The argument for a health care system in Vermont
Whenever Vermont health care is mentioned, what is really referred to is an arrangement that does not rise to the level of a system. This arrangement is ineffective at controlling costs and incapable of seeing to it that the expenses of medical care are paid for, or of seeing to it that all Vermonters obtain needed medical care in a timely fashion. It therefore falls far short of anything that can be reasonably described as a health care system.
At the same time it is widely acknowledged that Vermont's medical facilities and medical care are of high quality.
There are troubling signs, however. One is cost shifting. Cost shifting is a way of unburdening financial strain in one part of health care, say a hospital, by shifting it to another, say a private insurance company. Costs, once shifted, do not disappear. Ultimately, they reappear as higher private insurance premiums and higher public assessment, taxes and the like.
Virtually all of us, including the Vermont medical community, regard health care as a public good. This is especially true when we ourselves are in need of medical attention.
Most of us would say that what we want from health care, other than our free choice of doctor, are high quality medical facilities (hospitals, physicians' practices, nursing homes, allied health facilities, etc.), some assurance that those services will be there when we need them, and affordable medical care.
For a number of years, rising costs have diverted our attention from these reasonable expectations. So much so that our discussions of health care have obscured the idea of it as a public good. Our predominant focus has been on ways to ease costs or get around them somehow.
This can lead to our losing sight of important factors in the whole picture of health care in Vermont.
1 First of all, there is a tendency to overlook the fact that at any one time in a population of 600,000 (the size of Vermont's) a certain amount, or incidence, of disease occurs. This establishes the need for a certain amount of medical care. Health care facilities evolve in a shared relationship with the population's needs. The relationship holds reasonably closely as long as health care is not subject to the distortions of a market place that places profits first among all considerations.
Second, it is usually forgotten that it is the sick not the healthy who define the extent and kind of medical care available. This is another way of making the point above, that the health care bears a strong relationship to the incidence of disease in the population it serves. Payments made by the sick or in their behalf by third parties, are what support health care services in Vermont. This is captured in the notion that it is the sick who keep the beds warm for those who are healthy.
Third, health care facilities that have evolved in the way described become more or less fixed-cost entities. Their operating expenses are largely fixed. Whether they are working at full capacity at any one moment is subject to the normally varying need for those services at that moment. Regardless, their fixed costs remain the same. They must be met if they expect to avoid financial stress. Financial stress usually leads to cost shifting or to measures like staff cutting that invade quality of care.
Fourth, it is seldom emphasized enough that Vermont's medical community has always conducted itself under a strong ethic to provide care to those in need whether they can pay or not, and continues to do so. This clearly has financial repercussions when the care is not fully paid for or paid for at all.
Fifth, a crucially important fact must be kept in mind: that a small percentage (20 percent) of Vermonters are very sick and use 85 percent of the health care. But it would be mistaken to think of them as the same peop le all the time. They include accident victims and victims who suddenly become ill with life threatening diseases. The very sick should not be dismissed as too costly by the remaining 80 percent of the population who are largely healthy and use little health care. This for ethical reasons of course, but also because as stated above, they essentially define the amount and kind of medical services we have. Payments for their health care are the main financial support of the health care services that all of us expect to be available to us should we need them
# Unless these factors are taken into consideration upfront it will be difficult to remedy any perceived problems in Vermont health care. The relationships that hold among these five points are of great importance for any discussions of health care. Omitting or changing any one of them will have profound, undesirable consequences for health care.
For example, if medical care were limited to only those capable of paying in full, it would require a complete reversal of the medical community's ethics.
Even if the medical community could be convinced, which is highly unlikely, limiting care to those capable of paying would affect what kind and how many medical facilities would continue in Vermont.
The same problem arises if medical care is confined to the 80 percent of us who are mostly healthy. If this happened, the impact on medical facilities would be even more drastic. Without the very sick 20 percent, medical facilities would shrink dramatically because the money wouldn't be there to support them and because the patients wouldn't be there to require their services.
Changes to any of the five conditions listed above will impact negatively on Vermont health care. What may look like cost-saving proposals must be weighed against the social costs to Vermonters and the non-monetary costs to Vermont's medical care facilities.
These conditions can be modified to some small extent. But finally they must be accepted by any plan to alter Vermont health care, lest we permanently damage our social fabric in Vermont and the medical care facilities we have.
It is our contention that the fundamental problem in Vermont health care is structural. It originates in how we pay for medical care not the medical care itself or who gets it.
Our medical facilities are roughly adequate for the medical needs of Vermonters. Our ways of paying the largely fixed costs of these facilities, however, are not adequate to meet their financial needs.
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In other words, Vermont's health care arrangement provides medical care to virtually all Vermonters. The extent and kind of its medical facilities has evolved from the incidence of disease in the entire Vermont population. Yet our ways of paying for medical care do not make provision for all Vermonters. Nor do they cover full medical costs in many instances. This strains the financial stability of our health care.
The structural problem is, there is no structure.
The elements of health care are not structured into a system capable of assuring us that our medical care will continue to be good, will be there when we need it, or that it will be affordable. These are the minimum requirements a health care system is created to address.
Every other country in the industrialized world has recognized these factors. Consequently, they all have health care systems. Some are more successful than others. Some have the government delivering the health care, but most have private delivery. They differ in many aspects, but all have four common features.
Applied to Vermont this would mean: A system requires paying all necessary medical for all Vermonters, because the health care facilities service all Vermonters, not just some. A system requires overall stewardship to make it work, and because health care is for all Vermonters, not just some, that means public stewardship. A system requires systematic, budgeted financing, and because health care is for all Vermonters, not just some, that means public financing. A system requires accountability to its clientele, and because its clientele are all Vermonters, that means public accountability. A system requires cost containment mechanisms within a global budget.
On the other hand, a system does not require changes in how medical care is delivered, that is, in its private delivery by doctors of our choice. Nor does it require changes in medical care services themselves.
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The paper discusses in detail how budget mechanisms work to control costs and some ways to publicly finance health care. Systems in other countries are referred to and compared to ours. Reasons for our unnaturally high health care costs per person are given. All systems save large amounts of money over what we spend per person, and this is confirmed by a recent study demonstrating how one kind of health care system would save Vermont over one hundred million dollars.
For more information or for a copy of the white paper "Building a Health Care System in Vermont" please contact :
Deborah Richter, MD. PO Box 1467 Montpelier, VT 05601 802-224-9037 drich70480@AOL.COM