Editor’s note: Jon Margolis is VTDigger.org’s political columnist.
For at least two reasons, perhaps the most politically effective statement Randy Brock made in his first debate with Gov. Peter Shumlin was that the Shumlin health care plan makes Vermonters “lab rats in a grand social experiment.”
The two reasons are: (1) Nobody wants to be a lab rat; (2) It’s true. The Shumlin plan is an experiment. Otherwise, the Green Mountain Care Board established by the Legislature wouldn’t be laboring so hard trying to figure out how to make the proposed universal health care plan work.
Brock has a health care plan, too. It’s very different from Shumlin’s. It relies far more on the private sector. It provides individuals more choice, but also burdens them with greater responsibilities.
But you know what else it is? It’s a grand social experiment.
So, in the view of many experts, is the health care status quo. The present system keeps getting more expensive without making people much healthier and without covering everyone. Liberals and conservative fight over how to fix the system, but agree that it is unsustainable.
They also agree that it is “wicked complicated,” in the words of Anya Rader Wallack, chair of the Green Mountain Care Board. Slogans and sound bites, then, are more likely to confuse than to clarify. So are unsupported assertions.
But in the health care debate most of what Vermonters are hearing in the political campaign consists of slogans, sound bites, and unsupported assumptions.
On his campaign website, for instance, Brock states that “the power of individual consumers and the free market can drive the transformational change needed, just as they have done in every other aspect of the American economy.”
Well, maybe they can. But then again, maybe they can’t. For almost half a century, since an influential article by economist Kenneth Arrow (later a Nobel prize winner) in the American Economic Review, the prevailing – though not unanimous – view among health care economists has been that health care is different, an exception to the widely shared view that goods and services are best provided by the private, for-profit sector. In this view, health care is less like automobiles, sewing needles or restaurant meals and more like higher education. For-profit universities such as Devry or Phoenix may be just right for some students. But they are not on the level of such great public institutions as the University of California/Berkeley or private non-profits like Harvard.
Those economists might be wrong and Brock could be right. But he didn’t explain why he might be right. He just asserted it.
Nor has anyone yet challenged him or Shumlin to back up their assertion. On WCAX-TV (Channel 3) the other day, Shumlin, on the telephone with a reporter, said, “Randy Brock’s proposal for health care will raise rates 200 percent to 300 percent on those who really need health insurance and give the for-profit industries more profits.”
It seems not to have occurred to the reporter to ask the governor just how he got that estimate.
OK, TV news has its time constraints. Every news story can’t thoroughly plumb the depths of every issue. But some of them can try to relate what candidates claim to reality.
There is actual information about health care. There are examples of what works and doesn’t work elsewhere. There are data. There is, in other words, such a thing as social science, which as much as possible should be part of the public policy discussion, including the political discussion.
On the assumption that one good way to determine whether a policy will succeed here is whether it has succeeded anywhere else, one obvious question about health care that should – but has not – been posed to both candidates is: Where else does your plan or something like it work?
It’s an easier question for Shumlin and his allies. Canada, most of Europe, Japan, Israel, Costa Rica and other countries have the kind of mandatory, universal, government-run – or at least government-controlled – health financing system the governor wants Vermont to adopt.
That is by no means proof that it will work here. Unlike, say, France, Vermont is not sovereign. Officials in Montpelier have less control over the state’s health care system or its economy than do their counterparts in Paris.
Brock and his fellow health care conservatives have a harder time with the “where else” question because the answer appears to be … nowhere.
“So far as I know, Switzerland may come the closest, though I’m not sure how close,” Brock said (via email).
Not very. As in the Netherlands and a few other countries, Swiss health care is provided by for-profit insurance companies. But the system is universal, mandatory, subsidized and heavily regulated. The companies can not refuse to insure anyone or charge sick or old people more than healthy young ones. Also, the companies may not earn a profit on the basic, required health care, only on the supplemental care most Swiss purchase. In all these countries, the system is closer to the new Affordable Care Act (ACA, aka “Obamacare”) than to a free market purist’s paradise. And while those systems seem to work, health care in Switzerland and Holland is more expensive than in most European countries.
Brock has also praised recent health care changes in Maine, which has instituted a more market-based, less regulated, health care system. Brock’s health care proposal would “allow Vermonters, like residents of Maine, to buy insurance from licensed insurers, in any state in New England.”
Actually, that part of Maine’s system is not scheduled to go into effect until 2014, said Joe Ditre, the executive director of Consumers for Affordable Health Care, and when it does Maine residents will not be permitted to buy policies from Vermont. The changes that have taken effect have increased health care premiums for most customers of the state’s largest health care plan (the only one to report its results so far) without increasing their benefits, said Ditre.
Health care experts also question whether opening an inter-state health insurance market will hold down costs, at least not unless consumers are allowed to buy policies providing less coverage. Less coverage could mean lower costs, but also less health care, as customers put off care because their out-of-pocket “deductible” would be too high.
Brock pointed to a Rand Corporation study indicating that some “who enroll in high-deductible health plans are at no more risk for cutting back on needed health care than other(s).” But another Rand study found that while high-deductible plans “significantly cut health spending, they also prompt patients to cut back on preventive health care.”
Not that the Shumlin plan for controlling health care cost increases is guaranteed to work, either. At the heart of its cost-control effort is converting the dominant payment system for health care from “fee-for-service,” to some kind of “bundled payment” or “universal” payment system that pays teams of health care providers to keep people healthy rather than just “fix people when they’re sick,” as Wallack put it.
Asked for documentation that this shift would hold down costs without degrading treatment, Wallack emailed a document listing 30 academic or foundation studies indicating that, as one put it, “bundled payments show substantial promise for delivering savings and improved quality.”
But, she acknowledged, there are other studies, some from comparably respected scholars, that reach more ambiguous conclusions. The effort to cut costs and improve care, she said, will not stop once Vermont adopts its new health care system.
“Monitoring is extremely important,” she said, and it will continue to be. Fortunately, she said, “the status and ability of data systems is much better than it was 20 of 25 years ago. We’ve seen movement to models where providers are going to be held accountable.”
Brock argues, correctly, that Shumlin still can’t say what his plan will cost. But neither can Brock, some of whose proposals would also cost money. In fairness to Brock, he is running a relatively shoe-string campaign which can not afford a battery of issue researchers. In an interview, he said he made a “back-of-the-envelope estimate” that one of his proposals –a tax credit for some health care premiums – would cost only about $2.7 million a year.
There are credible arguments on behalf of a more market-oriented approach to health care. Brock mentioned a new book by John C. Goodman called “Priceless: Curing the Health Care Crisis.” Goodman’s proposals are being taken seriously – even as they are criticized – by the liberal health care website, “The Incidental Economist.”
In other words, Randy Brock can support his sound bites, slogans and assertions with examples and data. So, no doubt, can Gov. Shumlin. It’s not their fault that nobody has demanded that they do so.