Vermont: on the road to single-payer health insurance?
Tiny Vermont is probably the most leftist state in the union.
Like many other New England states, it has a mix of old-time residents and their offspring, who tend to be more conservative, and relatively new arrivals (“new” in New England meaning anyone who arrived during the past 70 years) “from away,” who tend to be very liberal.
Like other New England states except for Massachusetts (population 6.6 million; see this for all states) and Connecticut (3.5 million), it has a tiny population. Maine is big in geography but only has about 1.3 million people, as does geographically smallish New Hampshire, and diminuitive Rhode Island has about a million. But Vermont, with about the same square mileage as New Hampshire, has half the people, with a population of about 625,000. That’s only about the size of a medium-large city, although Vermont is decidedly rural. Its biggest city, Burlington, hardly even qualifies for urban designation at all at 42,000 people.
So whatever health care solutions Vermont comes up with, it will be difficult to extrapolate the results to the rest of the country, except perhaps for others of its ilk in the bottom tier of population (although their populations tend to be far more conservative than Vermont’s, such as that of Alaska and Wyoming).
That’s one of the reasons that federalism is a good idea. States are free to experiment with health care insurance systems for their residents. And Vermont has done just that, taking a step described as being on the road to a single-payer system.
I’m not so sure that’s so. Take a look for yourself:
Legislators say the plan, approved by the Democratic controlled House and Senate this spring, aims to extend coverage to all 620,000 residents while containing soaring health care costs.
A key component establishes a state health benefits exchange, as mandated by new federal health care laws, that will offer coverage from private insurers, state-sponsored and multi-state plans. It also will include tax credits to make premiums affordable for uninsured Vermonters.
Private insurers are included there rather than single payer. But the goal is certainly eventual single-payer, and in the next few years rather than later:
The exchange, called Green Mountain Care and managed by a five-member board, will set reimbursement rates for health care providers and streamline administration into a single, unified system…As designed, the goal is an eventual state-funded and operated single-payer system.
There are a number of things that have to happen first, however, and they could represent big speedbumps or even roadblocks along the way. Vermont has to make a good case (the word the article uses is “ensure,” whatever that might involve) that the new plan will be cheaper than the old. Of course, we’ve learned that’s not all that hard to do by making sanguine assumptions that are unproven. The state also must ultimately get a federal waiver from Obamacare in order to institute single payer, assuming Obamacare is still around by 2017.
I mentioned that Vermont is loaded with recent immigrants “from away.” One of them is Dr. Deb Richter, who moved to Vermont from Buffalo NY in 1999 for the express purpose of pushing single payer health insurance. She had found the atmosphere in New York state to be unreceptive, and correctly surmised that the idea might encounter more fertile soil in leftist Vermont.
Certain Vermonters of the Republican persuasion aren’t too happy about that:
John McClaughry, a former Republican state senator who is against the new law, said Dr. Richter meant well but did not understand the “long-term damage” it would wreak. In particular, he said the law would drive away businesses that did not want to help pay for it.
Businesses? Vermont?? The state is not known for its welcoming business atmosphere to begin with. For example, it was ranked as number 45 out of 50 states by Forbes in 2010. For comparison, note that New Hampshire, its more business-friendly twin, was number 19, and behemoth Massachusetts was 16. But Vermont needn’t be ashamed before most of its fellow New England states—Connecticut was 36, and Rhode Island and Maine brought up the rear at numbers 49 and 50, respectively.
I’m not sure why political progressives, given their many millions, even feel that they need the state as the prime agency in this matter.
You would think that some clever Democrat would start a non-profit, come one come all, voluntary insurance plan that would appeal to some significant portion of the 70 million registered adult Democrat members in the United States.
And which, if their theory of mass membership and purchasing power are correct, would manage through voluntary means to do what they say they hope to accomplish through government coercion.
They could thus prove their mass membership theory out that way.
How many millions of progressive members do progressives actually need in order to accomplish their, uh, stated, goal?
If 72 million are unwilling to bet on their house horse, then how about 35?
If not 35 then how about 25?
Twenty-five million ardently participating and paying Demos, is after all the approximate equivalent to the entire adult population of Canada.
Certainly Democrat/Progressive loyalists are sincere enough and motivated enough to place their chips on their own social bet in sufficient numbers to achieve that critical mass they predict will bring about a heath care cost revolution?
They are sincere enough, aren’t they?
I mean it’s not really about control instead of cost savings, is it?
Ah yes Vermont. The liberal boutique state with four black folks and three mexicans which qualifies it as America’s largest gated community.
Dr. Richter better go out and recruit more doctors to come to Vermont and practice. Otherwise, with price controls, I predict that there will soon be a shortage of doctors in Vermont. De facto rationing.
IMHO, there are three things that would reduce costs – tort reform, up-front copays of 20% of the bill, and posting prices in the doctors’ offices. Of course, few want that because then people would tend to make financial decisions about whether their physical complaint justifies a trip to the doctor. My doctor tells me he has too many patients that he believes are hypochondriacs. It’s unprofessional of him, but he sometimes complains to me about patients who visit too frequently and have nothing that he can find wrong. That sounds like he, and by extension me, is blaming a lot of hypochondriacs for running up the costs. I’m just reporting what my doctor has told me. I can only assume his experience must be fairly normal for a GP.
As we get older our bodies change for the worse, even those who take care of ourselves. New pains, changes in bowels and bladders, lack of energy, and more can make us wonder if the big C or something else just as ominous has made its home in our tissues. People should not ignore those things but once checked out and found to be normal aging or minor changes, we have to get on with living. Apparently many do not.
I recall my childhood days (1933-1954) and the medicine of that time as being mostly market driven. Few people had health insurance. I remember distinctly the price list mounted behind the reception desk at the village doctor’s office. Many people paid their bills in bartered goods. My mother paid bills by doing hair styling for the doctor’s wife. Few went to the doctor if they hadn’t tried a home remedy of which there were many. And yes, doctors made house calls. Hospitals were usually run by churches and counties. Practically no one paid in full at the time of service. Surgery or other hospital stays usually meant a time payment plan of some sort. Some church run hospitals often charged by the patient’s ability to pay. The church run hospital’s charitable medical work was provided through charitable donations. None of the hospitals were for profit. (Those came after Medicare became law.) Yet, I don’t recall that there was much unnecessary suffering or bankruptcy because of the financial arrangements of those days. Our local doctor was, along with the banker, the wealthiest man in town in spite of affordable fees and accepting barter for payment.
Four things have caused the medical system to become a monster. The first was company paid health insurance, which began rather small during WWII and grew like topsy during the 50s and 60s. That created a system that was opaque as to costs. The second was Medicare, which pumped new money into the system and created for profit hospital systems and opportunities for fraud. The third was the legislation, passed in the 70s, that required emergency rooms to take all patients irregardless of ability to pay. The fourth was the growth of the medical tort industry which has become a piggy bank for greedy (yes, greedy) lawyers and forced costs up in all areas of the medical field.
Any attempt to curb costs, and that is what everyone says needs to happen, will have to deal with those issues. At least that’s the way I see it.
J.J. formerly Jimmy J. Says:
“My doctor tells me he has too many patients that he believes are hypochondriacs. It’s unprofessional of him, but he sometimes complains to me about patients who visit too frequently and have nothing that he can find wrong. That sounds like he, and by extension me, is blaming a lot of hypochondriacs for running up the costs. I’m just reporting what my doctor has told me. I can only assume his experience must be fairly normal for a GP.”
Not just GPs. And not just hypochondriacs. Ask any young medical intern training at a large urban hospital what a “frequent flyer” is.
The Worried Well drove me out of internal medicine after just a few years.
I wonder how Dr. Richter earns her living, given that she has given >400 talks and had innumerable discussions with VT legislators, etc., etc., in her 12 years in the state. She is clearly a medical dilettante. But someone’s been keeping her off of food stamps. I suspect she talks the patient care talk, but doesn’t walk. Always follow the money, if you can find the trail.
I further expect the UVT Med Ctr in Burlington is fine with this, hastening the day when all “providers” and “caregivers” will be employed by it. That’s vertical integration and crony capitalism for you, which will take good care only of the cronies– the little DSKs of VT.
I will admit my belief that family physicians are little more than medical traffic cops, most of them. They all complain of being underpaid, too. But nobody made them be FPs, though the Dems eventually will do just that in their lust to create “barefoot doctors”.
A Vermont friend and long term Vermonter explains to me that the hippies moved to Vermont in the 60’s and 70’s and never left. Now they and their children run the place.
J.J. formerly Jimmy J.:
That’s a great summary. It reminds me of a Thomas Sowell column in which he said he didn’t have health insurance during most of his life. (If I recall correctly, after he got out of the Army he didn’t have health insurance until he was in his 40s).
During the period that he didn’t have insurance, he just paid the doctor out of pocket when he was treated for minor ailments. And if he was stricken by something more serious and costly, then he simply arranged to pay the bill over time, just as you said. Of course, during that era, people took their obligations seriously and wouldn’t imagine dishonoring themselves or their family by not paying. I’m not sure you can count on people to behave that way today.
So, you’re right that health insurance is a fairly recent financial innovation.
It’s my understanding that wage and price controls were instituted during WWII, and since it was illegal for companies to compete by offering higher wages, they introduced health insurance as a way to attract workers. Then the unions latched onto it, and it very quickly became a fairly standard part of compensation packages – for unionized and non-union workers.
Now today, liberals/socialsts have redefined health insurace as a universal “right”.
Sometimes I really yearn for the simpler times, which probably means I’m just becoming an old fart.
Scott: however, the medical bills people accrued back then were nothing like the bills now, even adjusted for inflation and standard of living.
Health care itself was completely different in terms of treatment of major illnesses. If you had cancer, it was more often than not a death sentence with very little possibility for treatment and recovery. Bypass operations and valve surgery began in the 60s and were not readily available till some time later. No CAT scans or MRIs till the 70s, and even then not very often. Knee replacements were crude in the 60s and not used that often till further refinements occurred in the 70s and mostly in the 90s. There has, likewise, been an explosion in the pharmaceutical world.
All these things are very very expensive, not just because of “greed” but because it is expensive to develop them, manufacture them, and run them. There are other reasons expenses have shot up, of course, but medical advances are most definitely a big factor.
Neo-
You are making the availability of medical advances appear earlier than was realistically the case. When the 1st brain CT scanners became available in the mid-1970s, Manhattan was profoundly limited in access due to Certificate-of-Need (CON) laws and regulations. I recall that Harlem Hospital was denied its own brain CT scanner because they could send patients to another hospital one day per week. If you were admitted one weekday later with a profound brain injury, it was a six-day wait, assuming you survived.
Most states then had CON laws to protect against “unnecessary duplication of services”. Those regulatory barriers gradually came down in many, but not all, states.
Body CT scanning emerged some years after brain CTs. MRIs became available in the latter 1980s. They were/are majorly more costly than CTs because of room construction needs (no steel!)
If you had a knee replaced before the 1990s, you were insane. Never mind what your orthopaedic site says. All infected prostheses must, repeat must, be removed.
J.J.’s synopsis was superb. It’s one of the best thumbnail sketches of how we got here that I’ve seen.
Veterinary medicine is still based on the free market. About a year ago my cat, Reggie, became very ill. I took him to the vet and she diagnosed him with acute kidney failure. He spent four days in the animal hospital on an IV to flush out his kidneys. The total bill, including hospitalization, medications, and follow-up visits, came to a little over $1000, which I paid out of pocket. He recovered fully and is completely healthy now.
A human could probably run up a $1000 hospital bill in a matter of minutes.
Neo, you’re absolutely right that advances in medical technology are also a cost driver.
What drives me crazy is the widespread attitude that everybody who suffers from a disease or condition is “entitled” to every new cutting edge drug or device that is developed simply because it exists and they need it.
It doesn’t matter that they have a disease that has been a death sentence for countless generations of people from time immemorial. A brand-new treatment is developed, and no matter how expensive it is, they feel they have a right to it.
That attitude needs to change. Cutting-edge technology is usually expensive at first, and only a few can afford it. How many people had home air conditioners in 1930, say? But eventually the price comes down, and more and more people can afford it. Today even people living on welfare in slums have air conditioning.
And how many people in 1930 had their pets put on an IV to save their lives?
DNW: I suspect Kaiser Permanente is pretty close to what you propose, it has 8.7 million members.
Don Carlos: actually, I did write “even then not very often,” meaning—CAT scans and MRIs were invented, but they were not used often till much later. And if you follow the link to the knee replacement site, it indicates that until the 90s knee replacements were not considered a generally good idea, and were not widely used.
I originally hurt my back in the mid-1970s, and no one ever thought to give me an MRI or a CAT scan. When I reinjured it in the 90s, I finally did get both, but only after doctors were perplexed as to why I wasn’t getting better. What’s more, the quality of the image even at that date was not very good. Nowadays it’s quite different.
Neo:
Just expanding and hopefully clarifying your themes.
One must appreciate that the improved prostheses were only one part of the joint replacement revolution. The other is strict acceptance of antisepsis, and the second, then third-generation antibiotics. All infected joint replacements must be removed to cure the infection. Try walking when your replaced knee no longer exists!
Re your mid-1970s back pain, I attempted to point out earlier that CT scanning was for some years limited to the brain, and that MRIs were only a concept, not reality, at that time. No one thought to have you get those because they were not available.
“”There are other reasons expenses have shot up, of course, but medical advances are most definitely a big factor.””
Neo
Can we deduce that the free market in healthcare somehow became so contorted through unsustainable insurance models that technologies were developed that really didn’t have enough customers who could afford them?
I mean we have the technology to build incredibly safe and reliable cars that are ten fold superior to the average vehicle on the road today. But we haven’t developed a compassionate payment scheme (insurance) to falsely make everyone think they can afford it.
I’ll second the motion that JJ hit it out of the park with his analysis. I’m a soon-to-retire family practitioner in MN who has watched with dismay as medicine turned from a profession of healers to one of “providers”; where payment became “re-imbursement.” Tell me, Ms. Sibelius, why am I the one who needs to be re-imbursed? Shouldn’t the patient who pays me ask for re-imbursement?
I’ve been following a blog called Vermont Tiger that has had many interesting observations about Vermont’s suicidal impulses.
A sample: http://www.typepad.com/services/trackback/6a00d834519c3c69e201538ebbc50b970b
Let me try again. That wasn’t the right link.
http://www.vermonttiger.com/content/2011/05/this-cant-be-good.html
How the heck is Vermont going to pay for this? It has the second-oldest median age — probably one reason free medical care is such a popular issue — and it’s 34th in per capita GNP.
I think it’s a great idea. Vermont should be an object lesson in why government-funded healthcare is a disaster. They’re going to run out of money almost immediately, and then either crank up the taxes (driving the few remaining taxpayers to New Hampshire) or start rationing. Assuming there are any doctors left at all, of course.
No VT responders. No one rising to its defense.
Steve H: no, we can’t deduce that.
Medicine is a business and it is in many many ways market-driven, but it is also different. It is about saving lives and/or making lives better in a very basic way. That drives it (and research, and development) as well. It is also ones of the reasons people have come to believe they are entitled to what’s available. When medicine couldn’t do as much for people, people weren’t as upset if they couldn’t afford the latest test or gadget, because those tests/gadgets didn’t make that much difference. Now they are more likely to make a difference.
Trimegistus: how Vermont will pay for it is something Vermont must solve. That’s why I’m so in favor of each state doing its own experimenting with the solutions that state favors. Vermont will find out if this works or not, without inflicting it on the other 49 states.
The tyranny of the majority and the dictatorship of the proletariat can only happen when a tiny minority ascend to power and force you to obey their commands, without leaving you a viable alternative.
If it is one state, tiny or large, you can always move out. That’s a more viable decision than moving to Europe. Less costly as well.
Democrats have this philosophy that people need to listen to what everyone else says in a debate. Once a loser is decided, then they say “I won, you lost, so shut up”.
That’s not “giving everyone a say”. That’s a military dictatorship. Officers and sergeants often tell people in the military that their place isn’t to argue with orders or countermand them. Their place is to voice their view and then obey the decision of the ranking authority.
But isn’t that what Democrats like Obama do? Have an election. And if they win, they act like they are rulers of the universe, with absolute power to do anything they want.
That is not the system of government the United States was supposed to be under.
The point of voting isn’t so much to decide the winner as it is to resolve problems that people would normally use violence and bullets to resolve. These problems DON’T END on election day or the day after.
The point of voting and what not is to give people alternative choices so that they aren’t pushed into taking up arms in rebellion and mass slaughter (French). But it doesn’t matter at all if they vote, and still have to obey the unjust, dictatorial edicts of the Victorious Class. So the point of limited government is to give people in a democracy the option of living the way they want, even if they should lose power politically.
The choice. The Alternative. The ability to do what the ruling class would prefer them not to do.
These protections were enshrined and implaced to provide security (like Israelis demand) and security paves the way for peace and prosperity.
When Democrats wreck them like they wreck the economy because they think they have the might and right, this increases the chance of civil war and it increases instability. Unlike Europe, there are numerous numbers of Americans armed with the knowledge and firepower to do something if you can find a way to motivate them to extreme measures. Their ideology or ideas may sound craptastically stupid, but that’s not going to change the shockwave of a bullet traveling in air.
Unlike in Europe, those that wish to resist the status quo actually has a a chance of success in the US. If this wasn’t so, how could the Left ever have ascended to cultural and political power without being crushed utterly by a majority of PTBs?
Three of the six New England states are in the bottom 6 of business-unfriendly states. That says something.
‘long as they keep it to themselves.
I’m amazed by the number of commenters who agree with my summation of how we went from a mostly market driven system to a financially opaque, insurance driven system that, while it has amazing capabilities, is not affordable. It is like we have gone from a population living on fish, rice and simple vegetables to everyone having to have caviar, lobster tails, organic arugulla, pricey imported wine, and baked Alaska or the equivalent for every meal.
I am personally acquainted with one area where Medicare is being ripped off and that is in paying for C-PAP machines and equipment. Medicare reimbursed the equipment supplier, Optioncare, $1500 for a C-PAP machine that I can buy on line for $750. A mask and hose with filters is $300 from Optioncare. I can get the same for $125. I called Medicare about this and they told me that it was “a customary and normal expense,” and they did not want to reimburse patients, even if it saved money.
WTF?
Then there’s this:
IBM offered a plan to save taxpayers $900 billion dollars wasted in fraud in the health care system – free. Incredibly, it was an offer the White House felt they could afford to refuse. Once again, WTF???
Read the whole thing here:
http://www.examiner.com/political-transcripts-in-national/health-care-fraud-ibm-made-900b-offer-to-obama-white-house-define-free
Whatever Obama and the dems are up to it is not, IS NOT, trying to reduce health care costs.
“”Whatever Obama and the dems are up to it is not, IS NOT, trying to reduce health care costs.””
J.J.
Really is no mystery that their goal is to crash all vestiges of competitive free markets in America. These people’s idea of fairness that seems to drive them has absolutely nothing to do with the human condition. Ideas over people.
I called Medicare about this and they told me that it was “a customary and normal expense,” and they did not want to reimburse patients, even if it saved money.
WTF?
They have a side deal going, where this money will be skimmed off the top and end up in somebody’s pockets as a bribe.