone to enroll on the Healthcare Exchange now through the cut-off date of December 15, 2017. We want to encourage our neighbors, friends, family members and others from within and outside of the Rutland community to enroll for three reasons.

First, we want you to have healthcare coverage. We know health is improved when people have access to care and they have insurance. It is in your best interest to have access.

Second, financially it supports the hospital’s programs and services. Of course the hospital takes care of anyone who shows up, but in order for us to continue to provide the care we do, and the programs and services associated with that care, we need to maintain financial strength.

Third, we are taking the bull by the horns and promoting the enrollment period because the Federal Government is not. The Federal Government has drastically cut back on their funding of marketing that is needed to encourage people to sign up via the Healthcare Exchanges. We want everyone to know that the time is now to sign up and that healthcare coverage is available to them.

This is YOUR healthcare and your health is important. If you have questions about this, please click through to our Vermont Health Connect information page. Here you will find additional information including important contact options for you to get help in signing up. Use this information for yourself or share it with other people in your family or in your community. Please do what you can to ensure that you, and those you know, find a way to get health coverage.

Harnessing Healthcare — October 30, 2017

In Washington, D.C., the chaos continues. There are two issues that we are paying attention to. The first one involves the 340b reimbursement program and the Federal Government’s desire to change the rule by which Rutland Regional receives reimbursement from pharmaceutical companies. There is a lot involved in this program but without going too deeply into the weeds, it would mean that the hospital would lose $2.8 million a year. The rule, which was established to help make medications affordable for low income patients, is proposed to go into effect in November. We strongly believe that the rule is illegal and that the government doesn’t have the statutory authority to make the change they’re proposing. As a result, the American Hospital Association (AHA) is planning to take the Federal Government to court to stop the rules implementation. Rutland Regional has volunteered to be one of the three hospitals nationally to be what is called a “Named Plaintiff.” This means that the facts and data from our organization will be used as an example of all hospitals across the country. We will seek to have an injunction to stop the implementation of this proposed rule immediately. If in fact it goes forward, we will then seek to have it overturned permanently. We believe we have an excellent case.

The other issue is related to the Health Care Exchanges. You may have read or heard that the administration in Washington, DC has said they will stop making the so-called CSR payments. These payments are used to subsidize insurance for lower income people on the Health Care Exchange. In many states, including Vermont, if these CSRs are eliminated it means two things:

  1. Over time it means that the exchange will no longer be financially viable as a whole, and
  2. That these lower income people in particular will not be able to afford healthcare coverage.
For Rutland Regional the effect will be an increase in bad debt and an increase in free care. Just a 1% increase in bad debt and free care at Rutland Regional would cost the hospital $5.3 million a year, a very big number indeed. Needless to say, we will oppose this in every way possible, politically and if available, legally. This is important, first and foremost, to ensure coverage for our patients so they can get the care that they need. But secondly, the loss of $5.3 million a year would cause us to have to examine our programs, and perhaps cut back on what we offer our community. That is not what we desire to do at all. Stay tuned as this evolves. This one will take more time than the 340b issue and will probably evolve over the next year as it is a much larger and more complex issue. I hope that cooler heads will prevail in Washington and that a bi-partisan solution can be agreed to. Our health depends on it.

Once a Bad Bill, Always a Bad Bill — September 26, 2017

The US Senate is set to once again vote on another version of “Repeal and Replace” in an effort to end the Affordable Care Act. It is unclear at this writing whether the Congressional Budget Office will have been able to score it sufficiently or if the Senate Parliamentarian will allow a vote. What is clear, however, is that an attempt will be made to have a vote. They need to have 50 senators plus the Vice President to vote in favor, and though it will be close, it seems it will not pass. If this version of “Repeal and Replace” were to be passed, Vermont would lose tens of millions of dollars of Medicaid funds between now and 2026. After 2026, there would be even greater uncertainty. The American Hospital Association, the Vermont Association of Hospitals and Health Systems, and I, do not support this version of the bill for many reasons and it will certainly have a negative effect on healthcare systems, and therefore patients, across the country. Stay tuned for the results.

2018 Budget is Approved — September 19, 2017

As we had hoped, our budget for our next fiscal year was approved by the Green Mountain Care Board (GMCB). They essentially approved our budget “as submitted”. This is great news to be sure, and a testament to the hard work and thoughtfulness everyone here put into creating our budget. We were both fiscally conservative and realistic in this budget and the GMCB, by way of their approval, recognized this. October 1 marks the beginning of our next fiscal year, so we are prepared to move forward with uninterrupted services to our community.

In 2019 we will have new challenges and that revolves around the All-Payer Model. To go forward we need to be in concert with our community partners which includes Community Health Center of Rutland Region (CHCRR) and Primary Care physicians in the area. At least half of them must participate in order for the All-Payer Model to work. Philosophically I believe the All-Payer Model is the right thing to move toward, we just have to ensure that the details are right.

Making our Case for Sustainable Care — August 31, 2017

Earlier this month I presented our 2018 budget at a hearing before the Green Mountain Care Board (GMCB). We testified for about two hours, went through our materials. I reiterated that in the past year and a half we voluntarily made three rate DECREASES as a response to the revenue caps GMCB has set forth. I explained that our revenue was up during that time because of an increase in market share, a decrease in bad debt and a decrease in free care due to the Affordable Care Act. Since then though, our market share has leveled to expected volume, our bad debt and free care are increasing, and Medicaid reimbursements are flat. I also noted that only 30% of our payers are commercial which leaves 70% falling into the Medicaid, Medicare, bad debt and free care categories. I believe we made our case well and that they better understand the financial healthcare landscape here at Rutland Regional.

They did have questions. There were plenty of questions about cost and what we can do to reduce it further. There were questions about whether or not we were committed to healthcare reform. There were questions about pricing and quality. And though the Green Mountain Care Board gave us high accolades for our work and our responses, I still worry that they might arbitrarily cut our budget. I hope I’m wrong. We were very careful to prepare our budget within the guidelines that they have established, and I am hopeful that they will find that to be sufficient. At the hearing, I made it clear to them that if they were to request further cuts, we would have to cut programming and services here at the hospital. That reality seemed to have resonated with them. The GMCB makes their ruling in mid-September so stay tuned.

Watch the early part of Tom's presentation to the GMCB on August 17, 2017>>>

A Balancing Act — August 14, 2017

This Thursday, August 17, at 9:10am I will go before the Green Mountain Care Board (GMCB) to make the case for Rutland Regional Medical Center’s 2018 budget. The hearing before the GMCB is a public hearing and I encourage all who are able to attend. The GMCB is a five-person panel that works to regulate the cost of healthcare in Vermont. At this hearing they will listen to presentations from several healthcare systems (Rutland Regional, Brattleboro Memorial Hospital, Southwestern Vermont Medical Center and Grace Cottage Hospital) to determine if the budget requests are warranted and whether or not they show some financial restraint. The panel will take the information presented and rule on the proposed budgets in September. I believe our proposed budget is consistent with the requirements they provided to us in advance, so I am hopeful that we will get full approval.

Creating a budget is a balancing act and this has always been true, but this year finding the balance is a bit more challenging. Certainly Congress’s struggle with the Affordable Care Act and their unsuccessful attempt to repeal and replace it, has added to the uncertainty for hospitals. There have also been changes in the State’s Medicaid reimbursement. That aside, we feel we have done a good job of meeting the requirements the GMCB provided to us in advance.

We consider many factors when making a budget: CMS (Medicaid/Medicare) reimbursed payments, 340b drug discount program, insurer rates, the viability of the ACA, the amount of uninsured individuals in our community, the amount of free care we will have to provide, the amount of bad debt we might incur, etc. We pull all these factors in to come up with a budget that will satisfy the requirements of the GMCB while still allowing us to remain financially sound. Providing high-quality care to our patients every single day continues to be our primary goal, regardless of the political forces and pressures that swirl around in healthcare.

A "Stay" for the ACA — July 31, 2017

It appears that the attempt to overturn the Affordable Care Act has failed. Last week the Senate was unable to pass any of the bills that were proposed but questions remain. What comes next? What things might transpire? I think we might look for two themes.

  1. For those trying to overturn the Affordable Care Act, I think there will be a period of grieving in all of its stages. I believe that will carry through late fall and perhaps into winter. At some point I remain hopeful that there will be a bipartisan effort to fix some of the things that are, in fact, damaged within the Affordable Care Act. We need to ensure subsidies continue and we need to stabilize the insurance marketplaces. Hopefully, in the spirit of bipartisan cooperation, our Congress can come back to that important work.
  2. Revenge is also a worry. I do think there will be attempts by the Executive branch to cut funding to programs that sustain hospitals like Rutland Regional. We’ve already seen some action on reducing 340B reimbursement (a drug discount program for outpatient drugs) and we may see other activity as well. Whether it is successful or not, none of us can be sure. Healthcare systems throughout the country have many friends within government who will try to help in this regard. Certainly, here at home, we have the support of the entire Vermont Congressional delegation as well as the administration in Montpelier. We will be counting on them in the weeks and months to come.

So, for now it looks like the healthcare discussion will take a break, much like Congress as they head off for their August recess. In the meantime, we will continue to do what we do best and focus on providing the best possible care for our patients.

The Seesaw Continues — July 18, 2017

The past week or so has been full of a bit of back and forth with regards to the Senate’s recent iteration of their proposed healthcare bill. The success of this version was questionable from the start. The slight changes they suggested did not change the substantial cuts in Medicaid and the subsequent losses on two fronts:

  1. Hospital Systems would be challenged to survive and provide adequate services to patients with the loss of Medicaid funds and
  2. Millions of the most vulnerable and needy would lose healthcare coverage.

According to the American Hospital Association, Rutland Regional Medical Center alone would lose $190 million in revenue between now and 2026 if the bill, as proposed, was passed. Clearly programs and services in our organization would have to be reworked to sustain a cut of that magnitude. As it stands today, the bill does not have enough support in the Senate to pass. As of this writing, the Senate Majority Leader, Mitch McConnell is proposing a complete repeal of the Affordable Care Act with no replacement. This is highly unlikely to pass. In the end a bipartisan approach is needed. Regardless of which way the seesaw sways, all of us at Rutland Regional continue to be committed to delivering the best possible care to our patients.

VPR Interviews Tom Huebner — July 12, 2017

The Senate Republicans new healthcare bill could mean a $19 million a year loss in federal reimbursements to Rutland Regional Medical Center.

Listen to the VPR interview with Tom Huebner about the effects of the currently proposed health care reform bill.

VPR Logo

Bipartisanship is the Answer — July 3, 2017

The Legislature in Washington, D.C. is now in recess for the July 4th holiday, returning on the 10th of July. The Senate left our nation’s capital without passing a bill to replace Affordable Care Act, also referred to as "Obamacare." This failure has brought some relief to us, but it is temporary relief at best. Make no mistake, the Senate bill, as written, would have seriously undermined our organization and our ability to deliver the quality care we are committed to delivering to our community.

So now what? Certainly the members of both the House and the Senate are hearing from their constituents during this recess, and we’ll have to see if they have heard anything that might affect what they do next.

I believe that there are three possible ways forward:

  • First, the bill may come back after the 4th of July with some slight revisions and move forward in a way that I do not yet see, but it is quite possible. Senator McConnell is a very capable tactician. If the bill changes only a little it would still not be good for Rutland Regional and our patients.
  • The second possibility is that they do nothing. That too is really not a great outcome since there are fixes to the healthcare exchanges that really need to be made. This is especially true in other parts of the country where there are very unstable insurance marketplaces. Some of the fixes will indeed require Congressional action. I hope doing nothing is not the course.
  • And then, there is the third opportunity, perhaps to do something on a bipartisan basis; to do something that does fix the exchanges and repair parts of the Affordable Care Act that could really use improvement. Wouldn’t it be great to see some bipartisan activity? I fear that if we do not get to a level of bipartisanship, that we will keep rocking back and forth between two extremes.

We’ll see, of course, how this plays out. In the meantime, the right thing happened last week. People slowed down and are now reconsidering how to move forward. I certainly hope that fair and effective progress can be made. We shall see.

Awaiting Impact of the New Healthcare Bill — June 26, 2017

Last week, the Senate bill on changing the Affordable Care Act was introduced. Regardless of one’s political position, make no mistake, this bill will have a dramatic effect on the number of people covered in Vermont, and it will substantially reduce Medicaid reimbursement. We are all awaiting the Congressional Budget Office to "score" this legislation to see exactly how large this impact might be. Senate leadership is pushing to have a vote later this week. If they vote "yes," and then the House accepts that vote later in July, this will have substantial impact on Rutland Regional Medical Center in the years to come. This impact will be negative and as a community hospital we will have to find ways to serve our community while remaining financially sound. This is the cold hard reality of not just Rutland Regional, but of countless hospital systems across the country. As your community hospital, we join the Vermont Association of Hospitals and Healthcare Systems and the American Hospital Association, as well as our healthcare colleagues across the country, in vocalizing our collective opposition to this bill and any bill that hold provisions that will seriously affect the health outcomes for our respective communities. The Vermont Congressional delegation has aligned their messaging with ours and will oppose this bill. We hope that Congressional leaders across the country will hear from their constituents and that they will encourage their legislators to oppose this bill as well. This is a big week in healthcare. Stay tuned and stay engaged.

A Sobering Assessment — June 19, 2017

I spent the last two days of last week at the American Hospital Association Regional Policy Board meeting. It was sobering. The AHA believes there is a real possibility that the Affordable Care Act will be repealed and perhaps replaced. It is not certain that this will occur but it is a significant risk. The Senate hopes to pass their bill before the July 4th recess and they will then tell the House of Representatives to either take it, or leave it. If It passes the Senate it will be with the slimmest of margins. It became further clear to me that not only would Vermonters lose coverage if it passes, but it will also impact our reimbursement. I estimate that 60,000 Vermonters would be without insurance by 2020 and that our Medicaid reimbursement could fall, perhaps as much as 25%. Again, the details are not certain. There is a lot of negotiation still going on, but that would be a devastating amount. A 25% reduction in Medicaid reimbursement would be about 8 million dollars. It reminds us, yet again, of the need to support the Affordable Care Act, first for the good of our patients, but second for the good of our organization and the care we provide for our community.

A Balance of Services — June 15, 2017

Vermont’s health care system is one of the most regulated in the country. This framework has helped to contain cost and expand health care in a thoughtful and responsible way. The Green Mountain Care Board (GMCB) is responsible for determining if new health care facilities are truly needed to enhance the health care system for all Vermonters.

The addition of an ambulatory surgical center (ASC) in Vermont like the one being proposed in Chittenden County is precedent setting. If one is approved in Chittenden County I worry that Rutland would be next. For mid-sized and critical access hospitals in Vermont, which operate tight financial ships, there is little margin to manage the impacts of new and unregulated competition.

On behalf of the hospital I lead in Rutland, I am concerned about the effects an ASC would have on our hospital and community should one eventually be approved in our area. ASCs do not take all comers like Rutland Regional does. At Rutland Regional we accept all patients, no matter their ability to pay. This means that often we provide free and uncompensated care to our community. This is what hospitals do—this is what taking care of a community’s needs looks like. ASCs do not have to be up and running 24 hours per day, 365 days per year to meet all the needs of the community like a hospital. They can focus on only the easier, more profitable services. That makes it very difficult for a community hospital to survive.

Unlike Vermont’s hospitals, the ASC would not be subject to the annual tax that funds our state’s Medicaid program. The ASC would not answer to the GMCB’s budget process or financial oversight; nor would it be subject to state licensing requirements or reporting requirements.

The fact is, Vermont has limited the amount of capacity in the system through tough but fair regulation as a way of containing costs and ensuring access. More buildings, especially unnecessary ones, equal more cost. In a small, highly regulated rural state, an investor-owned surgical center would absolutely affect the strength of some hospitals and the services we’re able to provide. In Rutland, we have expanded our capacity to meet demand and done so within the confines of the CON process. We had to prove that there was a genuine unmet need in our community. Any ASC should do the same.

27 years ago, when I joined Rutland Regional, the vast majority of services were inpatient. Now 60% of the care we deliver is on an outpatient basis. In 1990, a patient receiving a total hip replacement would be in hospital 12 days. They are usually now here for 24 hours. Technology improvements have driven many of these changes. But the needs of our community have changed as well. We now provide a wide array of behavioral health programs like the West Ridge Center for Opiate Addiction. Not all of these services are financially self-supporting, but our community needs them to be provided. To make investments like this for our community we also must be allowed to balance them with services like ambulatory surgery.

Here in Rutland, our hospital is investing in health care reform, addressing the opioid crisis, grappling with symptoms of poverty, and partnering with community providers and other hospitals to expand telemedicine and specialized services for our neighbors living with mental illness and chronic diseases.

There is a tremendous amount of work ahead, but together with our provider partners, state leaders and so many others we continue to make progress. I hope that we fully understand the implications of allowing for-profit surgical centers on all stakeholders before we set a precedent that could have a significant impact on our forward progress.

Protecting Your Healthcare Coverage — June 12, 2017

The political world keeps on churning and changing. The US Senate is trying very hard to complete work on a repeal and replace bill by the Fourth of July recess. They want to have the bill to the Congressional Budget Office for scoring before they depart. A big stumbling block still, is whether they are going to allow Medicaid expansion to continue and to provide adequate funding for Medicaid programs. Some other issues might moderate, but that is the key discussion point at the moment. We believe that coverage of individuals in Vermont and across the country should not diminish. The American Hospital Association, the Vermont Association of Hospitals and Health Systems, and Rutland Regional are all positioning and fighting to maintain coverage for our patients. We believe this is in our community’s best interest and we do this without apology. Please contact one of our State Senators, Sen. Patrick Leahy and Sen. Bernie Sanders, or Congressman Peter Welch, and thank them for their support of these positions and encourage them to keep fighting for your healthcare.

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