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.