Vermont, Single-Payer in the USA?

May 16, 2011 8:55 AM

With the constitutionality of the Affordable Care Act being argued in lower courts, it's probably also worth looking at Vermont's adoption of single-payer health care: "On May 26, Gov. Peter Shumlin of Vermont is expected to sign legislation that will create universal coverage in the state—eventually. Vermont will use subsidies from the Affordable Care Act to help create a Canada-style system. And its system, or so the theory goes, will become so popular and cheap that the rest of America will want to copy it."

BONUS
-Have Scott Brown and Ron Wyden figured out the way forward on health care?
-Sen. Bernie Sanders: 'Vermont stands a chance to be the first state in the nation to pass single-payer'
-Gov. Peter Shumlin: The man who'd bring single-payer health care to Vermont

posted by kliuless (51 comments total)

Uh...if anyone needs me, I'll be in Vermont.
posted by NoMich at 8:57 AM on May 16, 2011 [14 favorites]

So the enslaved doctors, will they be escaping to Canada or to Georgia?

And will Rand Paul be running the Underground Atlassian Railroad?
posted by orthogonality at 9:00 AM on May 16, 2011 [11 favorites]

By my calendar, they have about ... 18 months to make it "so popular and cheap that the rest of America will want to copy it."
posted by penduluum at 9:02 AM on May 16, 2011

So what happens when the ACA is overturned by the Roberts Junta later this year?
posted by T.D. Strange at 9:06 AM on May 16, 2011

If even one family moves out of Vermont for health reasons, the right-wing noise machine will make such a ruckus about it that the actual qualities of the Vermont single-payer system (whatever they may be) will not register on the public consciousness at all.
posted by Western Infidels at 9:11 AM on May 16, 2011 [5 favorites]

Government actually attempting to make citizens' lives better?

It'll never work.


Actually, it's nice to know that there are people among us that actually get it.
posted by Benny Andajetz at 9:11 AM on May 16, 2011 [4 favorites]

So what happens when the ACA is overturned by the Roberts Junta later this year?

If they find the mandate to be separable, no problem. VT clearly has the state-level power to implement a mandate. Really all VT needs to do whatever it wants is a clear federal statute that says "whatever VT wants is not preempted by any existing federal statute."
posted by a robot made out of meat at 9:21 AM on May 16, 2011

So what happens when the ACA is overturned by the Roberts Junta later this year?

Several states secede on the basis that the right to enslave doctors is a crucial part of their economy and that the Federal government is trampling states' rights, and civil war divides the nation?
posted by yeloson at 9:22 AM on May 16, 2011 [12 favorites]

SURELY THIS will keep us from having to choose between dying from injuries or dying from starvation.
posted by shakespeherian at 9:30 AM on May 16, 2011

And will Rand Paul be running the Underground Atlassian Railroad?

I'm sure The Government will find a way to keep him from testing his metal.
posted by bonehead at 9:33 AM on May 16, 2011 [3 favorites]

If they find the mandate to be separable, no problem. VT clearly has the state-level power to implement a mandate.

Oh, I'm sure the Roberts court will find some way to outlaw state-level mandates, probably based on the Second Amendment.
posted by dirigibleman at 9:34 AM on May 16, 2011

Hey, we've had a state-level mandate here in Massachusetts with 98.1% now insured.

Ya' know, the health care reform 'Flip' Romney signed into law in 2006 and now is trying explain to conservatives, as he seeks a 2012 Presidential run.

TIMELINE: Mitt Romney’s Consistent And Repeated Support For A National Health Care Mandate.

Romney On Obamacare: ‘President Should Have Been More Attuned To What We Did In Our Own State’.

Romney Omits RomneyCare From CPAC Speech, Despite Calling It A ‘Model’ For Coverage Expansion

.
posted by ericb at 9:52 AM on May 16, 2011 [3 favorites]

Several states secede on the basis that the right to enslave doctors is a crucial part of their economy and that the Federal government is trampling states' rights, and civil war divides the nation?

Enslave doctors?

Let me tell you how it works in the real world.

In the real world doctors have the highest labour mobility in the world. Apart from the United States, there is no westernized country in the world that will not accept a doctor for immigration on their "priority list" and give you a speedy, first class entry into a country.

There is no shortage of private positions even in single payer countries like Australia, the UK or Canda that want to provide a premium service for those who wish to pay more for their healthcare or for private insurance on top of their public health coverage.

Public health institutions need to pay on levels appreciably similar to the private sector, to other high quality westernized countries and even to other public systems in nearby states to attract and retain applicants at all, little alone high quality ones.

It's the private insurance sector that screws physicians and surgeons. It's the private insurance industry that fights tooth and nail to drive down the costs of procedures. They fight them on every dollar they want to charge every step of the way.
posted by Talez at 9:59 AM on May 16, 2011 [22 favorites]

A question about the Massachusetts insurance: can an individual with pre-existing conditions get coverage for those conditions for a reasonable cost?
posted by orthogonality at 10:02 AM on May 16, 2011

Talez, the enslaving doctors comments are inside jokes referring to the Rand Paul Post equating a belief in universal healthcare with slavery.
posted by Crash at 10:10 AM on May 16, 2011 [5 favorites]

Talez, the reference was to Rand Paul claiming ACA is tantamount to enslaving doctors. You're preachin to the choir.
posted by spicynuts at 10:10 AM on May 16, 2011 [2 favorites]

It's the private insurance sector that screws physicians and surgeons.

I've never forgotten this piece from Marketplace:

At Ortho Bethesda, an orthopedic practice in suburban Washington D.C., there are eight doctors on staff, and 14 people in the business office.

That's insane.

When my mom got sick, she was lucky to have good insurance. But the amount of time that I, her doctors, and the staff for her doctors spent on the phone with insurance companies - trying to make sure that this or that was covered, or trying to get an exception for something that wasn't technically covered because of a difference in billing codes (but not the procedure itself), etc. was madness. The time I spent on the phone and chasing down paperwork and re-faxing things I had already faxed was time I didn't get to spend with my mom. It sucked.
posted by rtha at 10:18 AM on May 16, 2011 [7 favorites]

@orthogonality The MA plan does not allow insurers to refuse coverage for pre-existing conditions but it does allow them to limit coverage for those conditions for 6 months. The rationale there being that you don't want someone signing up, paying a month or two of coverage, getting an expensive procedure and then unenrolling.

That still happens, but it's fairly rare.

More info available on Wikipedia and from the state itself.
posted by cmj at 10:30 AM on May 16, 2011

With the constitutionality of the Affordable Care Act

The recent health care legislation was all about expanding coverage and not at all about affordability or cost control. The irony burns... my health insurance premiums have risen over 50% in the last 6 months. That's not a type. 50%.
posted by Justinian at 10:37 AM on May 16, 2011

Type, however, is a typo.
posted by Justinian at 10:37 AM on May 16, 2011 [3 favorites]

Justinian--I'm not sure, though, how those increases relate to the recent reforms since most of that law isn't in effect yet. In fact, in my state, the governor famously went on record just a couple of months ago saying Florida wasn't even planning to start planning to implement the new law until it reached the Supreme Court.
posted by saulgoodman at 10:51 AM on May 16, 2011

My mom is a private practice therapist and she estimates that insurance companies pay her about 50% of the time, so she has to see two patients, on average, to get paid for one. Plus she has about half an hour of paperwork to do for every one-hour session.

Rand Paul has not the faintest idea what the fuck he's talking about. And if it weren't so damned cold, I'd cheerfully move to Vermont.
posted by restless_nomad at 11:01 AM on May 16, 2011

Justinian brings up the point that makes me highly ambivalent about the ACA. There's no real cost control/containment in the act. There's a bit of smoke and mirrors, and a lot of "If you do all this stuff, then OBVIOUSLY costs will come down." But, there's no actual cost control in there, either on the insurance side of things, or on the provider and manufacturer side.
posted by Thorzdad at 11:07 AM on May 16, 2011 [1 favorite]

The recent health care legislation was all about expanding coverage and not at all about affordability or cost control.

This is incorrect. Fundamentally, the plan was about expanding the risk pool to lower costs (the mandate) and creating a team of experts to standardize/stabilize costs (IMAP). The fact that any insurance premium has risen in the aftermath of the passage of health care is immaterial since the important components of the plan have not yet been instituted.

Remember that in the weeks leading up to the major votes for ACA, insurer Wellpoint raised rates. Rates had been rising fro years prior to the Obama Administration coming in to office. I'd imagine that rates will surge up until the very last moment in which the exchanges are created in the states.
posted by Hypnotic Chick at 11:13 AM on May 16, 2011 [2 favorites]

Here's some commentary on the rising rates, which the insurance industry has been quick to blame on the recently passed reform, but which are not related.

You might argue they don't go far enough, but the reform certainly does implement some cost controls on the insurer side. Here's some pro-reform advocacy discussion of the medical loss ratio requirements and the expanded state powers to review rate increases.

Basically the meat of the loss ratio requirements is this:

Now companies in the large group market will have to spend 85 percent of premium dollars on medical care and quality improvements, and companies in the small and individual markets will have to spend 80 percent. That means insurance companies will spend a majority of our premiums on actually keeping us healthy, and if companies have money left over, they will have to return it to beneficiaries!

And states will have the power to review rate increases and bar providers who can't justify increases from the state level insurance exchange.

There's cost control that could be effective in the act, if it's applied forcefully. But unfortunately, many states are in the pocket of the industry at the state level, so it's likely there will be big failures in implementation until the climate changes. But honestly, I don't think any amount of legal code is going to change that reality, as it's less a legal issue than a political one.
posted by saulgoodman at 11:19 AM on May 16, 2011 [1 favorite]

There are some hand-wavey attempts at cost control, but nothing terribly substantiative. The fact that some insurance companies turned 180 and decided to support it once they saw the form it was likely to get passed in, ought to serve as a warning to any future endeavors. If you're not doing it over the dead bodies of the insurance companies, you're probably just giving them a handout.
posted by Kadin2048 at 11:21 AM on May 16, 2011 [6 favorites]

God.

Just... the Supreme Court has a good chance at overturning, on some ridiculous pretext I'm not even sure Scalia has made up yet, the half-measure, insurance-coddling health care system it took Herculean effort to pass last year. That whole fight is starting to look merely the effort the Republicans and their corporate masters went through in order to obscure the fact that they have a trump card in the highest court of the land.

I can't talk with most of my family anymore, because if they bring up something political it's all I can do to avoid telling them what I really think about them, their lack of options that haven't been handed to them by Fox News and the Koch brothers, and their horrible, know-nothing politics.

I'm starting to think it's going to take something on the order of a full-scale collapse to teach these epic morons that apparently make up 50% of our "great country" anything.
posted by JHarris at 11:33 AM on May 16, 2011 [13 favorites]

There are some hand-wavey attempts at cost control

What's so hand-wavy about giving state authorities the power to review rate increases for instance, Kadin2048? I mean, assuming it was actually handled properly by the authorities at the state level? And what about the medical loss ration provisions?

Seriously, explain to me what from your POV is so hand-wavy about these particular provisions, or what makes them inherently weak provisions? Apart from giving the state the power to reject rate increases, what kind of cost control would you like to see? Or is the issue in your mind that the costs increases are the fault of the medical industry, and not the insurers? Because the power to reject rate increases seems like a pretty solid club to wield to me... Or what would you suggest instead, in other words?
posted by saulgoodman at 11:50 AM on May 16, 2011

I'm sure The Government will find a way to keep him from testing his metal.

He's an opthalmologist and a metallurgist? Is there no end to his skill?

Pedant Mode - it's actually "Mettle" ;)
posted by longbaugh at 11:54 AM on May 16, 2011

I've seen multiple doctors in France that literally had no staff whatsoever, not one secretary. All their appointment making was outsourced, the French medical software handled records and billing, and laboratory tests are prescribed in France, not done by the doctor's staff.
posted by jeffburdges at 12:02 PM on May 16, 2011 [4 favorites]

What's so hand-wavy about giving state authorities the power to review rate increases for instance, Kadin2048?

Many (most? all?) states already have such authority. It's whether or not they choose to use that power that is the big issue. In my state, many of the people working in the insurance commissioner's office come from the insurance industry and, as I pointed out in a post earlier, they don't even look at reviewing increases until they cross the 30% mark, and only then if they are pressured to do so.
posted by Thorzdad at 12:09 PM on May 16, 2011

In my state, many of the people working in the insurance commissioner's office come from the insurance industry and, as I pointed out in a post earlier, they don't even look at reviewing increases until they cross the 30% mark, and only then if they are pressured to do so.

Yeah, seems to be the same way in my state. But that's a political failure. The legal authority's there, there's just no political will to use it. The medical loss ratio provisions provide a little extra muscle, though.
posted by saulgoodman at 12:12 PM on May 16, 2011

The medical loss ratio provisions provide a little extra muscle, though.

A little. But it still all just amounts to nibbling at the edges and not really working on the meat of the problem that vexes so many citizens. It really does amount to hand-wavy stuff. It's a finely-crafted piece of showmanship that tiptoes around the edges, so as to not infuriate the insurers or the providers.
posted by Thorzdad at 12:18 PM on May 16, 2011

He's an opthalmologist and a metallurgist? Is there no end to his skill?

Pedant Mode - it's actually "Mettle" ;)
posted by longbaugh at 2:54 PM on May 16 [+] [!]

Double pedant mode: may have been a pun on the Rearden metal from Atlas Shrugged (which the government tries to keep the protagonists from using in a test stretch of railroad tracks) and Rand Paul's frequently, er, Randian stances.
posted by Lentrohamsanin at 12:18 PM on May 16, 2011 [3 favorites]

It really does amount to hand-wavy stuff. It's a finely-crafted piece of showmanship that tiptoes around the edges, so as to not infuriate the insurers or the providers.

But it's not: the problem, as you admitted, is that laws aren't being applied as intended at the implementation level.

That same effect would likely apply to any amount of cost-controlling written into the law, so long as the underlying political ecology is the same, wouldn't it? If we could craft laws that are self-enforcing, we might stand a chance, but we can't, so until the political reality changes--meaning, until we improve the quality of people getting put into the position of enforcing whatever laws we codify and hold them accountable for their failures--what would work?

It's not even logistically practical to have any proposed rate changes reviewed at the Federal level.

How would you do it, without being hand-wavy (I mean, apart from a federal or state single-payer system)?
posted by saulgoodman at 12:25 PM on May 16, 2011

But that's a political failure.

The law gives the power to do unpopular and unworkable things to people who will never use it. Might as well have stayed home.

The medical loss ratio provisions provide a little extra muscle, though.

Kind of. The high administrative costs in the US isn't the bulk of the problem; we really spend too much on medical care. It can also be skated around; by unloading work onto hospitals and offices, the MLR stays good looking with the same amount of waste.
posted by a robot made out of meat at 12:35 PM on May 16, 2011

It's not even logistically practical to have any proposed rate changes reviewed at the Federal level

Why not. It would seem far more practical to review rates at a single point, rather than 50 different times.
posted by Thorzdad at 12:36 PM on May 16, 2011

Yeah, seems to be the same way in my state. But that's a political failure. The legal authority's there, there's just no political will to use it

That's not a political failure, it's an obvious and inevitable result of the law. You can't pass laws which will clearly work one way and say but, hey, if things worked better it would work better. That's tautological.

Giving states review power is hand-wavy cost control. Actual cost control is a law saying "you cannot raise rates more than inflation+2% per annum".
posted by Justinian at 12:44 PM on May 16, 2011

When will the United States realize that they pay more for healthcare than most "socialist" countries, and receive a poorer standard of care on average?

Socialist healthcare is cheaper, and provides better outcomes.
posted by blue_beetle at 12:59 PM on May 16, 2011 [4 favorites]

Why not. It would seem far more practical to review rates at a single point, rather than 50 different times.

Well, yeah, but insurance is regulated at the state level (meaning costs of doing business are different within each state), and there's a lot of variability in costs of living across the states, too. Rate changes don't apply across the board for that reason, and there are so many specialized state-level divisions of the 35 or so insurance companies that operate in the US. A fair, manageable rate in one state would be burdensome in another.

It's not impossible to do this at the Federal level, but a lot of state insurance commissioners would probably be a bit reluctant to see the authority centralized, and it would require a significant effort to tool up at the Federal level (which would mean more spending).

It's not as simple as one review carried out 50 times by a long-shot, though. And the new rules, as clarified, would require review for rate increases in the range of 10% (much lower than the 30% range Thorzdad mentioned).
posted by saulgoodman at 1:12 PM on May 16, 2011

When will the United States realize that they pay more for healthcare than most "socialist" countries, and receive a poorer standard of care on average?

Probably about a generation or two after we figure out a better education system and stop buying textbooks from companies with vested interests in rewriting history and promoting privatization of things that shouldn't be privatized?

Oh! And legally require some form of accountability to any media claiming to present "news".
posted by yeloson at 1:17 PM on May 16, 2011 [1 favorite]

the problem, as you admitted, is that laws aren't being applied as intended at the implementation level.

This strikes me as being a bit like claiming that a pig with wings glued onto it won't fly because gravity is all wrong. If you're depending on state regulatory boards to cut costs by applying pressure to insurance companies, when everyone knows those boards are pretty toothless, you can't really claim to have done anything.

Although the insurance companies are the easiest actors in this particular play to put into the role of Bad Guy, most analysis that I've read gives them about a 3% cut of the action as profit. There's a little room to squeeze them, and it might be big if you look at it nationally in dollar terms, but it's not a huge slice. If you include marketing and IT and other overhead costs you can get it up to around 7% depending on the methodology, but it doesn't look like there's a huge amount of slack in there. You can give regulators all the power in the world to refuse rate hikes, but the insurance companies are pretty quickly going to be able to put together a case that will show that they're not asking for more than their usual 3 percent vig on top of increasing actual costs. And they're going to get those raises, because at least in the cases I'm familiar with that's really all they have to demonstrate given how those review boards are set up.

So if you want to do significant cost control, I think you have to do more than insurance regulation. You have to look at the other ~90% of healthcare expenses, which are the ones the insurance companies are passing through, and that (at least in front of a rate board) they're going to claim they have little to no control over. (Whether they do, in fact, is debatable, but from a policy perspective I think we'd be better to do it ourselves rather than let the insurance companies do it, lest they start a sideline in Soylent Green or something.)

The biggest single problem that I think the government is in a position to address at the Federal level is the supply of qualified doctors. We need to train many more; if medical schools say that they can't do that without compromising quality, then we need to fund new medical schools. I think the fastest and most direct way to do this, and a way that you might even get some conservatives on board with, would be by expanding the Public Health Service. The PHS is a Uniformed Service, and it should have a feeder program just like the Army has ROTC. Get talented students while they're finishing their undergraduate degrees, give them a full ride and stipend to medical school, and they do 2*x years (where x is the number of years in training) in uniform, starting at an O-1 pay grade. It would be, I suspect, the cheapest investment we could make, and if it were done on a large enough scale it could bring down costs by increasing supply relative to demand. After their stint, they'd be free to stay or go join the private sector just like any other uniformed officer.

Politically, you'd have doctors doing everything but setting themselves on fire on the Capitol steps to prevent this, but maybe you could balance it out with malpractice reform to bring down insurance premiums, which probably represent a not-insignificant chunk of the 33% of total national medical expenses represented by "physician services." Otherwise that's the argument you're going to have, true or not ("we get paid peanuts after all the malpractice insurance!"), so it makes sense to blunt it ahead of time.

At the same time, implementing (which is really no longer exempting) some sort of procurement control for drugs paid for by Medicare/Medicaid seems obvious. The drug companies should, just like anyone else who wants to sell to the Federal government, get on a GSA schedule, and that schedule would set the price for a particular product to all Federal buyers, including anyone using Medicare or Medicaid money. But the total expenditure on drugs is less than half that of physician services, so I don't think it's really the low-hanging fruit.

Also I'd like a pony.
posted by Kadin2048 at 1:17 PM on May 16, 2011 [3 favorites]

That's not a political failure, it's an obvious and inevitable result of the law. You can't pass laws which will clearly work one way and say but, hey, if things worked better it would work better. That's tautological.

No law is capable of enforcing itself. If the political and popular culture fail a legal system, the legal system fails, period. There are a lot of laws on the books that go unenforced because the political tides have shifted. Some of them are kind of funny.

And most of these kinds of archaic laws are completely empty of any authority in practice. not because of anything inherent to the way the laws were constructed or adopted, but because the culture and political realities have changed in ways that make them unenforceable. So, no, the fact that states often don't use legal authority they already have is not necessarily a defect of the law.
posted by saulgoodman at 1:18 PM on May 16, 2011

When will the United States realize that they pay more for healthcare than most "socialist" countries, and receive a poorer standard of care on average?

Not sure, but I'm guessing it will involve flying members of the family Suidae.
posted by Celsius1414 at 1:33 PM on May 16, 2011

The thing about the act was that it was supposed to slow down the increase of the cost of premiums, end "pre-existing conditions" cancellations/denials and subsidize healthcare for people with low incomes, not actually make healthcare cheaper.

If you want cheaper, you want something more efficient than the current system. To do that, you kind of have to either shrink or kill the HMOs as we know them. That means either a public option that would quickly become cheaper than HMOs because of a national pool like Medicare/caid and undercut them, or a single payer plan that would essentially do the same thing, except people don't have to subscribe to the public plan, they are on it by virtue of being American (I mean in terms of citizenship). We'd still probably have private healthcare plans, because no matter how great a system we get, there will always be rich people who don't want to wait in line behind poor people for an MRI, but it would not be the huge moneymaker it is today.

tl;dr: GO VERMONT AND SLIPPERY SLOPE, GO!
posted by mccarty.tim at 2:03 PM on May 16, 2011 [3 favorites]

If you're not doing it over the dead bodies of the insurance companies,

Your ideas are intriguing to me and I wish to subscribe to your newsletter...
posted by quin at 2:41 PM on May 16, 2011 [3 favorites]

jeffburdges, your story reminds of this bit from the Onion:
"Quick-Lube Shop Masters Electronic Record Keeping Six Years Before Medical Industry"

Bonus relevant article:
"Mitt Romney Haunted By Past Of Trying To Help Uninsured Sick People"
posted by dhens at 3:28 PM on May 16, 2011 [1 favorite]

My mother has been in hospital since November with neurological issues, and it looks like she'll need rehab for months more. It's now cost her everything she ever worked for, and us almost everything we own, and the insurance company is trying to —

Oh, wait. We live in Canada. There is no insurance company, and it hasn't cost her or us anything (apart from the travel to visit and some silly rules about bringing in her own nail clippers and lotion).

We haven't had to spend one second worrying about what this means financially.

Go Vermont.
posted by namasaya at 6:56 PM on May 16, 2011 [5 favorites]

thirding: Go Vermont!
posted by saulgoodman at 7:05 PM on May 16, 2011

Go Vermont.
posted by Hypnotic Chick at 8:16 PM on May 16, 2011

Go to Vermont. (It's lovely.)
posted by nicwolff at 11:55 PM on May 16, 2011