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Vermont Gov. Proposes Single-Payer Health Plan

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Vermont Gov. Proposes Single-Payer Health Plan

By Aimee Miles
Kaiser Health News, Feb 08, 2011

Vermont Gov. Peter Shumlin, who was elected last November after promising to reform health care in the state, unveiled a bill  Tuesday that would abolish most forms of private health insurance and move state residents into a publicly funded insurance pool.

His much anticipated proposal lays out a strategy that leaves a number of key details—including how to pay for the system—open for debate.

Under Shumlin’s “single-payer” system, Vermont residents would receive health benefits paid for by the state, regardless of their employment status or income. The plan is designed to help stem rising health costs, which state officials say have become unsustainable.

“Health care costs are climbing at a rate of more than 12 times the growth of the Vermont economy, and we’re not getting the best value for our money,” Shumlin said in a prepared statement. “The time for change has come.”

Former Vermont governor Howard Dean, who unsuccessfully sought to institute a single-payer system in 1994, praised the effort.

“It makes a lot of sense and it’ll save them a ton of money,” he said in an interview.

Some Democrats advocated for a national single-payer plan when Congress was debating the federal health overhaul that passed in March, but that plan was never considered politically viable because of widespread opposition and concerns about cost. Even efforts to offer a public option insurance plan that would compete against private insurers for consumers’ business failed after conservative Democratic senators refused to support it. Instead, the health law opted for tighter regulation of existing private plans, with a mandate that almost every American purchase health insurance.

Skeptics have questioned whether Shumlin’s reform agenda is feasible.  Lt. Gov. Phil Scott, a Republican, said before Shumlin’s bill was released that he had received letters from a number of state residents who have concerns.

“They’ve heard about the bill and they’ve heard the thoughts, but the devil’s in the details, and they’d like to see what it means to them,” Scott said.

The governor’s plan calls for creation of a health reform board this year to make recommendations for the plan. A full single-payer plan would not be operational before 2014.

Shumlin, a Democrat, has garnered some support for a health overhaul in the legislature, where Democrats overwhelmingly control both houses. The legislature had already commissioned its Harvard economist William Hsiao, who helped design Taiwan’s single-payer system, along with MIT economist Jonathan Gruber and Vermont policy consultant Steve Kappel to provide recommendations on how to reform Vermont’s health car system. Shumlin’s plan takes many of those recommendations into account.

But Republicans in the state have raised concerns and business groups have not yet signed on.  The state also will need to clear a series of administrative hurdles at the federal level.

The Need For Waivers

Shumlin’s strategy seeks to take advantage of federal resources that will kick in under the new health law in 2014. By that time, every state is expected to have its own “health exchange,” an online marketplace where consumers can shop for private health plans that meet new federal standards. Shumlin’s proposal involves using federal funding to build and exchange infrastructure that could later be converted to support the single-payer system.

But because a single-payer plan is not sanctioned in the health law, Vermont would also need to secure waivers from the federal government in order to move forward with its plans.

“At each step of the way, we may be dealing with constraints as far as federal law, and march forward,” said Anya Rader Wallack, Shumlin’s special assistant on health care reform.

The federal health law allows states such as Vermont to request waivers to opt out of many of its requirements starting in 2017, so long as they present an alternative that would achieve the same goals—broader health coverage for more people—with equal or greater success.

But Vermont legislators, fearing that support could shift against single-payer during the next election cycle, don’t want to wait another six years to deliver their reforms. They’re hoping they’ll be able to opt out of the health care law sooner.

That puts Vermont in a delicate position: for now, at least, the state will need to work out a plan to comply with the federal health law while simultaneously laying the groundwork for its own plan.  To make matters more complicated, Vermont officials would also have to work with federal officials to make critical payment adjustments within Medicare, the federal health program for seniors and disabled individuals.

Funding Is An Open Question

The governor’s team has not yet devised a way to pay for the new system. They plan to return to the legislature in 2013 with proposals, according to Wallack.

Hsiao and colleagues had earlier recommended that the state levy a payroll tax divided between employers and employees—an idea that raised alarm bells with small business owners.

Among them is Scott, who also owns a construction company. “I understand some of the arguments for this type of system was to take the burden off employers and I guess I’m not seeing where that burden is being moved,” Scott said.

Rick Rayfield, who owns a bookstore in Waitsfield, is tentatively in favor of a single-payer system—but wants to see how the legislature hammers out key details.

“It seems to me we’re trying to develop a philosophy about who pays for healthcare without asking ourselves exactly what we’re willing to pay for,” he said.  “We’re being asked if a single-payer system is something we would like without saying what we’re going get for it.”

Still, Rayfield sees some advantages. “I guess I’m so overwhelmed by the stupid complexity of the (current) system as it is that I just adore the simplicity of the single-payer plan,” he said.

Supporters of the change say the need is dire. They point to statistics showing that health spending more than doubled in Vermont between 1992 and 2009. Shumlin’s office has estimated the state would save $500 million in the first year of a single-payer plan.

That would come from reduced insurance marketing and administrative costs. Hospitals and physicians also lose time and money in filling out claims information for every private health plan they bill.

Shumlin’s plan recommends paying physicians and hospitals in a way that encourages them to provide higher quality care without providing unnecessary services.

“There’s a lot of smart things the governor’s doing,” Dean said. “The smartest thing of all is that he’s … saying, ‘We’re not going to come up with funding mechanism until we change the payment system.'”

http://www.kaiserhealthnews.org/Stories/2011/February/08/vermont-governor-shumlin-single-payer.aspx

Big employers shift more health costs onto employees

By Claudia Fegan, M.D.
Hyde Park Herald (Chicago), Feb. 9, 2011

Many residents of Hyde Park work for large employers, the University of Chicago being just one example among several. In the wake of the new health law, what benefit changes can workers at these large companies expect to see?
 
A survey of 72 big employers like IBM, Boeing, General Electric, FedEx and others conducted last fall showed that 63 percent of these companies plan to shift more of their health premium costs to employees in 2011, and that 46 percent expect to raise the maximum out-of-pocket costs (co-pays, co-insurance and deductibles) that their employees are expected to bear, including for prescription drugs.
 
In other words, big employers are shifting more of the financial burden for health care onto the shoulders of their employees. Significantly, the new health law doesn’t prohibit such hikes on workers’ share of health costs, and in fact perpetuates the idea that “cost-sharing” by employees is a good thing – despite solid evidence to the contrary.
 
There are some exceptions to this rule, however. Some preventive services like mammograms or colonoscopies will now require no patient co-pays or deductibles. (Some employers already offer this benefit, although studies show most workers don’t avail themselves of such preventive services when they’re offered.)  And patients will not incur a financial penalty if they see an obstetrician or a pediatrician without a referral.
 
But, in general, employees at large companies will be asked to pay higher costs for their care, and will see their wages negatively impacted by employers who will say that the rising costs of health benefits prevent them from giving workers pay raises. Much hinges, of course, on the individual employer and whether your wages and benefits are protected by a union contract.
 
There’s more. Under the new law, better-quality health plans face the threat of being hit with a punitive 40 percent excise tax starting in 2018. This is the so-called Cadillac tax on employers who offer decent health benefits. Because the “Chevy” plans of today are likely, thanks to rising health prices, to be the Cadillac plans of tomorrow, this could easily provoke many big employers to dump their health benefits altogether and to force workers to seek even costlier coverage in the proposed insurance exchanges.
 
Some beneficial parts of the new law include the removal of lifetime caps on benefits (annual limits will stay in place in many cases, however, until 2014), the eligibility of children under age 26 to remain on their parent’s insurance policy, and new restrictions on the ability of private insurers to deny coverage for persons with pre-existing medical conditions.
 
It’s fair to say that the new health law faces an uncertain future. Most big employers take it for granted that the law will survive efforts to repeal it or to declare it unconstitutional, and they are acting accordingly. And in fact most big companies are quite comfortable with it, as are investors who hold shares in health-related companies. They know that the law builds upon the status quo, where private health insurers and Big Pharma hold commanding positions in our system and where profits will still flow into the health industry.
 
Unfortunately, it’s precisely because the private insurers remain in the driver’s seat that we will suffer from ever-rising costs, from patients putting off needed care because they can’t afford it, and from the squandering of valuable health dollars on excessive paperwork. The result: even though the U.S. spends more per capita than any other nation on earth, our medical outcomes will remain far behind other industrialized nations.
 
I favor a system of financing care known as single-payer national health insurance, an improved Medicare for all. Under a single-payer plan, everyone would be covered, there would be no co-pays or deductibles, and everyone would have free choice of physician and hospital. A one-payer system’s bargaining clout would help us contain costs.
 
Vermont and some other states are taking a look at shifting to a single-payer system. Illinois should do likewise, as should Congress.
 
Claudia Fegan, M.D., is associate chief medical officer for the Ambulatory and Community Health Network for the Cook County Bureau of Health Services. She resides in Hyde Park. [This article was originally published under the headline “My thoughts on health care.”]

Rationing is not the only alternative

By DR. RALPH S. BOVARD
Star Tribune, Feb. 7, 2011

“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

THE REV. MARTIN LUTHER KING JR.

In a recent commentary (Opinion Exchange, Jan. 23), Dr. Virginia Dale told readers that they must choose between universal health insurance and rationing.

As a physician, I agree that we must get health care costs down if we’re going to achieve universal coverage, but I strongly disagree that the only way to do it is to ration.

There is another viable and proven option: a single-payer or regulated multipayer health care system, such as exists in every nation in the Organization for Economic Co-operation & Development except the United States and Mexico.

The average OECD nation spends 6 percent to 10 percent of GDP on health care; we spend 17 percent. Their per-person spending averages $3,000 to $5,000 a year, compared with $8,000 in the United States.

We could save huge sums — more than enough to insure the uninsured — by cutting the administrative waste and executive profit in our system, and by collective bargaining to lower the price at which drugs, devices and medical services are sold in this country.

The true “elephant in the room,” to use Dale’s metaphor, is the fact that our health care system has been “privatized” by an insurance industry more intent on lining its pockets than on ensuring that the American people get the public service and care that they pay for.

HMOs reap a hugely profitable business by denying and limiting care (a more severe form of rationing than exists in any other OECD nation) and by taking upward of 20 percent from every premium dollar and even tax-funded programs to pay excessive salaries to people who provide no patient care whatsoever.

The 80 percent they are obligated to spend on your health care is called their medical loss ratio. Nice, huh?

In a recent survey, 23 percent of Americans felt they were inappropriately denied care, compared with 4 percent of Canadians.

It was revealing to look at the political cartoons in the same Opinion Exchange section in which Dale’s commentary appeared.

One showed an American with a letter labeled “DENIED” and a caption stating: “50% of all Americans under 65 have preexisting medical conditions that may prevent them from getting insurance … .”

The next image showed a smirking lawmaker in his Washington office with his feet up. The caption: “100% of the 249 congressmen voting to repeal health care have their health care plan paid for by those same Americans … .”

And that is the truth.

The more somber note is that even if the American depicted in that cartoon has health coverage, with the loss of a job or the onset of a major illness that causes the loss of health benefits, he or she may easily join the millions each year who are bankrupted by medical bills.

That doesn’t happen under universal coverage or a single-payer system.

Providing universal health care is not socialistic. It is the pooling of resources by a highly ordered social structure to provide for the common good. Some call it civilization.

Think about it: This is how we fund all of our public services, including fire, police, water, education, libraries, sewage, parks and recreation, and highways. Health care would seem the most essential of public services.

Why do some people call it “socialized” (like it is a dirty word) only when we apply the term to medical care, but not to the other public services that we fund and use daily?

Tommy Douglas, who was voted the “Greatest Canadian” in 2005, nearly 20 years after his death, for bringing a universal health care system to his nation, was a humble clergyman dedicated to the importance of economic democracy and the “social gospel.”

If only our politicians had an ounce of his moral integrity and commitment to serving the nation’s best interests.

It is highly misleading to tell the public that our choice is between continued high numbers of uninsured people or rationing.

Our choice is continued high numbers of the uninsured vs. cutting the enormous administrative waste and corporate profit out of our system with a single-payer system that allows us to lower the prices we pay for medical services, drugs and devices to levels paid in other countries.

As taxpayers and voters, we need to demand accountability, and we are not getting it from our current HMO system. The industry has had more than 20 years to get it right and has failed miserably to do so.

 We are getting fleeced. As Paul Wellstone said: “We all do better when we all do better” — not when the CEOs and executives of medical care organizations do obscenely better at the expense of our national health.

Ralph S. Bovard is a steering-committee member of Physicians for a National Health Program-Minnesota Chapter.

http://www.startribune.com/opinion/commentary/115522679.html?elr=KArksc8P:Pc:U0ckkD:aEyKUiD3aPc:_Yyc:aULPQL7PQLanchO7DiUr

Will Mayo Clinic save money as an ACO?

Some insurance companies pushing plans with Mayo Clinic out of network

By Christopher Snowbeck
TwinCities.com
February 5, 2011

Bloomington-based HealthPartners last year started marketing health plans that feature a network of hospitals and doctors that doesn’t include the Mayo Clinic. In exchange for not having access with low co-payments to the iconic Rochester, Minn., clinic, subscribers pay lower premiums when they select a HealthPartners plan with Mayo as an out-of-network option.

Last year, Eagan-based Blue Cross and Blue Shield of Minnesota also started emphasizing health insurance products for individuals in which Mayo isn’t in the network of providers.

Mayo has been celebrated nationally for providing high-quality and low-cost health care, but health insurance brokers say the local reputation is different as far as cost goes.

“Mayo is cheap only compared to other national care centers, but in general is a higher-cost center when compared to its Minnesota peers,” said Christopher Schneeman, a health insurance broker with SevenHills Benefit Partners in St. Paul.

“The Mayo Clinic is world-class,” said Greg Sailer of Sailer Benefit Services in Lake Elmo. “But it’s expensive, and you’re going to pay for it.”

Mayo Clinic officials argue that the Rochester center offers greater value by providing comprehensive care that steers patients to the most-effective treatments. That ultimately adds up to lower overall cost, the clinic says.

“When we looked at Mayo’s total cost of care — the combination of price and utilization — they, on average, have a higher total cost of care than other health systems that are seeing comparable groups of patients,” said (Andrea Walsh, chief marketing officer of HealthPartners).

http://www.twincities.com/ci_17298533

Comment: 

By Don McCanne, MD

For many years, the most common example given of the variations in the costs of health care demonstrated by the Dartmouth Atlas was the high costs of health care in Boca Raton, Florida when compared to Rochester, Minnesota, home of the Mayo clinic. These observed variations throughout the nation have led to the recommendation – now enacted in the Affordable Care Act (ACA) – to establish accountable care organizations (ACOs).

Although the precise details of what constitutes an ACO have not yet been released by HHS, the law states that the ACO will be “accountable for the quality, cost, and overall care of the Medicare fee-for-service beneficiaries assigned to it.” Payment will be based on a “Medicare Shared Savings Program,” in which the ACO shares with the government the savings for which it is accountable. It is a program designed to reduce health care spending.

Since Mayo Clinic certainly has the capability of providing overall care of the patient, it would seem to be an ideal institution to serve as an ACO. In fact, the authors of the legislation had in mind institutions such as Mayo as important models that could provide high quality care at a lower cost.

But will Mayo deliver at a lower cost? Not according to the current experience in Minnesota. Mayo argues that they provide greater value because they provide “comprehensive care that steers patients to the most-effective treatments,” even if that care is more expensive than elsewhere in Minnesota. (Time for a little soft shoe?)

The point is that the cost savings in ACA, such as the ACOs, are not much more than a fantasy at this point. And for this we gave up universal coverage and have established under-insurance as the new standard. We can still reach our goals of comprehensive, affordable care for everyone by replacing ACA’s financing system with an improved Medicare for all.

Single-Payer Solution

Letter, The New York Times
Published: February 5, 2011

To the Editor:

Re “For Governors of Both Parties, Medicaid Looks Ripe to Slash” (front page, Jan. 29):

It is hard for me to understand why the governors, along with corporate chief executives, aren’t lobbying Congress and President Obama for single-payer health insurance.

It would take the burden of providing health insurance off state and corporate budgets and provide the broadest and least expensive health care solution.

Charles Pack
Red Bank, N.J., Jan. 29, 2011

Health or wealth? What's the mission of our health care system?

Switching to a nonprofit system in Maine would put the focus back on care.

By PHILIP CAPER, JOE LENDVAI and JULIE PEASE
The Portland (Maine) Press Herald
February 6, 2011

There has been a great deal of discussion recently about health care reform in America and in Maine. Many Republicans want to repeal last year’s federal health care reform law, and most Democrats want to implement and improve it.

In the meantime, pending full implementation of the law in 2014, health care costs for individuals, employers and the government continue to soar, and the number of uninsured Americans (including Mainers) continues to grow.

Many Americans believe that the forces of the marketplace can solve our health care problems. They won’t, and they can’t. We have been trying marketplace solutions for more than 30 years.

These “solutions” have led to out-of-control costs, rising numbers of uninsured and under-insured patients, the disappearance of primary care providers, fragmented and duplicative care, and a brutal system dominated by for-profit health insurance companies.

In this system, denial of care is the means to increasing profitability. Marketplace solutions have failed.

America spends about twice as much per-person on health care as the average of all other developed countries, even though those countries are able to provide health care to all of their residents.

Furthermore, by almost every measurement, other developed countries have better health care outcomes than we do, and their health care systems are almost universally popular with their people (including their politicians).

How do they do it?

First, only in America is health care considered a business. The mission of a business is to create wealth for its shareholders.

The mission of a health care system is to prevent disease where that is possible, and to diagnose, treat, cure, heal and comfort patients when they are ill.

Only in America has the business mission been permitted to trump the health care mission.

In all other developed countries, health care is financed by the government or nonprofit funds that are tightly regulated by government and run as public utilities. The for-profit financing of health care is not permitted for basic health care services.

Second, only in America is there such fragmentation of health care systems, with multiple tiers of care provided by Medicare, Medicaid, the VA, Tricare and private insurance.

In most other developed countries, everybody is in the same system. With everybody in the same system, everybody has an interest in seeing that the system is adequately funded and run effectively and efficiently.

Third, all other countries have some way of budgeting for health care for all of their citizens.

In America, the system for the civilian population is totally open-ended. Neither the federal government nor the states has yet shown the political will to control costs.

Some states are beginning to apply the brakes, but only if cost restraint is applied selectively to their most vulnerable and politically disenfranchised populations.

It is time for Mainers to replace our fragmented, expensive and fundamentally unfair health insurance system with a single statewide program of health care financing — everybody in, nobody out.

In recent testimony before the Maine Legislature, professor William Hsiao of Harvard University, one of the world’s leading authorities on the financing of health care, estimated that Mainers could save $1 billion in the first year of such a system, and permanently reduce the rate of health care cost increases by 2 percent per year thereafter.

Some of the savings would come from eliminating excessive insurance company profits and executive compensation.

More would come from standardizing benefits and coverage, eliminating the huge administrative costs that doctors, hospitals and other providers of health care incur in dealing with hundreds of plans.

Still more would come from eliminating the fights about money that are a byproduct of so many different insurance programs — who pays, what for, how much — that now consume so much time and effort, and impede the delivery of quality health care.

Replacing our profit-driven system of financing health care with a mission-driven nonprofit system is the necessary first step in reinventing health care in Maine.

Only then will we be able to address the need to effectively reform the way we pay hospitals and other health care providers to reward efficiency and outcomes, rather than profit and volume.

Maine AllCare proposes nothing less than reforming the culture of health care throughout Maine.

Maine AllCare’s vision is for a system for Maine in which:

• All Mainers have access to affordable and appropriate health care and its supporting social and community services.

• No Mainer is in danger of financial ruin because of health care costs or is locked into a job solely because it provides health insurance.

• No Maine employer is faced with health care costs spiraling out of control.

• No Maine worker is faced with stagnant or declining wages or the inability to bargain for better working conditions because of the rising cost of health care.

• Maine patients will no longer have to wonder whether their doctor’s treatment decisions are driven by their health needs or their insurance coverage.

• Maine doctors will no longer have their clinical judgment second-guessed by insurance companies. Medical practice will be decided by health care providers and patients, and will return to being driven by mission, not money.

• Maine hospital executives will be free to offer services determined by the needs of their community, not their need or desire to generate revenue.

• The Legislature will not have to stand by and watch rising MaineCare and state and local government employee costs steadily erode its ability to address other critical priorities.

Can it be done? Absolutely. There are plenty of examples from around the world. All other industrialized countries, many less wealthy than ours, are already doing it.

Can we do it? That depends upon the people of Maine.

The authors serve on the board of directors of Maine AllCare, a nonpartisan, nonprofit group committed to educating the public and policymakers about how to improve on the Patient Protection and Affordable Care Act to make health care in Maine universal, accessible and affordable for all.

http://www.pressherald.com/opinion/health-or-wealth_-whats-the-mission-of-our-health-care-system__2011-02-06.html

Individual mandate falls short in Massachusetts

Lack Of Access Due To Costs Remains A Problem For Some In Massachusetts Despite The State’s Health Reforms

By Cheryl R. Clark, Jane Soukup, Usha Govindarajulu, Heather E. Riden, Dora A. Tovar and Paula A. Johnson
Health Affairs
February 2011

Did the Massachusetts health reforms, which provided near-universal insurance coverage, also address problems of unmet need resulting from the cost of care and of inadequate preventive care for diverse patient groups? We found that nearly a quarter of adults who were in fair or poor health reported being unable to see a doctor because of cost during the implementation of the reforms. We also found that state residents earning less than $25,000 per year were much less likely than higher earners to receive screening for cardiovascular disease and cancer.

http://content.healthaffairs.org/content/30/2/247#aff-6

And…

More get waivers of health insurance

By Kay Lazar
The Boston Globe
February 7, 2011

Massachusetts regulators granted more exemptions last year to residents who said they could not afford the health insurance required by the state, waiving the tax penalty for more than half of those who appealed, according to state data.

That is prompting regulators to take a fresh look at how Massachusetts defines affordable when it comes to mandatory health insurance.

Massachusetts residents with the lowest family incomes, less than $33,075 for a family of four, make up the largest share — 43 percent — of the uninsured, according to state data.

“We may want to let them in [to government subsidized health insurance], but it would cost money, and we would have to decide if the state wants to spend money that way,” said committee member Jonathan Gruber, an economics professor at the Massachusetts Institute of Technology.

http://www.boston.com/news/local/massachusetts/articles/2011/02/07/more_get_waivers_of_health_insurance/?page=full

Comment: 

By Don McCanne, MD

Does an individual mandate to purchase private insurance with cost-sharing requirements ensure that citizens will have health care access and be able to afford it? It hasn’t in Massachusetts, and it will not throughout the United States because it is an irreparably flawed mechanism of financing health care.

The literature is replete with policies that would nudge us a little bit closer to the goals of affordability and expanded coverage, but, as Jonathan Gruber, an advocate of the private insurance mandate model, says, “we would have to decide if the state wants to spend money that way.”

But it’s the model, stupid! Dump it and replace it with an improved Medicare for all and then health care will be affordable for everyone. Why does Gruber and the others insist on separating state money from personal money, as if state money is sacred and personal money isn’t? It all belongs to us anyway.

Here's why a key part of Obamacare will get struck down

By Robert Reich
The Business Insider, Feb. 4, 2011

The Republican-led house vote to repeal the new health care law is purely symbolic. But there’s one provision of the law that Republicans are likely to try to defund, and they may have the public with them on this. It’s the so-called “individual mandate” – the requirement that everyone purchase health insurance, or pay a fine. According to a recent poll, 60 percent of the public opposes it. They just don’t like the idea of  government telling them they have to buy something.

The mandate is also particularly vulnerable to legal challenge. So far, two federal judges, one in Virginia and another in Florida, have struck it down. They say the federal government has no more constitutional authority requiring citizens to buy insurance than requiring them to buy and consume broccoli, or asparagus.  The Florida judge referred to broccoli; the Virginia judge to asparagus.

Yet the new system can’t work without the individual mandate.  Only if everyone buys insurance can insurers afford to cover people with preexisting conditions, or pay the costs of catastrophic diseases.

The curious thing is Americans don’t mind individual mandates when they come in the form of payroll taxes to buy mandatory public insurance. In fact, that’s the system we call Social Security and Medicare, and both are so popular politicians dare not touch them.

And no federal judge has struck down Social Security or Medicare as being unconstitutional requirements that Americans buy something.

Social Security and Medicare aren’t broccoli or asparagus. They’re as American as hot dogs and apple pie.

So if the individual mandate to buy private health insurance gets struck down by the Supreme Court or killed off by Congress, I’d recommend President Obama immediately propose what he should have proposed in the beginning — universal health care based on Medicare for all, financed by payroll taxes.

Read more: http://www.businessinsider.com/the-individual-mandate-in-the-health-care-bill-lets-trade-the-broccoli-and-asparagus-for-hot-dogs-and-apple-pie-2011-2#ixzz1DHmZ3KH3

In Vermont, historic opportunity is now

By Deborah Richter
Burlington Free Press, Feb. 1, 2011

Praise has been heaped on the 120-some page report issued by the Harvard health economist, William Hsiao, and his working group. Words like historic, ground-breaking, and masterful are used, and since I entirely agree I will put them to use as well.

The report is called “Act 128 Health System Reform Design: Achieving Affordable Universal Health Care in Vermont” but will forever be known as the Hsiao Report.

It does exactly what is was asked by the Legislature. It outlines the designs for three health care systems and offers the rationale behind the thinking for each, including facts, figures and the probable economic consequences. For Vermont, this is ground breaking.

Two of the three look good. One of them (the second, which is called the public option) is hardly in the running because effectively it will not achieve universal coverage.

The favored system designs have numbers. Option No. 1 is a single-payer system. Option No. 3 is a single-payer system. What is the difference? Not a lot. Operationally there are differences. But at this stage, far more important is what they share. It is something of overriding importance that we overlook at our peril, and in fact have overlooked at our peril for years. That peril can be described as unsustainable rises in costs.

Here is the Hsiao Report: “Vermont will need to reorganize existing systems and develop new administrative capacities to manage an integrated, single-payer health system. In addition, the state will need to institute a regulatory apparatus to oversee the functioning of the system.”

This admonition appears about nine-tenths of the way through the report, but it is the key to everything.

Our Legislature and new administration are called on to create an integrated health care system. System is not an idle idea. Without a system the costs of health care in our state cannot be managed, contained, controlled, budgeted and will in fact remain unmanaged, uncontained, uncontrolled, unbudgeted.

The Hsiao Report is a masterful piece of work. It is specific to Vermont, to our health care, to our economy, to our political landscape and to Vermont’s intersection with federal laws, regulations and, by implication, politics. It is not a template for other states. It is not a one-size fits all. It is particular to our state.

Vermont has never before had anything close to this to work with. It maps out routes to a goal that can be abbreviated as “high-quality health care for all Vermonters,” and by affordable is meant affordable to Vermont as a whole as well as to individuals.

Comments after its release Jan. 19 no doubt are pouring in. Because they are by post or e-mail we can’t know what they are. But the usual pattern is reservations, objections, gloomy prognostications, alternative theories, quarrels over details, complaints from idealists, self-interested criticisms from the what-about-me crowd, some valuable, some a deplorable waste of time, but all more or less beside the main point.

As the Hsiao Report implies in its gentle way, if we don’t move to an integrated health care system that is uniform and regulated we are done. The costs are going to bury us. That is the essential point.

A system oversees and coordinates. It integrates. At some basic level it abolishes the what-about-me chorus in favor of what-about-all-of-us. A system takes the fundamentally necessary step of grounding health care, and all of its elements, solidly in the realm of the public interest.

The Hsiao Report is a report, not a bill. It hands the Legislature and the new administration an historic opportunity.

The draft, or redraft, will be subject to the usual practice in committees and hearings — the standard back and forth of legislation — of picking away at the details (“the devil is in the details”). Not this time. This time the devil will be found in our failure to create and implement a system.

Dr. Deborah Richter of Montpelier is president of Vermont Health Care for All, which is campaigning for a single-payer health care system for Vermont.

http://www.burlingtonfreepress.com/article/20110201/OPINION05/102010308/Comment-Debate-Historic-opportunity-is-now

Health care's federal future, brought to you by the GOP

By Matt Miller
The Washington Post, Thursday, February 3, 2011

“Good afternoon, I’m Brian Williams reporting from Washington, where it looks like October 26, 2017, will be a day that truly goes down in history. In a few moments, at a table not far from where I now stand, President Hillary Clinton will sign into law the universal health-care legislation – “Medicare for All,” as she calls it – that completes a journey Mrs. Clinton began nearly 25 years ago. Back then, as first lady, her attempt to reform the health-care system proved a fiasco that cost Democrats their hold on power. Who would have thought then – or later, when President Barack Obama’s big health reform was overturned by the Supreme Court in a controversial 5 to 4 ruling in 2012 – that today’s bipartisan bill would be the result? For some perspective on the twists and turns of history, we’re joined by NBC’s David Gregory. David, health reform seemed dead in the water in 2012. How did we get from that Supreme Court ruling to today?”

“Brian, when historians look back on this period, they’ll see it as a classic case of shortsighted politics – of Republicans winning the battle but losing the war. It really dates to the fight to overturn Barack Obama’s health reform. There’s no question the GOP got a boost from that ‘victory’ – it galvanized their base, and, combined with high unemployment and the dollar crisis right before the 2012 election, denied President Obama a second term.

“But some Republicans now say the trouble was that their party never acknowledged that health care wasn’t just about politics – it was a major policy problem that needed real solutions. President Mitch Daniels, of course, had to spend virtually all of his term in office getting America’s fiscal house in order, what with the International Monetary Fund and the rating agencies telling Washington the jig was up. The new carbon and value-added taxes he enacted, and the spending cuts he muscled through, left Daniels respected but hardly popular.

“Meanwhile, as you know, Brian, health costs kept soaring, employers kept dropping coverage they could no longer afford, and by the 2016 campaign, with 70 million Americans uninsured, something had to give. It was Hillary Clinton’s moment, Brian.”

“David, it seems hard to recall now, but back in the fight over Obamacare, Republicans only offered plans to insure 3 million of the 50 million who were uninsured back then. Today, most Republicans have signed on to Mrs. Clinton’s plan to have government provide every American with basic coverage, with a much more modest role for private insurance as a supplement. What accounts for the change?”

“Well, Brian, a cynic might say that when you get to 70 million uninsured, some of them are actually Republican voters! But the key difference was the way business and labor came together behind Mrs. Clinton’s approach. Top chief executives agreed companies shouldn’t be expected to bear these costs anymore and backed the modest taxes needed to move health costs from private payrolls to public budgets, as happens in every other wealthy nation. The unions finally took a larger view, too. Instead of moaning about the ‘loss’ of a benefit they’d bargained for, labor leaders accepted that most workers had gone years without real wage increases, because health costs were devouring every penny available for compensation. Having government fund health care was the only way to give Americans a raise.”

“What seems so ironic, David, is that Republicans now endorse a much more ‘liberal’ solution than they would have had if they’d supported Barack Obama’s approach years ago.”

“That’s right, Brian. Obama modeled his reform on Mitt Romney’s in Massachusetts. It had an individual mandate because of something Republicans privately understood: The only way to reach universal coverage through private health plans that cover folks regardless of health status is to require everyone to be in the insurance pool. If people are free to wait until they’re sick to buy in, premiums soar and coverage erodes. Republicans who knew better assailed the mandate not because they really cared about some constitutional defect – after all, that could have been fixed easily by structuring incentives to buy coverage as opposed to a mandate. They did it because it was a way to take a bite out of Obama. In the near term, it worked. In the long term, they lost the chance to preserve the private-sector role they claimed to cherish in health care.”

“Ironic indeed. We’re getting word that President Clinton is about to speak. We join her now in the Rose Garden.”

“Thank you all for being here. It’s hard to imagine a better 70th birthday present for a president than the law I am about to sign. . . .”

Matt Miller, a senior fellow at the Center for American Progress and co-host of public radio’s “Left, Right & Center,” writes a weekly column for The Post. He can be reached at mattino2@gmail.com. Follow him on Twitter at @mattmillernow.

http://www.washingtonpost.com/wp-dyn/content/article/2011/02/02/AR2011020203149.html