Three Vermonters respond to Gov. Shumlin’s decision on health reform

PNHP note: The following opinion pieces are from three prominent figures in the health reform movement in Vermont.

Shumlin never said ‘never’

By Terry Doran
VTDigger, Dec. 22, 2014

It’s no surprise that Gov. Shumlin decided against presenting a financing plan for a universal health care system to the Legislature. Practically speaking, the numbers were unfavorable. Politically speaking, the Legislature’s mood was unfavorable.

Those of us who have long advocated for a publicly financed single payer universal health care system – often referred to somewhat inaccurately as a single payer system — and who attended the governor’s announcement did not hear him say the word “never,” or that Act 48 – the enabling law passed three years ago by many of the same legislators – is dead.

It will be interpreted that way. Funeral orations are being declaimed all over the state, and nation. But are they right? We think not for at least three reasons.

The first one is: high-quality, affordable health care for all (not just some) Vermonters depends entirely on a system of health care services that are financed by money collected from the public and managed in the public’s name. Opponents of this idea – and there are many from the purely self-interested to the ideologically motivated – can offer no workable alternative. Nearly every other country in the world does it this way, not in far-fetched theory but in practice. And it costs them about half of what it costs us and they generally get better health outcomes than we do.

So, to continue the first reason: For more than 30 years Vermont Legislatures have pursued the moral principle of high-quality, affordable health care for all (not just some) Vermonters without getting there. They’ve tried almost everything, under the guise of “coverage,” and still haven’t made it. Perfectly reasonable expectations tell us that eventually costs will compel adoption of a publicly financed system, or we will experience the slow-motion collapse of our health care services.

The second reason is that Act 48, the legislated road map to a universal health care system, is not dead. It’s been working feverishly for three years. It’s done this mainly in the form of the Green Mountain Care Board (GMCB). Never heard of it? That’s not surprising either. The board is charged with starting payment reform projects, regulating hospital budgets and evaluating any such steps taken in health care. There’s much more and I’d suggest readers check the GMCB website

The board has five members, a staff and advisory panels. You may think its work is deliberately invisible, but it isn’t. Its work is conducted transparently. Anyone can attend and comment at its meetings, usually four times a month, mostly but not entirely in Montpelier. Supporting and contrary opinions are welcomed. For those interested it is a very good way to learn about the problems besetting health care in Vermont and about the variety of solutions offered.

The third reason is that there are what could be called phase-in steps towards Act 48’s universal health care system. These are steps that reflect exactly the indispensable features of a universal health care system, but on a smaller scale. They would be publicly financed, they would provide health care to all Vermonters, they would operate under publicly scrutinized budgets. These are not to be confused with stop-gap measures to expand “coverage.” Legislatures are fond of the latter, but such measures have a 25-year record of falling short. There are good theoretical and practical reasons why.

Anyway, one of the phase-in steps would be to publicly finance primary care for all Vermonters. This could be done for about one-eighth (about 12 percent) of the money that has spooked legislators going into January’s new session. Primary care is where good health care starts. Primary care is a proven way to control and lower subsequent costs.

A second similar, except larger, phase-in step would be to publicly-finance Vermont’s hospitals. The price tag – meaning taxes – would be much larger. But so would the benefits.

A good guess is that the Legislature’s willingness is probably inversely proportional to the size of the price tag, so a primary-care phase-in step would allow them to sleep at night and allow them to claim to have done something really useful for every Vermonter.

Gov. Shumlin is probably right. The Vermont road to a fully developed universal health care system is likely too steep at this time. Still, we advocates for a publicly financed health care system are convinced the road has no realistic off-ramps. “Off-ramps” is a term legislators with the jitters use when they believe there is a way to get out of doing what has to be done.

It’s our belief that what has to be done hasn’t changed, nor will it change. At some future point circumstances will compel the right choice.

Terry Doran is co-author (with Con Hogan and Deb Richter) of “At the Crossroads: The Future of Health Care in Vermont” and “Gridlock: The Unhealthy Politics of Health Care in Vermont.” He lives in Montpelier.


We must keep trying

By Peter Sterling
Rutland (Vt.) Herald, Dec. 21, 2014

The governor shocked the political world this past Wednesday by announcing his administration is no longer supporting a tax package to publicly finance health care.

The plan had been to eliminate insurance companies and the roughly $3 billion we Vermonters pay them each year in the form of deductibles, premiums, co-pays, etc., with an approximately $2 billion package of taxes to fund the nation’s first universal health care system. I truly believe the governor and his team left no stone unturned in their effort to develop a financing package for this new system that was workable.

But before I go into the details of the governor’s decision, it’s important to remember the most important reason why we must change the way we pay for health care — it has been, and always will be, about people. Every one of us — healthy, sick, young or old, rich or poor, employer or employee — is affected by the high cost of health care. And there are many reasons one could identify, but the main culprits are the lower wages we are paid at work to offset our employers’ rising health care premiums, the debt from unpaid medical bills and increased taxes to pay for the almost 50 percent of us already receiving some sort of publicly financed health care.

According to the last estimate, there are about 40,000 uninsured Vermonters, people living a single accident or unexpected illness away from financial catastrophe. There’s a reason that unpaid medical bills are the No. 1 reason for bankruptcy in our country. They add up fast. Even having insurance in today’s world is no guarantee of being free from harm. For example, nationally more than 100,000 people diagnosed with cancer file for bankruptcy every year despite being insured.

The Time magazine article “Bitter Pill: Why Medical Bills Are Killing Us” has one of the many examples of how outrageous payment for care under the current system is. According to the article, it was standard practice, and fully legal, for a hospital in Connecticut to mark up many times over what it charges patients for a variety of standard medical supplies such as $18 each for 88 diabetes-test strips that Amazon sells in boxes of 50 for $27.85.

And Vermont Health Connect, the health care exchange, mandated by Obamacare, doesn’t go nearly far enough to make health care truly accessible and affordable for low and middle-income Vermonters. For starters, its open enrollment period is only three months long. After that, you need a special qualifying event to get insurance. And as an example of its high costs, take a couple whose gross income is $47,000 a year who buys the most common plan. They are still on the hook for more than $11,000 every year in premiums, deductibles, etc., before insurance will cover all of their medical bills.

So what does all of this have to do with the governor’s decision to halt his pursuit of a universal, publicly funded health care system? Pretty much everything. Without a universal system, it is going to be nearly impossible to make sure people can actually afford the care they need, when they need it while truly reining in the rising cost of health care.

Under the governor’s proposal, every Vermonter would have had next to no deductible or co-pays, much like our incredibly successful Dr. Dynasaur program. It would have divorced all of us from getting insurance through our employer so we all could be free to change jobs, start our own businesses or even retire early without fear of going uninsured.

One Band-Aid solution is for the state to further subsidize low- and middle-income Vermonters insurance costs incurred under Vermont Health Connect. This would have the very real effect of lowering consumer’s premiums, deductibles and other “out of pocket” costs and thus greatly easing the financial strain of paying for care. One possible source of financing for this subsidy that has been widely discussed is a tax on sugary beverages such as soda, sports drinks and energy drinks. This tax would raise close to $30 million a year, more than enough to fund this and other initiatives to help Vermonters lead healthier lives.

So the question for all of us to ponder in light of the governor’s announcement is how do we keep moving forward to achieve the goals of creating a health care system that insures everyone, is truly affordable and stops the rising cost of health care? Because only then will our work be done.

Peter Sterling is the director of Vermont Leads, a nonprofit advocacy organization dedicated to enacting a universal, publicly funded health care system in Vermont.


Single payer is not dead

By Deb Richter, M.D.
Rutland (Vt.) Herald, Dec. 21, 2014

I moved to Vermont more than 15 years ago to practice medicine and to engage in an educational, and ultimately political effort to achieve universal, publicly funded health care in one small state. The prospect of such reform happening at the federal level had always seemed very dim. The prospect just got dimmer in Vermont, but I am not giving up.

I am a primary-care physician. I help my patients to the extent I can, but there is little I can do when someone can’t afford their prescriptions or their surgery or their specialty care. Long ago, I realized I could not be true to my calling and merely witness health care injustice; I also had to be an agent for change. Thankfully I found many people in Vermont who believed as I did.

One of those people was Peter Shumlin. He had co-sponsored one of the first single-payer bills to be considered in the Legislature, and he was intensely interested, as I was, in figuring out the nuts and bolts of moving from our complex, wasteful and unfair nonsystem to something more akin to the successful health care programs in developed countries around the world.

Without Gov. Shumlin’s bold leadership I am sure we would not have passed Act 48 — the landmark 2011 legislation that laid the framework for Green Mountain Care. The only missing pieces were the benefit package, the financing mechanism, and a federal waiver, all to be put in place for a 2017 launch date.

Now, we are facing a political reality that makes passage of a financing package all but impossible in the near term. The governor and his team made a valiant attempt to devise something that legislators would approve, but in the end, I think they realized that even their best efforts would not create the political will to shift so much money from insurance premiums and out-of-pocket expenses to public revenue.

When I heard the governor’s announcement that for the time being he was pulling the plug on single payer, I was disappointed, but I was not surprised. For the past few years, I’ve watched a growing torrent of narrow-minded, cynical and misinformed attacks on the single-payer concept, and I’ve been dismayed to hear so many mean-spirited attacks on the governor’s character and motives.

Therefore, I do not fault Shumlin for his decision as much as I fault the vested interests that fought so hard against the idea that providing health care to all people is worthy of public finance. These vested interests include institutions with a commercial interest in health care, out-of-state PAC money and large businesses too miserly to provide decent health care to their employees or to pay a tax for that purpose.

Also at fault is our apathy as voters, our disengagement from meaningful political discourse, and our lack of appetite for change, even when change is sorely needed. I must also mention the media, which in its zeal to hold the governor accountable, often seemed to be adding to the drumbeat of the doubters.

Single payer is not dead. The injustice and dysfunction of our present system will not go away, and only with a commitment, at a societal level, to take care of people’s health care needs as a public good, will we become a community of humans that truly cares about each other and that shares the burdens of doing so.

But commitment without follow through is not sufficient. There have been too many health care platitudes and resolves through the decades that have amounted to nothing. Please, let us not put Act 48 in that category. There may be sectors of the health care landscape that can be publicly financed and made universal one by one, so that we build toward our goal more gradually. I hope that in the coming weeks, we will have fruitful discussions about this idea and others.

As a physician, I know that it is not enough to diagnose an ailment; I must also map a course of treatment; and then see to it that the treatment is implemented. As a Vermont health-reform advocate, I think we have an accurate diagnosis of what is wrong. I think we have a good treatment plan in Act 48, but the implementation is still not clear.

Thus, we are stymied, but not defeated. We have met an obstacle, but we are not dissuaded from working over a longer time frame. I remain convinced that we can have universal health care, maintain quality and control costs, but to do all three, we must have public financing. That is my conviction, and I feel morally compelled, as a physician and person of conscience, to continue acting on my conviction to the best of my ability.

Deborah Richter is a practicing family physician who resides in Montpelier.