First, I want to quickly get two zombie canards out of the way:

• Uncertainty – Uncertainty regarding taxes and regulations is always a part of doing business.  Also consider the uncertainty of your fellow Vermonters: will they be able to afford a doctor if they lose their job or want to start a new business themselves?

• Rushing – we've had literally years to debate and work on HCR.  If you're worried about uncertainty, then move the process forward rather than holding it back: delay only hurts Vermonters.

Even though it won't really change the minds of people who cling to these flimsy excuses for opposing H.202, I think repetition is good.  Speaking of which, let's address another nefarious meme in a little more depth: SOCIALISM!

I am not going to refer to any dictionary definition of socialism.  That's the last refuge of debaters and only invites even more ridiculous parsing–can a community insuring itself really be controlling means of production, wouldn't Employee Stock Ownership Plans be socialism, etc–that only serves to obscure people's true objections.

Besides, the word 'socialism' at this point is a matter of perception and political framing, not any real definitions.  When you strip away the empty rhetoric and misinformation, I think we're just left with usage equals meaning.  And that appears to be “replacing corporate premiums with government taxation to provide a service.”

I don't see any other reason why the socialism label is applied to single-payer health coverage.  Insurance of any stripe socializes risk, as Adam Smith himself observed:

The trade of insurance gives great security to the fortunes of private people, and, by dividing among a great many that loss which would ruin an individual, makes it fall light and easy upon the whole society. 

Heck, we've socialized the risk (though strangely, privatized the profits) of nuclear power, why not healthcare?  All we're talking about is creating a single, large insurance pool to maximize access to medical services, reducing costs through greater efficiency, and administering it through a transparent and accountable entity the People have incorporated for the public good.

And that's the key: healthcare is a public good.  

I hold this truth to be self-evident.  That's why Michigan, for example, explicitly says so in its constitution, as does our Act 128: health care is a public good for all Vermonters.

Other public goods financed through the constitutional power of taxation (as opposed to paying fees or premiums to corporations): the military; police and fire protection; highways and waterways.  Anybody going to call that stuff socialist?  Anybody going to call our state constitution socialist because it establishes a Commonwealth?  Wherein:

That every member of society hath a right to be protected in the enjoyment of life, liberty, and property, and therefore is bound to contribute the member's proportion towards the expense of that protection,…and previous to any law being made to raise a tax, the purpose for which it is to be raised ought to appear evident to the Legislature to be of more service to community than the money would be if not collected.

Free Mark Hero Adam Smith again:

[A] duty of the sovereign or commonwealth, is that of erecting and maintaining those public institutions and those public works, which though they may be in the highest degree advantageous to a great society, are, however, of such a nature, that the profit could never repay the expense to any individual, or small number of individuals; and which it, therefore, cannot be expected that any individual, or small number of individuals, should erect or maintain. The performance of this duty requires, too, very different degrees of expense in the different periods of society.

Like the air we breathe, we take a lot of public goods for granted.  Their benefit and funding is invisible to us, particularly if they were first implemented a long time ago, so most people wouldn't decry them as socialist even as they rely on taxation and help society as a whole.  If I might indulge in a quick aside that pertains directly to me an my neighbors, consider the Rural Electrification Act.

Before the REA, only about 10% of US farms were electrified.  That had serious implications for their sustainability and efficiency, as milk could spoil without refrigeration, creating unsanitary conditions and causing a lot of waste and financial loss.  Add electricity and storage isn't so much a problem, irrigating more lands increases productivity, feeding and milking becomes less labor-intensive, and so on.

Yet bringing power to rural areas in Vermont and elsewhere was cost-prohibitive and profit-driven companies were reluctant to make the necessary investments.  So the Federal government in this case stepped up during the Depression, seeing the need for increased competitiveness and stimulus (agricultural activity has a huge economic multiplier).  As a result, the village of Binghamville (the section of Fletcher my family lives in) was electrified through the Vermont Electric Coop by 1940.

Now in a not-entirely-dissimilar situation, the Feds have done a little bit to deal with our healthcare issues to make sure there's greater access and affordability.  We've eliminated the pre-existing conditions scam, for instance, but there still are corporate death panels since the default position of a profit-driven insurance company is denial of coverage.  It doesn't seem like the folks in DC are going to finish the job any time soon, it's up to us to take the lead at the state level.

Given that we're not going to enjoy more uniform, nationwide reform, some folks have raised the specter of doctors leaving Vermont for friendly states if we implement single-payer.  Democratic Representative Till is the Leg's only doctor and he sent a survey to 1600 licensed physicians in Vermont, 610 of whom answered:

Till noted one response that worries him — the percentage of doctors who said they might leave Vermont is a single-payer system was enacted. Among all doctors, the percentage was 28.4. When looking just at specialists, the percentage rose to 37.

“We could make insurance available to everyone and lose a lot of the access,” Till said, because of a doctor shortage.

I'm not entirely sure where to start unpacking this.  I guess I'll ignore the validity of such a survey and accept it at face value for the sake of argument, and then go for the low-hanging fruit.

First, note that 28.4% of 610 is about 174 doctors who said the MIGHT leave the state.  I'm going to assume that this is a self-selecting survey and that the other 1,000 who didn't respond really don't care either way.  Thus, we have a handful of physicians who are not overly concerned about the communities they serve who might think about going somewhere else to re-establish their practices.  And that's balanced by over 200 doctors who would do the reverse and come to Vermont BECAUSE of our enlightened health insurance system.

Of course this all sounds like people who threatened to move to Canada if Bush won in 2004, or to Galt Gulch if Obama won in 2008, so I don't put a lot of stock in this, glaring issues with the survey method aside.  The problem is that we hear a lot of similar anecdotal evidence about Doctor Flight if Some Very Scary Reform is passed.

In general, we've been hearing about the US losing doctors for, like, ever, and it doesn't appear to be true.  Just another FUD meme so people will defer to whatever physicians want, methinks.

But could such a thing really happen if there's an imbalance in healthcare policies between states?  I have been unable to find any conclusive data on that, though I still believe we can quash the suggestion based on what is available to a simple blogger.

The closest analog we have to Vermont is Massachusetts, both geographically and reform-wise.  Romney's legislation, which is quite similar to the Affordable Care Act, was enacted in 2006.  I've read a variety of material that asserts MA is losing doctors, either to other careers or other states, but they provide nothing to back up their claims.  MA doesn't hit the Wall Street Journal's radar, either.

I looked at Census data, and that doesn't appear to bear out any claims of Doctor Flight either.  The doctor-to-patient ratio in 2005 was 456, 462 in 2006, 469 in 2007 and 468 in 2008 (latest figures I could find).  While there was a slight drop (-0.2%) from 07 to 08, the total number of physicians actually increased a smidge (+0.8%).  Given that the law appears to be quite popular amongst medical professionals in the state, color me unconvinced that the doomsayers are right about MA, which makes me skeptical of any similar warnings in VT.

If you want to rely on anecdote, I find it hard to believe the doctors we see at the Community Health Center would bail on our state.  Sam's pediatrician is heavily involved in homeless healthcare here in Vermont and in her spare time regularly works at clinics in Haiti (she rushed down after the quake, too).  These folks are dedicated to fostering healthy communities and ain't gonna run away when we implement something that helps more people get treatment they need.

We can certainly quibble about some details of H.202–I have some beefs with it myself.  But let's stop with the rhetoric that only serves to scare and confuse people, and rather work constructively to cut our healthcare costs, create jobs and improve the health and competitiveness of our workforce.

ntodd