Should Vt. be a model?
Toolbox
By Louis Porter Vermont Press Bureau - Published: June 28, 2009
MONTPELIER – Vermonters are very familiar with the terms and questions in the national argument now going on about health insurance reform.
During the last two decades the state fought its own battles over whether to implement a single-payer system, offer a state-backed public insurance option or whether to require health insurance. In the end, a compromise between lawmakers and Gov. James Douglas in 2006 added a public subsidy so that more Vermonters could buy a state-sponsored by privately run insurance policy, but stopped short of broader insurance reforms.
But during the current national debate, the state's influence is coming from a much less attention-grabbing but perhaps more important aspect of health care reform in Vermont. Over recent years, both the administration and lawmakers have worked to develop, and begin implementing, a program known by the umbrella name of the Vermont Blueprint for Health.
That program includes initiatives (and regulatory changes) to put in place programs to address chronic disease management, establish more and better coordination between care providers and encourage healthier living.
Starting last year, pilot programs were established to make a number of changes, including establishing a local medical "home" for patients that is responsible for overseeing their health care and payments for health-care providers based not on how many procedures they do, but on how well and how comprehensively they care for their patients.
All private health insurers in Vermont are involved in the program, as is Medicaid. Medicare (the largest single insurer) is not yet, but Douglas and the governors of all but one of the other New England states are trying to expand the program to include the federal insurance program.
That approach to unifying improved health care approaches and information technology – and save money by doing it – is still too new to be truly tested. But it is gaining more attention from Washington, D.C., health reformers than the state's still not completely resolved struggles over private-versus-public insurance.
Ultimately, it will be more important, according to Douglas.
"In the long-run, that is not what is most important. It is containing costs, it is keeping people away from expensive intervention," he said.
Those connected to Vermont's efforts will likely have a lot to say during the current debate. After all, U.S. Rep. Peter Welch is on one of the key committees in the House dealing with the issue, while U.S. Sen. Bernard Sanders, an independent, is on the central Senate committee.
Meanwhile, Douglas co-hosted one of the national forums on health care earlier this year at the request of President Barack Obama and met with the president and other national officials about the issue this week. Several of those involved in Vermont's innovations, including most importantly its approach to managing patient care, now are involved in the national debate.
Ken Thorpe, the consultant who has worked with lawmakers in Vermont and other states to design those systems and is advocating for them nationally, agreed with Douglas that those efforts will be more significant than the discussion about insurance mechanisms.
There is the potential for saving money by redesigning who pays for health care, but the huge savings are to be found in dealing with obesity (which accounts for 30 percent of the growth in health spending) and chronic diseases (which account for 70 percent of overall spending), Thorpe said.
Coordinating what happens to patients when they go from a hospital to a nursing home, for instance, or making sure their medicines do not conflict, might seem like merely practicing medicine, but it is important for health and saving money, he said.
"It's good primary care … the problem is, it doesn't happen," he said.
The two things do not necessarily go hand in hand. Medicare is essentially a single-payer system, and there is nothing inherently wrong about that, but "they provide the worst chronic care system in the country," Thorpe said.
But the approach in Vermont – and in some other states like Massachusetts and West Virginia where he has been working recently – is attracting positive attention nationally, Thorpe said.
"It's novel," he said. "There is a lot of buzz around what they are doing."
Hunt Blair, Vermont's deputy director for health care reform, has been among those making trips to visit those working on health care reform in Washington, D.C. – and hosting visitors from there in Montpelier. He agrees with Thorpe that the question of who pays – private insurers, government or some hybrid – really is second to figuring out how to replace a disjointed system that pays based on procedures with one based on paying for health.
"If we had a single-payer system tomorrow, we would still have to do all of this delivery system change," he said.
That's the part of the Vermont effort that resonates in Washington, he added.
"A lot of the influence we are having is on the non-sexy but really important stuff," Blair said. "We kind of forget how really significant what we have already done is."
State Sen. Doug Racine, chairman of the Health and Welfare Committee, had not yet returned to the Statehouse when Catamount and the state's other health care reform efforts were undertaken. But he has worked on them since and the Blueprint for Health, and is associated programs (it has been steadily expanded and altered) are a step forward, he said.
"I don't think it is fair to say yet that we have seen results because it is really just getting started," Racine said. "I believe we are absolutely headed in the right direction."
Elements of the Vermont approach already have been included in the congressional bills.
But if Vermonters involved in health care reform are more or less unified around the ideas in the Blueprint for Health, they remain divided – as does the Congress and much of the nation – over how to change health insurance.
The Obama administration, for example, is pushing for a middle-ground approach: health care reform that includes a so-called "public option" for insurance but not a single payer system such as the Canadians have.
Douglas, who resisted a push by some lawmakers toward a more comprehensive government program, has said he believes the country at large should not enact a government insurance program or require that individuals carry health insurance. A system like the one he and Democratic lawmakers reached through compromise – a public subsidy but not a public program – is a better option, he said.
Sanders, meanwhile, would like the reform effort to go farther. He has said he will support a public insurance option if that is all that can be achieved politically; but what he really believes the country needs is something more sweeping: an expansion of Medicare into something like the Canadian single-payer system only with better funding, Sanders said. That would be achievable, given that the cost of administering plans through 1,300 private insurance companies would be eliminated and given that Americans already spend more per capita on health care than most other countries for, in many cases, worse outcomes overall.
"We spend twice as much as the French yet (in health-care outcomes), they do better than we do," Sanders said.
"Many of us believe a single-payer system makes a whole lot of sense," he said. But in the Senate, probably not enough to make it a successful amendment to the health care reform bill, he acknowledged.
In part, that is because the verdict still is out on the success of Vermont's Catamount Health compromise. "We have a payment mechanism through Catamount and that has been quite successful," Douglas said.
There are thousands more insured through a combination of Catamount and increased outreach and education about other public insurance programs like VHAP and Medicare itself.
But it seems unlikely to many that the state will reach its goal of 96 percent of Vermonters having insurance by 2010.
Even if it does make that benchmark, the state will remain far from the ultimate goal – universal coverage that will mean Vermonters can get and afford care without passing the cost onto the rest of the population with private insurance.
The Obama administration put out a list of statistics about each state on Friday in an effort to explain the need for health care reform. The list for Vermont is not encouraging: Family premiums have increased 92 percent since 2000, according to that report, and 10 percent of Vermonters report not visiting a doctor because of high costs.
Catamount Health, and the associated outreach effort to get people who qualify for Medicare, Medicaid and other programs to sign up, is resulting in more people having health insurance in Vermont, said Racine.
"Catamount it doing a lot of what it is designed to do," said Racine.
But the program likely will fall short of its goal of 96 percent coverage next year, he cautioned. For some insurance, even with a Catamount subsidy, is expensive. Others, especially some of the young and male who don't believe they will get sick or hurt, are unlikely to sign up for insurance, even if it is free, said Racine, who in addition to closely following health care policy in the Statehouse also is likely to be a candidate for governor next year.
"It is not a universal program, it doesn't guarantee universal access, and more has to be done," he said. "I would not recommend that the (federal) government use Catamount as its model, unless politically you can't get anything better."
After all, the compromise program was the result of a deadlock – and veto – between Douglas and a Legislature that wanted more sweeping reform, Racine said.
"The political reality was this is the best that could be done," he said.
While he said he believes the Blueprint for Health will succeed in its aims, he also is convinced that without a mandate requiring insurance or a single payer system the state and the country will never reach complete access to good health care, Racine said.
"If you want everyone to be part of the system, you have a universal single-payer system or you have a mandate," he said.
louis.porter@timesargus.com
42