• Confronting doubts
    August 31,2014
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    An op-ed piece appearing in these pages last Sunday has struck a nerve among advocates for the single-payer health care plan that is due to be unveiled this January.

    Paul Ralston, a Democratic House member from Middlebury who is not running for re-election, warned that the poor performance of Vermont Health Connect, the state’s new health care exchange, has created doubts about the state’s ability to manage a new single-payer plan. He warned legislators against becoming lemmings marching to the sea in a mindless embrace of a plan that would not work.

    The common thread among responses has been that the exchange and the single-payer system are two separate and quite different projects and the purpose of single payer is to avoid the complications that have made the exchange such a mess.

    Meanwhile, those designing the new system have many variables to juggle as they develop a plan that provides affordable, universal, comprehensive coverage for all Vermonters. And in some areas there is good news that might bode well for the future of health care and for single payer.

    A story last week in The New York Times charted the changing forecasts for the growth in spending for Medicare. For the past six years forecasts for Medicare spending have steadily declined so that the difference between the current forecast for spending in 2019 and the forecast for that year that was made four years ago is $95 billion. The shrinking cost estimates for future Medicare spending mean that future federal deficits can also be expected to shrink.

    Vermont’s single-payer system is not Medicare. But shrinking costs for Medicare could well be an indicator of shrinking costs more generally in health care. And cost projections about health care spending in Vermont will help determine whether legislators face a lemming-like leap off a cliff or a steady march toward affordable, universal care.

    Health care officials are well aware of the importance of containing costs, and many projects are under way, with some success, in bending the cost curve downward. Initiatives to manage chronic illnesses more effectively are helping to restrain spending for costly conditions such as diabetes or heart disease. Widening awareness of the danger of obesity has allowed physicians to focus on improving health rather than merely racking up a steadily growing tally of treatments for Vermonters’ worsening health.

    The many moving parts of the health care system will require constant attention by state health officials. Thomas Huebner, president of Rutland Regional Medical Center, testified before the Green Mountain Care Board that he suspects high-deductible health care plans for which people have signed up on Vermont Health Connect have led to increased patient debt. He said he saw increased hospital usage before those plans kicked in because, he surmised, patients didn’t want to pay high deductibles for the treatments they needed.

    If Huebner’s suspicions about the high-deductible plans are valid, it would be an indicator that Vermont Health Connect is failing to achieve one of the major goals of health care reform — freeing consumers from high-deductible plans that do no good for the policyholder.

    One of the conditions for a workable single-payer plan is that it is affordable. Affordability means that health care costs will have to be contained and that the cost to taxpayers does not become overly burdensome. Supporters of single payer say that unless these conditions can be met a plan will not be enacted. And yet decisions about going forward may hinge on judgment calls about what is an affordable tax and how fast we expect costs to rise.

    There are unintended consequences. Another New York Times report showed how the expansion of Medicaid coverage under Obamacare has led to a booming new demand for mental health care and that lack of sufficient providers in Kentucky has led to long wait times. A wait time of that sort might be characterized as rationing, except before Obamacare, there was often no line to wait in. Now at least there is a line.

    Forward-thinking policymaking requires a willingness to embrace the complexity of the task. The health care system is in flux, with much promise for major improvements. To achieve those breakthroughs we cannot become timid before the inevitable problems and doubts. Nor can we remain dogmatic about a desired solution.

    The state and nation have embarked on a grand endeavor to fix a system that has become cruelly distorted by market forces, greed, haphazard growth and the unwillingness of the people to believe in their power to achieve great ends. Doubt is natural and useful as long as it does not become transformed into paralyzing fear.
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