Editor’s note: This post is a column by Hamilton Davis, a former lawmaker, managing editor of the Burlington Free Press and chairman of the Vermont Hospital Data Council, the predecessor to BISHCA. Davis writes about health care for VTDigger.org.
A brief kerfuffle last week about the Canadian single-payer health care system once again illuminated the Alice-in-Wonderland quality of the web-based discussion of the Shumlin administration’s effort to develop a single payer system for Vermont. The issue arose on the conservative website, Vermont Tiger, in the form of a report from John McClaughry of the Ethan Allen Institute.
McClaughry wrote that he had asked Gov. Shumlin at a meeting in St. Johnsbury how his proposed Green Mountain Care system would differ from the single payer system in Quebec. McClaughry quoted the governor’s response: “In Quebec health care providers work for the government. They will stay private in Vermont. Vermonters will have universal access.”
McClaughry professed shock at this statement on the grounds that it is common knowledge that doctors in Quebec do not work for the government and he went on to conclude: “Shumlin’s Green Mountain Care will operate exactly like Quebec’s Medicare, right down to the controlling board, government definition of essential benefits, setting compensation rates for providers, writing the checks to pay private providers, and setting a global budget in the name of cost containment.”
Well, all in all, a blizzard of misinformation. The governor first, since he has no excuse. McClaughry is right that in the Canadian single-payer system the doctors are private — they do not work for the government. It is also not yet clear that Vermonters under a statewide single-payer system will have universal access. Green Mountain Care may come close, but there are several elements of federal law that may block that achievement, desireable though it is.
There is simply no question that Shumlin should know the basics of the Canadian system because for the last two decades it has been the model for the single-payer system in Vermont. It’s true that the governor may have been distracted by some other issues — think Vermont Yankee and Irene. But still …
It has been clear from day one that the Shumlin administration has no intention to install a Canadian-style single-payer system.”
It is also worth noting that we are relying here on the accuracy of the McClaughry report for the governor’s response. VTDigger asked the governor’s press office to confirm its accuracy, but got no response. Moreover, while McClaughry has sharp elbows — actually, extremely sharp elbows — he’s usually right about stuff like this.
His conclusions, on the other hand, are completely absurd. First, it has been clear from day one that the Shumlin administration has no intention to install a Canadian-style single-payer system. The key flaw in the Canadian system is that it created huge demand with no cost containment strategy at all. The key was the determination to maintain a fee-for-service reimbursement system: Do anything you want and send us the bill. The bills, not surprisingly, went through the roof, generating a payment shortfall at the national level of government as well in all 10 of the Canadian provinces.
Government payment shortfalls with no ability on the part of the Canadian delivery system to manage the constraints led to severe dislocations. One was the need to send many of its people to the U.S. for treatment that the Canadians couldn’t deliver themselves. Another was the development of long waiting times in Canada, even for critically needed care. The flow of patients to the U.S. has apparently abated, but as recently as the last year or so there was a scandal in Montreal where wealthy residents were bribing health professionals so they could move to the head of the line.
The Canadian system does maintain its central attraction: its universal coverage, something the commentators on Vermont Tiger never seem to mention.
McClaughry goes completely off the rails in his claim that it is clear that Green Mountain Care will be identical to Quebec Medicare. That is simply false. The whole reason for hiring analysts like Anya Rader Wallack and industrial strength bureaucrats like Steve Kimbell and impressively credentialed members of the Green Mountain Care Board is the need to dramatically increase access while controlling costs. That means moving away from fee-for-service reimbursement toward something else. If you don’t have fee-for-service, then you can’t have rate setting. Government rate setting in a fee-for-system has an unbroken record of failure to control costs in the United States.
The claim that Green Mountain will control costs with a global budget is also misguided. Somebody on the Green Mountain Care Board or in the system somewhere may think they can do that, but there is not evidence whatever that anyone knows how.
The problem with a global budget is that in financial terms, there isn’t any “globe.” There isn’t any functional connection between, say, what Fletcher Allen does and what the community hospital in Bennington does. And one of the most important players in the Vermont delivery system — Dartmouth-Hitchcock Medical Center — isn’t even in the state, and it delivers most of the specialized care east of the Green Mountains.
Getting to a system sufficiently integrated to enable some sort of capitated reimbursement model may be possible, but no one has seen one yet.
These kind of challenges will be extremely difficult for the Shumlin administration to surmount. But surmounting them will be necessary if a single-payer system is to work in Vermont.
The goals, however, are absolutely vital. Universal access to health care at a sustainable cost is as important to the state as any initiative it has ever taken. Well thought out opposition actually contributes to that goal. What we’re seeing so far is not even close.