Vermont is experiencing some of the problems that all state-level single payer efforts face. They are hindered by a complex quagmire of federal and state programs, laws and regulations, plus pressure from vested interests who would prefer other options, if not the status quo.

Those of us who are quite knowledgeable about health policy are often astounded by not only the amount of misinformation about health reform, but also by the self-confidence of those who are often the least well informed. This new California Field Poll provides some interesting observations in this regard.

Under Republican control, the House Budget Committee proposes phasing out the traditional Medicare program and replacing it with an insurance exchange offering a variety of private plans with the government’s role limited to offering a premium support (same mechanism as a voucher) to apply toward the purchase of a plan. This converts Medicare from a defined benefit (specified benefits are covered) to a defined contribution (the premium support being a specified dollar amount contributed toward the purchase of a private plan).

Accountable care organization (ACO) is a concept that grew out of concerns over excessive levels of spending for health care that is often only mediocre. It was thought that health care professionals and facilities could organize themselves into integrated organizations through which they would become accountable for both the cost and the quality of health care.

Conservatives have framed the problem of our very high health care costs as being due to a lack of sensitivity of health care prices by patient-consumers who are simply demanding too much care. This is been repeated so many times that moderates and liberals are now parroting the same message. They profess that patients must face large deductibles, co-payments and coinsurance if we are ever going to get our health care costs under control.

Because of market dominance, Blue Cross Blue Shield plans have been able to negotiate lower hospital prices in many regions throughout the nation. Hospitals, in turn, have been able to negotiate higher prices for insurers that do not dominate the markets, resulting in higher premiums and consequently less ability for the smaller insurers to penetrate these markets. The U.S. Justice Department quite appropriately is investigating these agreements.

The Affordable Care Act has established silver or bronze plans, with low actuarial values of 70 or 60 percent respectively, as the new standard for plans to be offered in the insurance exchanges. Since the plans will have to provide a mandated basic level of benefits, it is inevitable that they will have to include high deductibles since an average of 30 to 40 percent of the costs of health care will to be shifted to the patients to pay out of pocket. Is the wholesale adoption of high-deductible health plans a wise policy decision?

Accountable care organizations (ACOs) began as an abstract concept of integrating health care providers into a not-yet-defined entity that would be rewarded for improving quality and reducing costs. Without knowing what they were, Congress included them in the Affordable Care Act (ACA). Dartmouth’s Elliott Fisher, who was one of the first to promote the concept, now says that “there are some really important questions about whether this will work.”

The most important innovation in coverage established during the managed care revolution was that private insurers could contract with physicians and hospitals to establish networks of providers with agreed-upon payment rates. Part of the backlash against managed care was that patients wanted the freedom to choose care outside of the networks, and they wanted their plans to pay for that care. So what did the insurers do to control fees and prices for services rendered by providers who had no contractual obligation to the insurers?

What is the current state of the development of health information technology (HIT) and electronic health records (EHRs)? Quoting from this NEJM article, “Today’s EHRs do not sufficiently support aspects of care delivery that are vital to improving care and controlling costs.”