The following text contains the March 10 testimonies of professor Ellen Oxfeld of Vermont Health Care for All and Dr. Peggy Carey, interim chair of the Vermont chapter of Physicians for a National Health Program, before the Vermont House Committee on Health Care, regarding H.202, “An Act Relating to a Single-Payer and Unified Health System.”

Make it clear that single payer is the goal

By Ellen Oxfeld
 
I am Ellen Oxfeld. I’m a faculty member at Middlebury College and a board member of Vermont Health Care for All.
 
I have long supported single payer because it is conservative and practical and efficient, but that is not why I came today.
 
I don’t think I need to tell you that with single payer, we get more and pay less. We would be able to cover everyone, and cut down on bureaucracy. Nor do I need to tell you that single payer has been tested and tried, so we have plenty of experience with and evidence from single-payer systems in other countries and even with Medicare, which is really single payer for people over 65 (even though it is not perfect, we know it can work and has overhead of only 3 percent).
 
The challenge
 
H.202 is a road map to single payer and you should pass it. The comments that follow are simply measures I think would ensure that there are no “roadblocks” unintentionally placed in this “road map.” Any measure which might increase bureaucracy or inefficiency should be carefully considered since one of the goals is reducing cost through greater efficiency and less paperwork.
 
Payment reform and ACOs in H.202
 
I understand that some parts of H.202 are necessary in the transitional phase because of federal law and the prospect of federal funding – for instance, unless we can get an early waiver, we must construct exchanges. I understand that medical homes and other pay-for-performance projects can be constructed as ACOs and may qualify for federal funding which you all want.
 
However, I would still suggest a slight change in the pace of payment reform development so that we can adhere to the guidelines Professor William Hsiao has outlined. As he states, we have little evidence about how payment reform projects would work in Vermont. (These are called ACOs in Hsiao’s report, but they are clearly a parallel concept since in Hsiao’s report ACOs are entities that would be the focus of payment reform and which would attempt to coordinate patient care. That these two concepts are linked is also clear from Richard Slusky’s preliminary report on payment reform, in which the elements of reform and the type of organization he talks about parallel many of the features we commonly attribute to the concept of ACOs.)
 
It’s important to keep in mind that unlike single payer, ACOs are actually a new concept that was only developed in 2006, and there is barely any agreement on what they are, how they can be defined, or what they would look like. (We know the term was first used by Elliot Fisher of Dartmouth, that for a variety of reasons it became a popular idea, and that once it caught on it became part of the Patient Protection and Affordable Care Act.) However, it is certainly problematical to implement something that we can barely define (unlike single payer which is well defined and has been implemented all over the world).
 
For instance, on page 161 of his final report, professor Hsiao gives several possibilities of what an ACO might look like in Vermont, and they are really divergent – everything  from a Federally Qualified Health Center to a community hospital to a big hospital such as Fletcher Allen. He tells us that “the most effective ACO structure has not yet been determined.”
 
And to move to H.202, “payment reform pilots” are themselves not even defined, even though all other key terms in the bill are defined, such as the board, Green Mountain Care, health services, and health care professionals.
 
As such, it is not surprising that given the haziness of the entire concept, Hsiao recommends “rigorous evaluation” before anything is set in stone and implemented statewide (p. 159).
 
There are many complexities to the ACO/payment-reform concept. For instance, it allows for free choice of doctor and hospital, and patients are not restricted (nor should they be) to a particular ACO entity. Yet, how do you attribute savings to a particular entity when the patient is not a defined member of that same entity? How do you pay per member per month when you don’t really have members? If you have members, and they are bound to a particular health care entity, then it is getting close to an HMO, never mind an ACO, and you will have a hugely negative public reaction. And, finally, do you need a new bureaucracy to oversee this all? (For instance, you would need a complex set of rules and regulations and a new bureaucracy to figure out the payment system, such as to work out formulas for how to pay for a patient from one ACO who seeks treatment at a different ACO, etc. etc.)
 
Furthermore, how do you do any of this before your new financing system (single payer) is in place? H.202 states that insurance companies will cooperate on payment reform (p. 15), but then they will not be in the picture once we have implemented single payer (except to possibly administer claims). So, does it make sense for them to be involved in the design and implementation of a new payment system that they will have to let go of within a few years?
 
In short, to be successful payment reform needs be part of system reform and not to precede it. Additionally, something that has not been defined cannot be implemented on a wing and a prayer.
 
Recommendations
 
Based on the issues above, I would suggest the following:
 
1. Pass the bill. It is a road map to single payer.
 
2. Make it clear that single payer (universal health care that is publicly funded) is the GOAL of the bill and that the exchange is only an intermediary stage, and make clear that single payer is not an afterthought or a final stage that can be aborted.
 
3. Make some changes in the pace of “payment reform” as spelled out in the bill as follows:
 
a. Regarding p. 17, part (e). Rather than a payment reform pilot that will be operational no later than January 1, 2012, and two more pilots to be online by July 1, 2012, why not one pilot that will be operational by July 1, 2012?
 
b. “Rigorous evaluation” of this pilot should literally be written into the bill as professor Hsiao recommends in his final report (p. 159). There can be no doubt that you can’t start implementing an untried concept on a large scale before this evaluation.
 
– The criteria for this “rigorous evaluation” should also be spelled out in the bill.
– In the present version of H.202, health insurance companies are to play a key role in the strategic plan and implementation of payment reform. Shouldn’t their role be thought through more carefully, even in the design and implementation of a pilot? The ultimate goal of H.202 is a publicly funded health care system, and not a health care system based on multiple private insurers. It seems a bit odd that they would play a key role in designing something meant for a system which does not include them.
 
c. Define “payment reform.” You can’t have a pilot of a thing you have not defined. The bill does define even common sense or easily understood terms such as “health care provider” and “board.” Yet it does not define payment reform.
 
Conclusion
 
We don’t
want to add something that might possibly add more complexity to the simple and efficient system that is single payer. Single payer is not a concept, it exists in numerous places. “Payment reform” and “ACOs” are much trickier to grasp because they exist primarily in the concept world and not the real world. Thus, I would suggest a go-slow approach to payment reform while making a clear commitment to single payer. The financing system (single payer) must be implemented first. Experimenting broadly with new forms of payment during the transitional phase to single payer, and before the new system is implemented, may unnecessarily complicate our ability to get to the real goal – establishment of a single-payer system.

Vermont can do better: enact single payer

By Peggy Carey, M.D.
 
Thank you for inviting me to meet with you regarding single-payer health care. I am a family doctor presently working at Burlington Primary Care in Burlington. I have also worked for the University of Vermont Department of Family Medicine, practicing in Milton for 15 years.
 
When did I get interested in health care reform? Thirty years ago, when I was diagnosed with Type 1 diabetes and hospitalized with no health insurance. The same month I actually was married to my college sweetheart by a justice of the peace just so I could go on a group health insurance policy. I had been denied coverage through my own job in a bakery in Brattleboro. Because of my situation, I vowed to change the system and put my head in the books for the next 10 years to become a family doctor.
 
Our current health care “system” is failing as it denies care to millions in need, inflicts economic suffering, including personal bankruptcy, on our citizens and communities and is economically unsustainable.
 
How are health insurance company profits part of the “solution”?
 
In 2006, Vermont spent $3.9 billion on health care that didn’t include all Vermonters. In 2012, Vermont will spend $5.9 billion on health care and still not cover all Vermonters. This year, Vermont cannot sustain this $2 billion increase without true cost-containment reform.
 
Working with my medical colleagues as interim chairwoman of Vermont chapter of Physicians for a National Health Program, together we have collected over 200 signatures of both specialists and primary care physicians who support this single-payer legislation, H.202.
 
Over 380 Vermont family physicians endorse Dr. William Hsiao’s report, “Achieving Affordable Universal Health Care in Vermont.” In communities across Vermont, specialists and primary care physicians depend on one another and work together in the best interest of our patients. Both groups work hard to help Vermonters have optimal health care and both groups are frustrated when insurance companies deny care and decide what doctors an individual can see.
 
Implementing a single-payer health care system will remove obstacles to caring for patients by streamlining paperwork and incorporating true quality improvement and cost-containment through overarching planning and budgetary control.
 
Vermont is in a position to do better and lead the nation out of our health care morass.
 
In closing, I refer you to “Learning from Geese”: By flying in a V formation and alternating most forward positions among themselves (substitute doctors here), geese save 50-72 percent of their flying energy. As thrifty and fair-minded Vermonters, I urge your committee to choose the V-formation, the single-payer system that will save lives.

By Don McCanne, M.D.
 
As the author of a PNHP blog entry in November 2010 on the limitations of the Wyden-Brown amendment, which would move up the date when states could obtain waivers from the federal government to introduce their own state-based health reforms, I’d like to clarify my position.
 
It is true that moving up the date by three years alone is not enough to ensure that states like Vermont can enact a “pure” single payer model of reform. There would be more work to do. But that is not a reason to not move forward with enacting a system that is as close to single payer as is possible under current law, and to continue efforts to enact measures that would give states more flexibility in designing a comprehensive financing system.
 
What we really need is a national single-payer program, but, considering the national political scene, that is highly improbable in the near future — not that we shouldn’t continue to advocate for it in the strongest terms. But it would be wrong to say that we must have a national program or nothing. Too many will face financial hardship, or worse, suffer physically and perhaps even die, if we do nothing.
 
In parallel to our national efforts, the states should move forward toward accomplishing as much reform as is possible in the face of our current politics. If the states can provide some temporary relief from suffering and hardship before we are able to enact a national program, then, by all means, we should make those efforts. We should apply for all waivers currently allowable at the same time that we seek to change the law to allow the granting of other waivers that could further improve the state legislation.
 
At the same time, above all, we must continue the parallel effort to enact a national single payer program — an improved Medicare for all. If some states get there before the federal government does, then the relief from suffering will have been well worth the state level efforts.
 
Don McCanne, M.D., is senior health policy fellow at Physicians for a National Health Program (www.pnhp.org). You can subscribe to his “Quote of the Day” here or read them at the PNHP blog.