Of all the ruts the Vermont left seems to be in, the policy rut seems to be the most problematic. There are tremendous upsides to living in such a small state, where political interactions are generally more personalized affairs than in other arenas, but among the downsides is the political stereotyping – or perhaps archetyping – that happens. People slip into roles, and often seem to simply go through the motions in acting out those roles time and time again on the political stage.
Case in point, the needless tragedy that is the failure of H.304, which would have set up the State of Vermont to become the functional single insurance payer for Hospital care, in an attempt to jumpstart the transition to a single-payer system. As many on the left opined (myself included), 304 was a bad bill, poorly conceived, supported and understood – and as such doomed to failure as written. It was, however, the first meaningful, tangible attempt to make a real first step in the single-payer attention, and as such deserved more than to be unceremoniously dumped. Unfortunately, neither its supporters nor legislators were interested in making any progress, so immersed as they were in playing their respective, traditional roles.
For the legislators, that simply meant throwing up their hands because it was too hard. Now, this is a “citizen” legislature with limited time and support, and who depend on the executive branch to flesh out the legal nitty-gritties of whatever they pass, programmatically, so I have some sympathy given all that they’re asked to do – but still, there is no more important issue period, so the time must be made. This bill should have been taken on and at least discussed as a serious starting point.
And for the activist/supporters, it meant virtually phoning it in. A half-baked bill that makes it hard to believe they expected it to get a serious hearing. A public support campaign which cavalierly insulted people, rather than spoke to them, and a harsh unwillingness to accept any criticism. I received a rather unpleasant email from someone who, by their email address and “behind-the-scenes” take on things, was clearly a Vermont Health Care for All insider. Let’s just say it was anything but open to criticism from anyone – even someone who publicly supports their cause. And the display in the Statehouse was even worse. When met with incredulity from serious lawmakers looking at the partially fleshed-out revolutionary overhaul of the system, many of the same, usual activist suspects just fell back on their old roles and chastised even friendly legislators like Senator Racine (D-Chittenden) and Representative Maier (D-Middlebury). It was as though they were covering their ears and going “na-na-na-CAN’T-HEAR-YOU-na-na-na” to even ideological allies who were merely skeptical about this particular approach.
The final result, predictably, seems to be a big fat nothing. Everybody going through the motions, and nobody surprised by the outcome. Is it possible that we need not only some fresh faces in the legislature, but also some fresh faces among the activist community?
Let’s talk solutions after the fold…
As GMD commenter SPS pointed out at the time:
My concern with this bill is the incentive structure it may put into play for many Vermonters with high-deductible insurance. Basically, if a person needs to go to the doctor, but has a $3000 deductible, s/he is likely to try to go to the emergency room to try to take advantage of this benefit and avoid the deductible charge. It encourages people to use the most expensive part of the health care system for relatively simple problems. Maybe I am reading it wrong, but that is what it sounds like.
It might make more sense to start single-payer on preventative and chronic care side.
Agreed. But how?
The most successful progressive program in Vermont is arguably Efficiency Vermont. Efficiency Vermont is run through a private nonprofit and “provides technical assistance and financial incentives to Vermont households and businesses, to help them reduce their energy costs with energy-efficient equipment and lighting and with energy-efficient approaches to construction and renovation.” The concept is that the program and its recommendations, if implemented, conserves energy (across the state and for individual users), as a result bringing a user’s utility costs down by a certain amount, while getting funded with a charge on that bill that creeps it back up by far less than the savings provided by the program itself, maintaining a significant net decrease in consumer costs while perpetuating itself financially.
Could you do that with health care?
It’s not a clean fit, but it could be rhetorically powerful if you could make a programmatic approximation. It’d make the concept a much easier sell to a public (and to a legislature) which has grown comfortable with the Efficiency Vermont model.
Here’s a shot at it:
- Create a privately managed and administered network of providers to provide a set list of basic, preventative care procedures (e.g. health screenings, mammograms, and basic health maintenance including blood testing – possibly even inexpensive medicines for conditions like diabetes and hypertension. Some of the most common medications for those conditions are actually pretty inexpensive). Or, better yet – retrofit the already existing Catamount system to handle it…
- Have these procedures for Vermonters in the program paid for by the new state authority.
- Modify community rating so that signing onto the program can be considered by private insurers in setting rates. Mandate that Vermonters on the program must have their premiums reduced or rebated by a certain percentage.
- Pay for the program through a surcharge on health care premiums – but one far less that the premium reduction afforded for joining the program, leaving a significant net savings for the consumer in place.
- I would consider making the program as financially stable, predictable and manageable as possible, maybe by surveying how many Vermonters are likely to participate and giving participating providers block payments, rather than having them bill each individual procedure. If a doctor reaches the limit of what they’ve been block granted, an effort can be made to direct patients to another nearby doctor who isn’t so maxed out – and of course if that isn’t possible (or there is no other nearby participating provider), the state can start covering procedure by procedure. The block grant approach could have the added effect of further cutting into the clerical costs of health care. Of course, it would also make for some heinous end-of-year reporting requirements, but it’d still be less paper work than billing every individual procedure to the state. Perhaps a special recording/accounting/reporting software package could be standardized for participating providers.
Hopefully, such a system could be rigged to largely pay for itself, while bringing down premiums for individual Vermonters – again, mirroring Efficiency Vermont. There would be broad payoffs at the community level as well, as the health care costs impacting town budgets and local businesses could be noticeably effected.
One of my favorite elements is the idea that we wouldn’t be counting on all the mystery money saved by reduced paperwork and early treatment. Over the last couple decades, there has been a game of activist telephone played on those numbers. Somebody gives a ballpark estimate of x-many-millions that could be saved, that gets picked up, repeated, passed around – and then gets promoted as a firm value that budgets can be predicated on, which is nuts. There are guesses and speculations, but nobody can say for sure how much will or won’t be saved from such changes. In this system, we wouldn’t be depending on such phantom numbers. Those savings would simply present themselves – whatever they may be – and we can work with them from then forward.
It would also get more people comfortable with the idea of the state brokering their health care, and would be a meaningful way to grease the wheels towards single payer, should we ever get enough flexibility from the feds to go that far. As I’ve stated before, for such a transformational change as a single-payer health care system, there has to be enough buy-in from the general electorate to support taking the plunge, come what may.
Under such a program, it might end up making even more sense to a broader range of Vermonters for all the ethical, commercial and practical issues the rest of us talk so much about.
So – your turn. How might you make tangible steps into a single-payer world? Throw your ideas out there, or tear mine to shreds… or both.
