I’ve been looking into Vermont’s brand new single-payer health care law.(pdf). I’ll just pick out some highlights:
As provided in Sec. 4 of this act, upon receipt by the state of necessary waivers from federal law, all Vermont residents shall be eligible for Green Mountain Care, a universal health care program that will provide health benefits through a single payment system. To the maximum extent allowable under federal law and waivers from federal law, Green Mountain Care shall include health coverage provided under the health benefit exchange established under chapter 18, subchapter 1 of Title 33; under Medicaid; under Medicare; by employers that choose to participate; and to state employees and municipal employees.
The board shall negotiate payment amounts with health care
professionals, manufacturers of prescribed products, medical supply
companies, and other companies providing health services or health supplies in order to have a consistent reimbursement amount accepted by these persons.
Read the whole thing or just the good parts. It’s like liberal policy porn.
Maybe we can do a group analysis of the law here, because we don’t hear a lot from (sitting) liberal governors. There are apparently four available lots for rent on the valuable real estate that is commercial news, and those lots are reserved for Mitch Daniels, Scott Walker, John Kasich or Chris Christie.
The state-level policy debate stretches all the way from far Right in Indiana to far Right in New Jersey. In terms of geography it’s broad, I guess. Can anyone deny that Indiana is many miles from New Jersey? There you go. The media defense rests.
Reading the Vermont law, I think of Bernie Sanders. When I think of Bernie Sanders I think of community health centers. I’ve described my great experience with a community health center before. But I relied on a county community health center for affordable, sliding-scale fee pre-natal care (a long time ago). Mine wasn’t a federally qualified community health center. At the time I knew nothing of these distinctions, but I did know this was the only primary care provider that would take me because I looked.
This is the definition of a federally qualified community health center:
non-profit, community-directed providers that remove common barriers to care by serving communities who otherwise confront financial, geographic, language, cultural and other barriers. Also known as Federally-Qualified Health Centers (FQHCs), they: are located in high-need areas identified as having elevated poverty, higher than average infant mortality, and where few physicians practice; are open to all residents, regardless of insurance status or ability to pay; tailor services to fit the special needs and priorities of their communities, provide comprehensive primary and other health care services; provide high quality care, reducing costly emergency, hospital, and specialty care, and saving the health care system $24 billion a year nationally.
40% of the low-income uninsured in Vermont rely on a federally supported non-profit community health center for basic health care, now, today. Compare with Texas (12%), or Ohio (14%) or California (25%). Then compare with Washington. 47%. Take a look at all the states.
Is an existing non-profit or public primary care delivery system a good prerequisite to a universal single-payer payment mechanism? Or, does an existing non-profit or public primary care delivery system make a transition to a universal single-payer mechanism more likely?
I’d add the caveat I began with: federally supported community health centers are not the only non-profit or public health care provider. Looking at the percentage of uninsured who rely on this provider may be misleading. Perhaps Texas, for example, has a great network of county health department centers that aren’t (directly) established at the federal level. Of course we know that all health care delivery in the U.S., public or private, is federally supported one way or another, despite the persistent libertarian fantasies of media and conservatives.
Here’s where you can find a federally-funded community health center, if you’re looking for one.
Paul in KY
Not germane to this thread, but Glenn Greenwald has removed Balloon Juice from his list of ‘Blogs I Read’.
I used to use that link from Salon to come here. Now I’m forced to go thru Yahoo. Glenn, how could you?!
Yutsano
Washington does get a lot of Hispanic migrant workers, and there are several dedicated health systems designed just to accommodate them. The really great part of those systems is they don’t limit their mission. We might just be doing something right here.
Yevgraf
OT, but fuck me – leave it to a DFH to cartoonishly (always cartoonishly) fuck things up. He could have bludgeoned the nasty old bastard with a brick, shivved him, clubbed him – but he had to go with the ludicrous cream pie gag. Hell, that doesn’t even instill fear like red paint or tomato sauce.
Asshole.
From the Guardian liveblog:
Kay
We have a migrant health center 30 miles from where I’m sitting. I had no idea.
Just to be clear, the distinction (for me, anyway) is non-profit. That’s what I’m curious about, how that status might play into making the leap to single-payer.
Poopyman
@Yevgraf:
Wow. Hiring that guy couldn’t have cost Murdoch more than a couple of thousand quid, and look what it bought him.
Best deal Murdoch’s made in a loooong time, all things considered.
kay
What a shame. Such good questions, and he was doing so poorly.
On to his core business: deliberately misleading people on the estate tax, or tort “reform”, or voter fraud! Time’s a wasting, Rupert. Catapult that propaganda.
jwb
Yevgraf: We’ll see, but it smells like a PR set-up to me.
Dave
It will be interesting to see how Vermont’s move into single-payer, and future states doing the same, drives national demographics. Will younger people flock to more socially progressive states regardless of climate/nightlife/whathaveyou? I would.
Martin
I would say it makes it more likely, but isn’t necessarily a prerequisite. How much more likely I think is a function of how that non-profit is perceived by the public and how large they are. For example, I think Kaiser is the key to CA going single-payer – it’s large and generally very well regarded and should be able to serve as a roadmap for how to do this properly.
Barring a non-profit, the state would need to build it on their own, and that’s fucking hard – not only the work of building a complex system which they lack expertise on that meets a ton of federal regulations, but also overcoming the enormous amount of friction that the existing for-profit care deliverers will put out there to try and prevent the thing from ever happening.
Not impossible, but if I were to make a prediction, there will be 10-20 states mostly small, but a few big ones (like CA who have passed single payer in the legislature but had it vetoed by Arnold) where conditions are right that will carry the ball here and implement it. Once there’s enough, then the national debate can begin. 10 years minimum before that happens.
slag
Good questions. It would seem that a liberal political climate is the primary prerequisite for both. But it would also make sense that an established delivery system would at least make the transition easier, for obvious reasons.
SiubhanDuinne
O/T but is comment thread screwed up in the previous post (“Still not getting it”)? It says there are 80 comments, but in fact there’s nothing after #28, including the comment I just posted. Is it just me or are others having the same experience?
Poopyman
@Dave:
I paid careful attention to bennies in my younger days when there was a wider difference than now (in my industry). I suspect folks will be comparing state’s bennies the same way I compared corporate bennies. It is to be hoped* that there will be some airplay about how things are going after a few years’ operation.
Sorry to have interrupted the thread with Murdoch–mania, Kay.
(* — I know, I know.)
Ron
@Paul in KY: Or you could, you know, go here directly.
nellcote
I love our community health clinic. I’ve been using it for primary care for 20+ years. It’s county based but they got an infusion of funding from the feds to digitize records and get solar panels and some other behind the scenes stuff. In some ways it reminds me of using a credit union. The scale just seems more personal.
slag
@SiubhanDuinne: Nope. I’m seeing all 80+ comments in that thread.
Poopyman
@SiubhanDuinne:
I can read all 85+. Check that you’re not landing on a comment, or just go back to the front BJ page and re–enter the comments.
Yutsano
@SiubhanDuinne: Your comment is number 73 in that thread. So I dunno.
@Martin:
We don’t have a system quite like Kaiser up here in WA, but there are several large health networks that might expand out. I’m thinking specifically Group Health, but there is also Regence which is home-grown as well. Uniting the two would be…interesting.
OzoneR
they won’t have a choice. My cousin moved to Florida for the climate, she wanted to be near a beach. She’s in hock, having a tough time, her siblings and her cousins in Indiana, Pennsylvania, New York and Connecticut are not.
She’s going to have to leave Florida soon, she can’t survive down there. She’s going to have to suck it up
Paul in KY
Good point, Ron. I tend not to be adventurous when on the Intertubes.
Citizen_X
@ SiubhanDuinne: It’s real; I’m getting the same exact thing. Going back to the front page does nothing.
I’m using Safari (also why I can’t use the reply-button fix).
Hmm. They show up in Firefox! AHA!
kay
I wonder if people accustomed to a private provider would sort of accept a public health approach to basic health care, (which I believe is what I got at the community health center). Because it’s different. I know that now because I’m in the private for-profit system, and have been for years, because I have insurance.
The county clinic was essentially a team of friendly maternal health-bullies who hectored me incessantly on everything from diet to exercise to sleep. It works, too. I eventually followed orders. There was no god damned resisting those women. It was futile to try.
In the private system I am treated more as a client than a patient. It really is different.
Martin
Should be easier than you’d think. Even Kaiser is split NoCal/SoCal, plus we have the UC care system, and a bunch of others.
Once you go single payer, then the insurer side of these guys largely falls away (they’ll almost certainly retain some kind of add-on system, but it’ll become independent of the provider side) and the provider side then just needs to abut to the single-payer system. They’ll likely embrace one existing system to serve as that model since these guys already know how to bill each other. Here in CA it’d almost certainly be Kaiser, mainly because they’ve already eliminated the paper-handling and have fully electronic record keeping. I don’t think anyone else has caught up to them on that front.
So, they’d pluck out the best payer system, modify it to serve everyone, and then on the provider side the hardest part is eliminating redundancies and so on, but depending on how the single payer is set up, that may happen largely independent of the state. The providers can remain just as they are, without uniting, they just get paid what the state pays, and it’s up to them to make the costs work. Or the state could take a more hands-on approach and seek to build a single statewide provider network and combine the players in the market. There’s lots of options there. They all have their own challenges. I’m generally opposed to a single statewide provider if it can be helped, but in a small state like VT it probably can’t be helped. Shit, the largest city in VT is not much larger than the population my homeowners association covers – we call that a ‘neighborhood’. In WA or CA it should be possible – large populations, larger geographic area to serve, etc.
LGRooney
Posting again because it says I am in moderator jail.
Every single doctor with whom I have spoken through the years has said they would prefer a single-payer system because they want to practice medicine, not argue with insurance co. monkeys about what’s best for their patients. This could be a good testing ground to see whether doctors want the big money or the practice, if having to choose between the two.
I can only imagine that as soon as one greedy MD leaves because s/he is not getting paid enough it will be announced as a devastating trend on Fox and shouted from the hilltops by conservatives that it it socialism and it doesn’t work and it will leave us without doctors and “So’s your mother!”
Roger Moore
@Martin
Kaiser is actually a pretty good example of why we should go with NHS rather than stop with single payer. Single payer solves the problem of providing everyone with health insurance. NHS includes single payer, but it also solves the problem of health care costs spiraling out of control, which is the real long-term crisis.
Poopyman
@Kay:
Good question. In my own case, I have experience with my doctor’s office, the local hospital’s urgent care facility, and the ER. I think I’d be tempted to assume the clinic was just like the urgent care facility, which it pointedly is not. Getting people past that perception might be the first difficulty.
Yutsano
@Martin:
I may be exaggerating things a touch. In Seattle there are the four major hospital systems, at least three large clinic systems (I’m in one of those which I really like) and the major HMO is Group Health. Regence is an insurer but they’re a non-profit, so if this goes like I think it will (we go the way of Australia) they’ll still be around as a supplemental system. I haven’t read the VT law but does it allow private supplementation? Or is it Canada-style everything paid through the state?
Martin
Again, perceptions. If the private care system is perceived to be better than the public one, forget it. You’ll never sell it. But I’m not aware of any place where that’s true. If they’re perceived to be comparable, it’ll be a hard sell, but it should be possible.
The wildcard in all of this is that as the uninsured population climbs, then it won’t matter what the folks in the private care system think – the uninsured will simply overrule them. That’s always been the danger to the US healthcare system and until recently they were decent at keeping that population small enough to not matter, but their inability/unwillingness to contain costs and the drive for profits caused them to lose that focus. If single payer comes in, the for-profit healthcare system will have nobody but themselves to blame. And I think you’d be surprised at how many HC executives out there are convinced that it’s coming. They know it’s coming but due to a variety of factors they’ve simply failed or been unable to change course. Oh well.
Comrade Javamanphil
No help for the climate. Bloody 90 and humid all this week. Miserable stuff.
As for the nightlife, we do quite well, thanks. I walked to lunch for pho today but the didn’t have AC so I went to the thai place next door. (Not nightlife, per se, but representative of the available opportunities.)
The big barrier will be jobs. Our unemployment is low but so is our base industry. Also, too. General living expenses are higher. Still, we find a way to make it work.
kay
Yeah, I agree, and to be clear, I’ve had both and private wasn’t better. For (healthy) pregnancy, public was actually “better”, because it was comprehensive and prevention-based. The nutrition aspects were so pervasive at the clinic it was essentially cheerful brainwashing. I don’t know if that holds true if you’re sick, or really, really sick, but that was my experience.
SiubhanDuinne
@slag, Poopyman, Yutsy :
Thanks y’all. I still can’t see anything after comment #28 on my iPad or BlackBerry but it’s fine on desktop. Weird, but I don’t plan to lose any sleep over it.
ETA: this is definitely the first time I’ve had BJ open at the same time on three separate devices!
Martin
Agreed, but that’ll take even longer to happen. My hope is that CA goes single payer, Kaiser comes out the big winner here because they’re already a fully managed care system and if they can expand under a single payer system, they could become large enough to accomplish some of what a NHS could otherwise do, simply due to the size of the state (Canada and CA are about the same population). If that happens, then the benefits of a national system will become blindingly obvious.
Lymie
I can see Vermont from my house!
Infuriating to live in New Hampster which is driving right, how can one river separate states going in such opposite directions? Gah.
Carol from CO
Does anyone know what happens to these providers under obamacare?
btw, I believe W increased funding to these clinics. No body’s all bad. Just sayin’.
PeakVT
@Lymie: I’m convinced it’s the motto that has made New Hampshire nutso.
Vermont: “Freedom and Unity”
New Hampshire: “Live Free or Die”
El Cid
I think someone needs to tell these fireverbaggermonters that THE AMERICAN PEOPLE have rejected their radical and immature demands for their single payer health care!
mb
There was a reactionary Take Back Vermont movement that followed the creation of civil unions, so it’s not all sunshine and rainbows on the other side of the border. It too has a political faction that is best left in the woodwork. One that might not have been, had the Bush administration not been such an abject failure.
Vermont’s Republicans do seem better than the national average. I was amused to see one campaigning to close down some public schools and repeal Act 60, but still believed that global warming was a major problem that had to be dealt with–even stressing his ownership of a hybrid automobile.
nellcote
Kay, thanks for that last link. It turns out my clinic is “federally funded” and that there are about a dozen more in our small rural NorCA county. I had no idea!
kay
Anytime. That’s one of the Big Conservative Lies about health care. They’d like us to think it’s exclusively urban poor using these places, but that’s not true. It’s rural people. That’s why funding used to be an area of bipartisan agreement, before Republicans went completely insane.
Republicans still funnel money to rural areas, of course. Now they just lie about it. And rural Republicans (here, anyway) lie to themselves when they take the money. It’s all a misunderstanding, really :)
Caz
THAT’S what you think of when you think of Bernie Sanders?! Hmm, I tend to think “communist” when I think of Bernie Sanders. Which isn’t surprising, since he says he’s a communist.
I guess we are at a point in our society when being communist is not only acceptable, but laudable. That’s quite a vivid fantasy land you liberals live in.
mb
Bernie Sanders actually describes himself as a democratic socialist, but reading for comprehension is perhaps not Caz’s strong suit.
kay
No, you think of “communist” because you don’t know the first thing about community health centers, or the Vermont law, or how health care operates as a practical matter. How it works, where the centers are, who relies on them. Rural people in conservative districts rely on them, for example. True! Fact!
None of that specific knowledge is needed on the Right. Screaming “COMMUNIST” is enough. While you’re screaming COMMUNIST, just know that rural people in predominately conservative districts are relying on federally-funded community health centers, because they always have. For years. Decades.
nellcote
Bernie claims to be a S*cialist, also, too
Mnemosyne
Poor Caz. He’s so completely unequipped to discuss public policy that his only answer to our soaring healthcare costs is name-calling.
kay
I used to think it was sort of a tic, with conservatives, the terror words that shut the whole thought process down. Now I think it takes more effort than that, because they can’t follow the simplest practical matter without running from the room when they encounter the reality of how the country really works, and has worked, for decades. That’s a lot of effort. That takes some doing.
Are they still insisting that if they renounce the debt they piled up in the Bush Years strongly and decisively enough it will just go away? I think that approach is harder than just grappling with the reality of it, myself, but to each his own.
Felanius Kootea
I don’t know about other parts of California, but in Los Angeles, in addition to the federally qualified health centers (which offer mainly primary care services), we have county health facilities (both primary care clinics and hospitals offering specialty care). I don’t know how much federal dollars the county facilities get, but when you add those to the FQHCs, a lot more than 25% of low income Angelenos are relying on the safety net (FQHCs, county health facilities or both).
PeakVT
@mb: There’s reactionary element in any population group, and Vermont is no exception. It’s just not dominant here.
To me the question as to why New Hampshire is out of sync with its neighbors is an interesting one. Both Vermont and Maine are more rural, so that doesn’t explain it. A lot of New Hampshire residents are Boston suburbanites and exurbanites, but so are a lot of Rhode Island residents, and that state isn’t notably more conservative than the rest of the region. New Hampshire’s population is overwhelmingly white (~93%) so there’s no Southern-style racial divide that would push its politics to the right.
Since none of the obvious explanations seem to apply, I’m left with cultural ones. And in that area, the simplistic and absolutist motto really sticks out.
PeakVT
Caz is right; Bernie is a total commie. He nationalized Ben & Jerry’s back in the 1980s and now we have no private businesses whatsoever in the city.
Comrade Javamanphil
@PeakVT I like shopping at my local GUM store.
mb
Usually the game gets played from the other direction: attributing the loss of Vermont’s rugged individualism to transplants from New Jersey.
I suspect that NH’s tax policies attract more migratory wingnuts than its motto causes brain damage. However, I do recall it being mentioned by some Free Staters when they were deliberating over which state would make a more attractive target for them to usurp and transform into an
asylumlibertarian paradise.Older
Federally funded community health centers — what a lovely idea. I looked up the ones in my community and noticed that three of the five listed are no such thing. They serve limited populations according to their individual corporate missions. For that matter, there are limitations on who can be served at the other two as well.
Here in Oregon (I don’t know about other places) Kaiser doesn’t look to be much better. Although if they had a monopoly, they might rise to the occasion. I had Kaiser through my employment for several years, and I can’t remember ever being worse served by a health institution.