From the AP:
Vermont could offer health coverage to all its residents and spend $51 million less a year on health care under a single-payer system, according to a legislative consultant’s report released Tuesday…
…[Chittenden County Senator Jim] Leddy called the report “one more step in our ongoing process that will continue.”
So around we go on this…again. There are two things missing to move on single payer: one, the political will. Two: a real roadmap. Now before people go all nuts on the first one, the fact is that without a practicable road map, there won’t be enough political will in the universe to make something this radical happen.
The problem with the activist left on such issues is our frequent inability or lack of interest in thinking about the road map. There’s a “just do it,” leap-of-faith mentality – as most of us are more interested (and practiced) in organizing than policy making. But we need to come to the realization that if there is a road map to progressive change on the table for all to see and consider, there isn’t necessarily a “leap of faith” required, and the problem of political will among our elected leaders diminishes rapidly.
I know I covered all this in a previous post from some time back, but with the above news, it seems more timely now. In the previous post, I just threw out my own, naive roadmap on the table (based on my extremely brief, but instructive experience with medical billing in an IT capacity) in an attempt to jumpstart discussion. With this latest news hopefully rekindling debate, I’m going to reprint it below and invite boos, catcalls, eyerolls, cheers, shrugs, or alternatives…
It’s likely there are many ways to get to single payer. Piloting a system with state employees and incentivizing others into it gradually, for example. However, there are a few cold political realities that must be faced to make something like this work. First, there can be little or no perception of tax increases, or any up-front increase on the burden of working and middle class citizens. Second (and most daunting), the bulk of the changeover must be complete within the two-year election cycle, so incumbents can feel confident they will have results to run on and not face a backlash in the midst of a painful transitional period (and yes, this is the opposite view expressed by many current legislators, I know).
The devil’s in the details, of course but in the interest of keeping all options alive, the following are five broad steps that, as part of a comprehensive reform bill, could facilitate the transition under these preconditions.The basic premise is this: legislatively lock all current health plans and malpractice insurance plans into place during the transition period, gradually move all insurance reporting to a centralized state-based reporting/tracking/reimbursement system rather than having patient accounts systems and departments at every medical facility, then slide all current commercial planholders into comparable state-administered plans with the same premiums being paid directly to the state rather than the commercial payers. Then use the profit (and there IS profit under the current payment rates – plenty of it) from the premiums (along with taxes levied on larger employers that weren’t adequately covering employees already, as the Catamount plan does) to assume basic coverage for uncovered Vermonters. This gives you a dramatically larger revenue base from which to build a coverage pool for the uninsured, and sufficient resources to have the state implement it directly, rather than farm it out to a commercial payer. By the time the transition is over, we zero out remaining profits (the state shouldn’t be in the for-profit business) by passing on savings to the ratepayers, businesses, and physicians by actually bringing DOWN premiums.
That’s the abstract. Somebody gimme some money to fund a study and I’ll hash out the details. In the meantime, to flesh that out a little bit, I see it playing out in the following order of steps:
1. First, freeze all current private insurance plans with the understanding they will be discontinued within one year. Within that time, require all providers (doctors and hospitals) to convert to electronic medical records. The state should then enter into a partnership with an established commercial “practice management” software provider (no, it doesn’t have to be IDX!) to refit their system to centrally receive, convert and process insurance claims under all the current plans and communicate with the current payers. Collect all existing coverage information into a central database.
2. Once coverage and patient data is centralized, cancel all private insurance and assume the responsibility for all existing, catalogued plans at the state level. All providers will be submitting patient claims to this centralized system, but the insured and their employers will be paying the same rates and receiving the same plan. From the current health care consumer’s standpoint (both individuals and employers), transitioning them into the system should be seamless. There is, of course, profit taking in the system currently, so just transferring the system of premiums and provider recoupment to the state will also transfer those profits, helping to fund the system. The state should put some initial money into a pool to keep the system solvent long enough for the revenue to start flowing.
3. After a comprehensive analysis, settle on a system of a limited amount of coverage plans (much like a for-profit insurance company) that mirror Medicare and Medicaid plans for uniformity, since those forms are dictated to some extent by the federal government. Simplifying and streamlining plans to mirror the federal programs’ systems will also make it simpler for the newly created (and only modestly-sized) State Patient Accounts Division to be the go-between between Medicare and Medicaid eligible patients and the federal government for payment. Fold current users into the new plan that most resembles the commercial plan they are leaving behind and offer uninsured residents their choice of plans with a sliding-scale premium based on their ability to pay.
4. Conduct a parallel process with physician malpractice coverage, with an eye towards a rapid phase in of premiums that truly reflect an overall revenue-neutral, cost/benefit survey on the real costs of supporting malpractice insurance based on historical projections of payouts (I guarantee you such an analysis focusing on Vermont and without a profit incentive or excessive overhead would generate a FAR lower premium for physicians – bringing down what is often cited as the number one spiraling cost on physicians end of the equation). Malpractice costs are an often overstated, but nevertheless very real source of spiraling costs. In fact it seems to be every bit the racket that much of the health insurance industry is. Taking over malpractice insurance at the state level and implementing it with a zero-profit, realistic cost-benefit analysis is therefore critical to the overall goal of controlling helath costs in the state so that any Vermont single payer plan can be predictable and sustainable. In the interest of bringing down costs, drug re-importation also becomes a priority, which is yet another way that implementing such a plan could put the state on a collision course with the feds. Sometimes it’s worth playing chicken though.
Once the data is centralized, a market “going rate” analysis can also be made of what current employers can reasonably be expected to pay into a system, based on a snapshot study of what businesses were paying into commercial plans at the time the transition started. A fair rate for a business premium can be based on this analysis, and should also be based on business’s ability to pay.
Finally, a generic “bare bones” coverage plan can exist for all those that aren’t reached to choose their own plan option (emergency cases), and charges to such patients can be submitted under a “dummy account” to the state, pending proof of residence (as defined by the legislature under the plan).
5. Savings from lower emergency room services, lower paperwork and administrative overhead (providers’ patient accounts personnel resources can likely be reduced by 50-100%) can be used to boost the coverage pool for catastrophic conditions and the sliding premium scale.
Under this approach, there are no new expense increases for the consumer – simply a redirection — and the draconian increases in coverage hitting individuals, employers, and local property taxpayers annually will all but vanish.
There would be bumps in the road of course, not the least of which being confidentiality and privacy concerns. But if nothing else, weary legislators and policy advocates could take heart from this example and not give into cynicism. Obviously working out the details and passing such a plan would be a Herculean task.
But not an impossible one.
Your turn.