Tuesday, March 22, 2011

Republican Party Obfuscates


H.202, the House health care bill will be debated in the House on Wednesday, March 23rd and Thursday, March 24th. In addition Senate Health and Welfare Committee will be holding public hearings on S.57 – the Senate version of the health care bill. These hearings will be held on Thursday, March 24, 2011 in Room 11 at the state house for Vermont business community, employers and employees; Thursday, March 31, 2011 in the House chamber for the Vermont consumer community; and Thursday, April 7, 2011 in Room 11 for the Vermont provider community.

Do not let these opportunities go by. Now is the time to voice your concerns and to ask those questions which seem to have no answers. Email or call your Representative(s) now as H.202 is being debated in the House. You can also testify in person at the Senate hearings noted above or submit written testimony to the Senate Committee by emailing Agatha Kessler at akessler@leg.state.vt.us. The Senate bill can be found here.

Most Vermonters will agree that the current system has serious problems primarily because of its escalating costs and lack of built-in cost containment. In addition Vermont has 47,000 uninsured, half of whom are eligible for Medicaid, leaving approximately 24,000 Vermonters without insurance. In response the Administration and majority legislature are pursuing a completely new approach to health care. However, the question needs to be asked: Aren’t there better ways to deal with rising costs and the uninsured without completely changing the current system, driving insurers out of the state, and imposing government control over our health care? Aren’t there other approaches to be considered? For example, why not open the market up to the insurance industry across state lines to lower the cost of premiums, get serious about tort reform, continue to tweak Catamount to help the uninsured and continue to follow the Blueprint for Health to improve outcomes for everyone rather than turn the whole system upside down when we don’t even know where we are going?

As you may know, the House and Senate health care bill does primarily three things:

It lays the groundwork for development of an Exchange. The Exchange is intended to serve as a marketplace where Vermonters can compare and purchase health insurance. The federal health care reform law gives states broad authority regarding the operation of exchanges, including how many there are within each state, the breadth of the population included in the exchange, and the requirements placed on insurers who provide coverage to exchange enrollees. This definitely sounds good and as conceived by the federal health care reform law does have potential – except that the Administration believes they can use the Exchange as a platform to get to single payer/universal health care and are trying to only let one insurer into the Exchange – even though federal law requires more than one insurer in the Exchange. The Exchange would become operational in 2014 and the Administration is proposing that the Green Mountain Health Reform Board would develop a plan for the legislature by 2012 to supply the details of the Exchange design.

The Administration is proposing Vermont include in the Exchange employer groups with fewer than 100 employees (expanding the current small group market from up to 50 to up to 100 employees). They also propose that state and municipal employees (including teacher unions) become part of the Exchange, and that Vermont integrate Medicaid, Medicare and workers’ compensation medical payment coverage into the Exchange. A number of waivers will be needed to accomplish this.

It establishes the Green Mountain Health Reform Board. This 5-person Board would be analogous to the Public Service Board and would be appointed by the Governor. The Board will control the entire $5 billion health care system. Members would be responsible for all aspects of development of the Exchange and the design of the single payer system. They will develop cost containment strategies, including payment reform, design the benefit package under the single payer/universal health care system and set the budget and the global payments to providers. This Board would also be given the authority to review and approve health insurer premium rate increases. The cost of this Board is estimated to be approximately $1.3M/year.

As proposed, the Legislature is completely cut out of any governance process and has no means of overriding the Board’s decisions. Immediate concern has been expressed by legislators of both political parties and by Vermont’s health care providers because all decisions would flow through this group. The power of this group is beyond anything Vermont has seen because it is essentially in command of 20 percent of the state’s economy. The tough decisions will be made by the Board, not our elected leaders, and in so doing, the public is largely removed from the debate as well.

It puts in place the superstructure for the single payer/universal health care system but with no details. The Administration will ask for permission from the federal government to transform the Exchange into a publicly financed Exchange, which would be the single payer system. At that point, current premium payments by individuals and employers would be eliminated unless an employer chooses to continue providing health insurance coverage. All Vermonters would receive coverage by virtue of their residency for a package of health care benefits, coverage would not be linked to employment and most Vermonters would pay into a system for financing this coverage. This would be the single payer/universal health care system. The Administration has yet to propose the financing mechanism for the single payer/universal health care system, and will not do so until 2013 through the Green Mountain Health Reform Board.

All employers will be “asked” to join in the single payer/universal health care system as the state is not permitted to mandate participation; however, all Vermont employers will be subject to the payroll tax, assuming that is the financing mechanism chosen. If an employer chooses to keep its own insurance covered, that employer would be paying twice (once through the payroll tax for single payer/universal health care and then for its own insurance plan). Finally, the Administration has stated that employers would be free to provide supplemental coverage to their employees, financed completely by the employer/employee, on top of the payroll tax.

Using the payroll tax as the way of financing the system raises significant equity issues. Those who do not have a taxable wage would pay nothing as well as those at the lower end of the income scale. Those Vermonters remaining would shoulder the burden, in return for what most people would consider to be drastically reduced benefits.

As you can see there are many unanswered questions. For instance, how will this reform be financed and why is the financing proposal being delayed 2 years? The net effect will be to destroy the current system and begin to replace it before we know what the new system will cost. This will result in a de facto single payer/universal health care system. By its very nature, the proposal eliminates the “safety net” of a private insurance market; will there be a Plan B in case things do not turn out as expected? Will it be sustainable over time?

What will happen if Vermonters get care outside Vermont – will it be covered and what will Vermonters have to pay for it? How will border issues be addressed, i.e., if a New Hampshire employers have employees who live in Vermont, and vice versa? What will this plan do to the business environment in Vermont? Will it encourage or discourage new businesses?

Finally, what about state employees? Will they be required to be covered under the single payer/universal health care plan? Their right to bargain for health care benefits is in statute (3 VSA 904 and 3 VSA 631). If the state requires that they be covered under the single payer, the state would have to repeal these statutes, taking away their bargaining rights. The loss of bargaining rights would also apply to educators and municipalities. Being able to bargain for “wrap-around” or supplemental insurance will do nothing to contain costs and will raise questions of single-payer/universal health care equity. See the AP story on this here. According to the current version of H.202, the state will select an insurer to offer one plan with two levels of out-of-pocket expense. On January 1, 2014 those will be the only choices available to individuals and small businesses to obtain health insurance coverage in Vermont.

The fundamental problem is: there are currently no answers to basic and important questions. Vermonters are being asked to go along with a plan without any answers and are being asked to just trust that “they” will release the details later. Can we do this with our health care system that is $5 billion and 20% of the state gross product? Why is the plan being pushed through so quickly? Why at the last minute does H.202 now refer to single payer as “universal health care”?

Reach out to your State Representative(s) and Senator(s) now and require them to slow down the process. All that needs to be done right now is to allow the Exchange to go forward in accordance with Federal law. The Administration and the Legislature can then pursue alternatives that will begin to address cost containment, establish performance measures and assist the uninsured without expending $1.3M/year in support of the 5 member Green Mountain Health Reform Board. It will take time to develop the right system for Vermont and we should move ahead deliberatively and thoughtfully, engaging the public and having answers to questions at the ready to ensure public understanding and commitment rather than pushing through a bill that does not provide answers to basic and important questions. Your concerns are being heard. H.202 as passed out of the House Health and Welfare Committee now requires a fiscal analysis from the Legislature’s Joint fiscal Office by April 21st. So keep asking those questions and sharing your concerns.

{ 1 comment… read it below or add one }

Stephen Marshall March 22, 2011 at 3:00 pm

Your comment is awaiting moderation.

You’re not up-to-date on the bill. The house committee has issued a working draft to create a nominations board, with two year terms for 11 members, essentially just to identify qualified persons for the Green Mountain Care board.

I can understand doubt about the benefits package, since it hasn’t been created so far, but you have no right to assert they will be “drastically reduced”. You just don’t know. And two things: The people planning this thing will be covered by it, too, so its not going to be shabby, and those who want additional coverage will have the entire insurance market to get it from.

The arguments you have used to slow things down are edge issues. A complete and detailed plan would be terrific, but as yet we have not found any crystal ball to figure out the best plan. The fact is that these details will be resolved by thoughtful people from all political parties and there is no reason to worry about the pace. The fact is that the costs of health care are accelerating so fast we cannot afford to wait a year before implementing a plan to change the system. And besides the fact that the current system is a market failure, and there are thousands of people who need health care and are not now getting it, once the destructive properties of the profit motive are removed from the health care and health care financing systems, the terrific efficiencies gained will make Vermont a great place to do business.

Friday, March 18, 2011

Insurance is the Wrong Model for Health Care

As the citizens and legislators of Vermont consider a plan to displace private insurers from the essential care component of the health care delivery, I wonder why they wouldn't be relieved to get out. After all, the purpose of insurance is to protect the customer from an event that is possible but not inevitable, is not likely, and is terribly inconvenient, giving the customer reason to avoid the event. To me, this does not describe essential health and medical services.

For us, the people of Vermont, the services of doctors, hospitals, physical therapists, mental health therapists, midwives, chiropractors and so on, are routine, necessary, and, if not desirable, amount to the desirable response to another, actually unwanted, "event". In fact, the growth in deductibles tells us that the insurance companies don't want this responsibility either, and are doing exactly what the insurance model predicts they would do: they are offering more and more plans with larger and yet larger deductibles. Here are some numbers:

Between 2003 and 2009, premiums in employer-based plans, depending on the plan type, increased in Vermont in a range from 32% to 54%. And as a percentage of median incomes, these premiums went from 15% to 17.4% for singles, and from 14.4% to 19.4% for families. That's a painful lot of money that is cutting a lot of people and businesses out of the market. But meanwhile, deductibles for employed singles increased two and a half times (+148%), and doubled (+112%) for families with employer based insurance (Commonwealth Fund, 2010). But the deductible is the cost zone where essential care occurs, and these plans are only helpful in the event of - I am repeating myself - the unlikely and undesirable. I think the insurance companies do not want to be in the essential care business.

Simply put, the insurance model is the wrong way to pay for health care. If I buy a shirt, the retailer is happy when I take my shirt with me, and is happier yet when I wear it out and want more shirts. In the insurance business, what I buy, the seller hopes I will never use. And as the chances of my unlikely event occurring increases, the insurance salesman wants less and less to sell me any thing. His (her) best customer is the one who needs that product least, or not at all!

The problem for Vermont is that even though the insurance market does not want to, and cannot, provide what the people of Vermont want and need (universal, reliable, affordable, accessible health care), they also don't want to get out of the way so that we, the people of Vermont can provide it for ourselves. Could the insurance industry please answer this question? Why are you resisting a public system to pay for essential health care? In 2003, 58% of insured Vermonters had a deductible. In 2009, 71% had a deductible. Do you really WANT this job?

Most Vermonters think it's about the money. But how much is the essential services sector really worth to you? Is your profit in the essential care sector really worth more than universally accessible, quality health care is to Vermonters?

Sunday, March 13, 2011

The Fate We Choose

I asked my pharmacist, “Have you been following the debate over single payer?”
“No.” he said, “I don't think it's going to happen.”
“Why not?” I asked.
“The insurance companies won't let it happen. There is too much money involved.”

If we were not on a national and international stage, we might only be asking “What is the best way to deliver health care?” But the debate here in Vermont – our debate over single payer health care delivery – is much larger than how to best deliver health care. It's even larger than the the question “What is the relationship between the citizen and the government?” This debate is about the question “What do we want our lives to be like?” What is the reason for life? Why are we here? Why are we engaged in the democratic experiment? And “What fate shall we choose?” Is it our goal for everyone to have a reason to live and a quality of life that justifies living, or is it our goal for some few to live richly, while the vast majority of people live from pay check to pay check, at risk of eviction for any episode of ill health, eating second rate food? As the income gap widens, as the federal budget shrinks and college becomes less accessible, parks are over-run by commerce, as police and fire departments are halved or eliminated, as class sizes grow and arts and music disappear for our children, as the middle class disassembles, as the uber-rich cut environmental law exceptions for themselves, allowing them to pollute with eternal impunity, the fate of the poverty class awaits the middle class.

We are in a fight for our lives, our nation, and humanity. Confronted nationally by a declining quality of life, by increasing insecurity, the dogma being shouted is to preserve the right of a few to get rich. Too many of us believe this dogma. Confronted by downward mobility, we are told to blame the government for “spending too much”, for excessive social welfare, for too high entitlements. We are promised that if we reduce taxes, reduce even the bulwark of the middle class, Social Security, even while the rich get richer and the regular people become poor and then poorer, our wealth will come. They will invest with their hyper-exuberant tax savings, they say, the economic pie will get bigger, they say, and those jobs will restore prosperity, they say. Really? Do you really believe the uber-rich will not just keep the profits for themselves? Confronted by the end of the middle class, we desperately hope these promises will reverse the slide of our fortunes. But these promises are the cause of that slide.

How is it that keeping more tax money enables the uber-rich and corporations to invest, when their bank accounts are fuller than ever and corporations are hoarding money? While the US spends more on its military than all other countries combined, how is it the same political-right that demands lower taxes also takes the military budget off the chopping block? How is it that just when the political right has finished its spending spree, and the priorities of an economy in recovery under their political opposition take hold, then they call for austerity? How is it that just when the Treasury must begin to repay America's debt to the Social Security Trust Fund, just when the people of the nation need their collective safety net most of all, then they call for cuts in Social Security benefits, lest taxes must be raised. Whose money are they saving?

The extreme political right is not just unwilling to pay for their own priorities, they want to destroy the social safety net. They will do anything to advantage their own accumulation of wealth, even destroy the democratic experiment we are living. Read the libertarian literature. They want to end taxes. But without taxes, only oligarchs have money, and an end to taxes is an end to democracy. They say “Freedom is incompatible with democracy”, because democracy promotes tyranny of the majority. They show no temperance, no self-restraint, no regard for the commonweal. They are prepared to destroy our system government. And with their control of the right-wing media machine, they are succeeding.

And they will go to any end to prevent us from instituting a single payer health care system, because our success will endanger their project to make America safe for Oligarchy.

If we allow our political and economic policy to be guided by the anti-government pseudo-populism, only one political principle applies: The ends justify the means. Do any harm needed to hold and keep wealth and power. Scream, lie, distort, manipulate, steal, kill, take, hoard, what ever is needed, get it. Truth be damned, science be damned, justice be damned, the fate of the Earth be damned, the fate of other people and our democratic experiment be damned! Just get power. And blame the government for everything that goes wrong.

They would have us forget the power we have, demonize our institutions of collective action, and accept the slight of hand by which their wealth accumulates in ever deeper piles, while our nation, the first nation founded by the people, for the people, is stolen from us. They conveniently overlook that the government is us. They want us to forget that from we the governed comes all of the power. That the government is the institution through which we effect our common goals. They plan on us being hypnotized by the drumbeat of “get yours, you are alone”, and that we will lose the ability to fight back, make this our nation, make this a nation that is just, make this a nation in which lives can be lived with hope.

The choice we have is between living like the Japanese or Norwegians, whose lives are quite good, or like the Pakistanis, the Libyans, or even the Somalis, whose countries follow the writ of Libertarian-Capitalist self-interest. In countries with high social equity, like Japan and Norway, in the vision of our founders, and in our country until the Libertarian attack, two principles are (or were) joined in the means (by which ends are accomplished): the rights of personal voice, prosperity, and well-being, and the responsibility of a shared fate. In a just society, advocates for different ideas of how to create that nation seek a shared solution that aims for the most good for the most people. And it is in the resolution of different principles and visions that meaningful solutions are found. In an unjust society, only one principle applies. That one principle which destroys opponents. The principle of power. That one principle which we must summarily reject.

We have decided that “Health Care is a Human Right” because our conscience tells us we must, because whither the law, prevailing opinion or the demands of national security, we know that the better life it produces for individuals produces a better life for everyone, even those who can afford all the health care they could want, and that makes it the Right thing to do. Access to health care, education, healthy food, sound housing, are absolute human goods. We decide to call them “Rights” because we need to, we must, push back against the belief that “to get wealthy is a right, and for you to be impoverished is not my problem”. To get wealthy is not a right. And to be impoverished is not necessary. (Read extensive research by Richard Wilkinson and Kate Pickett in The Spirit Level, Why Greater Equality Makes Societies Stronger, Bloomsbury Press, 2009)

We must fight now for health care as a human right with everything we have. When the advertising rolls out telling us about the great plans the insurance companies have to improve health care, when they charge that taxes will increase, when we are attacked with the label “Socialist”, when they talk about their passion for the health of patients and what a great job they do, we must answer their distortions and lies with truth, we must forcefully tell how they fail to deliver health care, and we must remind everyone: all they want is our money – they do not care about us. They haven't delivered, they can't deliver, and they won't deliver, the health care we need, because affordable health care for all, because health care as a human right, for profit, just isn't possible. It's a social project that only we, the people, through our government, can undertake.

Which fate do you choose?