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Posted at 11:55 AM ET, 02/10/2011

Gov. Peter Shumlin: The man who'd bring single-payer health care to Vermont

By Ezra Klein

Peter Shumlin, the newly elected governor of Vermont, has a plan for health-care reform: Rather than repeal it, he wants to supercharge it. His state will set up an exchange, and then, as soon as possible, apply for a waiver that allows it to turn the program into a single-payer system. You can read a summary of the plan here (Word file). I spoke with Shumlin this morning, and a lightly edited transcript of our conversation follows.

Ezra Klein: The report (PDF) prepared by Dr. William Hsiao offered three options for Vermont: single payer, a strong public option and a form of private-public single payer. My understanding is that you're backing the third option. What separates it from a traditional single-payer system?

Peter Shumlin: Single payer means something different to everyone. The way I define it is that health care is a right and not a privilege. It follows the individual and not the employer. And it’s publicly financed. The only difference between single-payer one and single-payer three in Hsiao's report is that in single-payer three, the actual adjudication of payment is contracted to an existing insurance entity. So the state doesn't have to set up a new bureaucracy to run it. His modeling suggests that’d be more economical. It's a minute difference.

EK: And why go to a single-payer system at all?

PS: In Vermont, this is all about cost containment. There are 625,000 people in Vermont. We were spending $2.5 billion on health care a decade ago. Now we’re above $5 billion. And we project we’ll be spending a billion dollars more in 2014. This is where everyone has failed in health-care reform. And this will go after three of our main drivers of costs.

First, Vermont spends 8 cents on every dollar on administrative costs, just chasing the money around. That’s a huge waste of money. Second, we’ll use technology to conquer waste. You'll get a Vermont medical card, and everyone’s medical records will be on that card, so you’ll go into a doctor’s office and they’ll know what the last doctor did to you. That helps avoid duplication of services. And the last piece, the most challenging, is remaking the payment system so providers are paid for making you healthy, not for doing the most procedures.

EK: Single-payer systems often lose on the ballot and in the legislature. No state has successfully managed to pass one into law, much less implement it. And the objection that usually stands in the way of these projects is that I'm happy with my health-care insurance, and I don't trust the government to create something new and put me into it. How do you answer that?

PS: I suspect I’m the only politician in America who won an election in this last cycle with TV ads saying I was going to try to pass the first single-payer system in America. This election was a confirmation of my judgment that Vermonters are tired of enriching pharmaceutical companies and insurers and medical equipment makers at the expense of their family members. The reality in Vermont is that there are not very many Vermonters who are happy with the current system. We’re losing our rural providers. Our small hospitals are struggling. And Vermonters are lowering their coverage and paying more and more for it.

EK: How will the funding work? Right now, a lot of money comes from employers. What happens to their share?

PS: Where health care has failed is in designing a cost containment mechanism that works. That’s the really hard part of our job. So I’m asking us to spend the next 12 months designing the tools for cost containment. Once we do, we'll figure out how to structure the way we pay for it.

EK: One of the things you asked of Dr. Hsiao was to preserve provider incomes. How can you do that while cutting costs? At some point, doesn't lower spending also mean fewer doctors or hospitals or lower incomes?

PS: The reason Vermont has the opportunity to be the lab for a different kind of change is that we don’t have a lot of high-paid physicians in Vermont. We have a lot of low-paid physicians. We have rural providers who’re making less than they did when they graduated from medical school. Our cost driver is not that we have a lot of physicians running around in Mercedes-Benzes. It’s waste in the system.

EK: How will this interact with other systems? Let's say I have Kaiser Permanente. I come to Vermont and break my leg. What happens?

PS: Nothing different than what happens right now. You’d go to one of our providers' offices, and they’d bill Kaiser for that one. No different than if you break a leg in France or Switzerland. Radical as this seems to Americans, the rest of the world has figured this out and gotten it right. We keep getting it wrong, and we’re paying for it.

By Ezra Klein  | February 10, 2011; 11:55 AM ET
Categories:  Interviews  
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Comments

Oh, my. Another arrogant politician who believes that he can repeal the law of economics. Make using healthcare services free and containing costs at the same time.

Yeah, the laws of supply and demand don't apply to goods and services that the Left decides are rights, not privileges.

If waiting in line for hours, weeks, or months to get a procedure is not a cost, then maybe you're right. Or getting a lower quality service and medical care isn't reflected in the accounting statistics then fine: like driving a Ford is the same as driving a Mercedes.

The moronic thinking on the Left is stupendous. There's only ONE WAY to truly reduce medical costs, and that is to encourage individuals to adopt behaviors that lower their morbidity rates. Nothing proposed in Obamacare or any Leftist does this. If we want a nanny state, then let's go full speed ahead. Calibrate our income taxes or Medicare taxes to our body fat percentage, cholesterol count, blood pressure, and other biomarkers under an individual's control. That would get real results that save lives, increase healthy enjoyment of life, and lower health care costs.

Eliminating the tax incentives that maximize the interposition of an insurance company between a patient and his doctors would be second best thing to do. But Ezra, Obama, and the rest of these idiots won't do anything that truly lowers costs and makes people healthier.

Just pathetic!

Posted by: ElGipper | February 10, 2011 12:13 PM | Report abuse

"The only difference between single-payer one and single-payer three in Hsiao's report is that in single-payer three, the actual adjudication of payment is contracted to an existing insurance entity. "

So this is basically turning an existing private insurance company into a monopoly within Vermont much like a public utility?

Posted by: jnc4p | February 10, 2011 12:16 PM | Report abuse

Vermont may be the one place where this could actually work and the problem is that single payer advocates will scream from the rooftops (come say 2020) that oh it worked here we should do it everywhere. Well the key is what he said here:

PS: The reason Vermont has the opportunity to be the lab for a different kind of change is that we don’t have a lot of high-paid physicians in Vermont. We have a lot of low-paid physicians. We have rural providers who’re making less than they did when they graduated from medical school


Try taking that same plan to MA, NY, CA and many other states where physicians are paid very very well and you'll get a much different response which is what Ezra was getting at.

Posted by: visionbrkr | February 10, 2011 12:22 PM | Report abuse

Ezra -

How much of a difference does population make when administering a single-payer system? Is Britain the biggest provider of single-payer, population-wise? It seems applying this model to 625,000 people would be instructive, but I wonder how it would applying when dealing with 300 million people. Is there a tipping-point where the system starts to crack as a result of diverse issues?

Posted by: workmonkey | February 10, 2011 12:23 PM | Report abuse

Yes, a government-run monopoly, that's the solution to our problems! They have such a successful track record!

Posted by: ostap666 | February 10, 2011 12:26 PM | Report abuse

--*Vermonters are tired of enriching pharmaceutical companies and insurers and medical equipment makers at the expense of their family members.*--

Hear, hear. We don't need no steenkin' pills or insurers, and we sure don't need no steenkin' high tech medical equipment factory greedheads forcing us to pay for stuff that makes our lives better. No, sirree. Let them work for minimum wage until we say otherwise and they better be happy about it. Oh, yeah!

Posted by: msoja | February 10, 2011 12:50 PM | Report abuse

I'm ready to move to Vermont.

Posted by: AuthorEditor | February 10, 2011 12:59 PM | Report abuse

visionbrkr - Provider reimbursement constitutes about 20% of medical care expenses. It is also not growing as quickly as healthcare cost in general.

Lowering physicians payments would save money, but is not the primary driver of our cost problem.

Posted by: CarlosXL | February 10, 2011 1:00 PM | Report abuse

Love it, Love it, Love it!

Here we have a leader who is going to try something bold and ambitious in an effort to solve a real and recognized problem. Unlike many of the commenters preceding me, his attitude is one that says let's try to tackle this mess instead of "oh my god, we are helpless, hopeless, can't do anything, victims of a predatory corporate environment that nevertheless must be supported at all costs and pay no attention to all those other countries in the world that have come up with workable solutions."

Bless the man and bless his efforts. We don't know how it will come out, but we DO know how things have been working til now - Badly. Kudos to people who try to work the problems instead of throwing their hands in the air without even trying.

Posted by: Melinochis | February 10, 2011 1:02 PM | Report abuse

@workmonkey - others can correct me if I'm wrong, but Britian is not, actually, a single payer. The NHS employs doctors and staffs hospitals directly. The government itself is the provider of health care.

Single payer, on the other other hand, is where the government is a provider of insurance. Doctors and hospitals are still private entities, but a single insurance pool pays them. Canada is the best example of this.

Posted by: strawman | February 10, 2011 1:04 PM | Report abuse

Use federalism. Let the 10th amendment work. Let Vermont "prove" that single-payer works.

While Vermont is trying to make that work, end Obamacare.

This is simple. Follow the Constitution and let federalism work. If the liberals are right and Vermont's plan works - then other states will follow. Otherwise, just another failed socialistic experiment that does not harm the rest of the country.

Posted by: airboy | February 10, 2011 1:04 PM | Report abuse

"But Ezra, Obama, and the rest of these idiots won't do anything that truly lowers costs and makes people healthier."

"Yes, a government-run monopoly, that's the solution to our problems! They have such a successful track record!"

http://blogs.ngm.com/.a/6a00e0098226918833012876a6070f970c-800wi

and

http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate

Is it possible that health care may be a special case when applying free market principles?

Posted by: Chris_ | February 10, 2011 1:05 PM | Report abuse

I'm a Vermont resident. I'm lucky enough to have insurance through my employer. In Vermont as a whole, though, there are a lot of people who are self-employed or who work for small (read VERY small) businesses. So insurance that goes with the person and not with the job will really help people. My friends who are self-employed either have gigantic deductibles or have no coverage at all. Note that we have had the local equivalent of SCHIP for years and it has worked very well.

Posted by: bouvier7 | February 10, 2011 1:10 PM | Report abuse

It's truly radical to think that a notion that is currently working well in about 75% of the world, in a wide range of structures and many different political environments could work here. I mean, just because it's worked everywhere it's been tried and things are utterly failing here doesn't mean we switch to a government run healthcare system. How do we know it would work? Remember, evidence is the devils words in your ears. Jesus supported free markets, says so in the bible.

Posted by: theamazingjex | February 10, 2011 1:10 PM | Report abuse

Posted by: ostap666: "Yes, a government-run monopoly, that's the solution to our problems! They have such a successful track record!"

You mean this sarcastically, but you are exactly right if you are referring to the governments of other countries who have actually implemented single payer and other universal health policies decades ago. They get similar or better levels of service as us and pay half the price, I would call that a pretty successful track record.

We have the most privatized healthcare system of any industrialized nation and we are the least efficient. Show me another system that is more privatized than ours that works better and I will believe a private healthcare system is the way to go.

In most industries, private systems are the way to go. They provide the best and most efficient level of services. The healthcare industry does not work well in a private, for profit system. The significantly higher prices and the lack of evidence showing better quality in the American system prove that.

Posted by: DeanofProgress | February 10, 2011 1:27 PM | Report abuse

"Our cost driver is not that we have a lot of physicians running around in Mercedes-Benzes. It’s waste in the system."

The doubling in spending has been due to waste? Sounds implausible, but then again people aren't paying for the services they receive directly, and so maybe they are paying for a lot of waste.

As an aside, health care costs are 19.7% of GDP (using the $5 billion figure and gross state product of $25.4 billion in 2009). Despite all that, a doc can't even buy a Benz? Why would anyone practice there?

"First, Vermont spends 8 cents on every dollar on administrative costs, just chasing the money around. That’s a huge waste of money."

Good to know. I can't wait for the annoucement for all of the state's employees with administrative jobs to be fired, as administration is clearly purposeless waste.

"everyone’s medical records will be on that card, so you’ll go into a doctor’s office and they’ll know what the last doctor did to you. That helps avoid duplication of services"

That sounds great, but how many patients are really so hopeless that they can't remember what the last doctor did for them (especially in the realm of expensive tests)?

"I suspect I’m the only politician in America who won an election in this last cycle with TV ads saying I was going to try to pass the first single-payer system in America."

You got Americans in a state that voted for Bernie Sanders to vote for a government provided free lunch.

"How will this interact with other systems? Let's say I have Kaiser Permanente. I come to Vermont and break my leg. What happens?"

Let's take it one further. I live in another state. I come down with a serious illness and didn't buy insurance. I buy an apartment in Vermont and make it my permanent residence. Is health care still my "right", or a privilege (or a service)?

Posted by: justin84 | February 10, 2011 1:28 PM | Report abuse

All those who think that comparing infant mortality rates and life expectancy of the US and countries with nationalized health care policies probably also believe that the sun rises because the rooster crows at dawn.

You're not holding constant huge differences in the nutritional and exercise habits of individuals between nations. Also subgroups of our populations that are more prone to drug use and obesity contribute disporportionately to our poor infant mortality statistics. That is hardly a shortcoming of our healthcare system.

Funny, when it comes to healthcare, the Left suddenly forgets the "root causes" mantra. The root cause of high healthcare costs are the lousy nutritional and exercise habits of our citizens compared with other developed countries.

For that I blame the US government that subsidizes road building, encourages automobile driving and urban sprawl, provide agricultural subsisides for crops that are used to feed cattle and make all the processed food garbage we fill our stomachs with. It's the government's fault, not the market.

Posted by: ElGipper | February 10, 2011 1:32 PM | Report abuse

--*Is it possible that health care may be a special case when applying free market principles?*--

Yes. It attracts busybodies, meddlers, moochers, and looters out of proportion to most other industries.

Otherwise, no, health care is no different than any other service or commodity.

Posted by: msoja | February 10, 2011 1:35 PM | Report abuse

--*I'm ready to move to Vermont.*--

Aw Reet! Gotta get you some of that cheap health care out of someone else's pocket. If enough people follow suit, Vermont will start imposing new conditions relating to residency, etc. And every person that moves to Vermont with a pre-existing condition, will bump up the cost of health care for all the current residents. Some of them may conversely decide to move out, rather than watch their wealth leech away.

And then what?

Posted by: msoja | February 10, 2011 1:44 PM | Report abuse

"http://en.wikipedia.org/wiki/List_of_countries_by_infant_mortality_rate"

Singapore's has the lowest or second lowest infant mortality rate, depending on the source.

Singapore's government spends 0.9% of GDP on health care, vs. roughly 10 times that proportion in the United States. Total spending is just 3.8% of GDP. Singapore is a richer country than the United States, so the argument that poorer countries spend less on health doesn't apply.

Only ~24% of total funding in Singapore is provided by government, vs. ~50% in the United States. Much of the funding in Singapore comes from individual savings, as opposed to comprehensive insurance resulting from government tax incentives or direct government spending in the United States.

http://www.moh.gov.sg/mohcorp/programmes.aspx?id=202

Singapore isn't a perfect free market either (it has a few public hospitals even, but in fairness so does the United States), but it's much closer than the United States in many ways.

"Is it possible that health care may be a special case when applying free market principles?"

Singapore's experience suggest that markets work quite well, provided they are allowed to function.

Posted by: justin84 | February 10, 2011 1:52 PM | Report abuse

@carlosxl,

you're forgetting that in a lot of states (like my own) doctors own surgical practices so where does that fall? I'm sure it falls under the "hospital care" type part of this pie chart in the attached. Trust me doctors in general in the US will not go for a reduction in their income of 40-50% to make single payer work no matter what "PNHP" says. Yes that's a great 18000 doctors out of 800,000 or so nationwide.


http://www.kaiseredu.org/Issue-Modules/US-Health-Care-Costs/Background-Brief.aspx#What is driving health care costs?

Posted by: visionbrkr | February 10, 2011 1:57 PM | Report abuse

EIGipper claims "Funny, when it comes to healthcare, the Left suddenly forgets the "root causes" mantra. The root cause of high healthcare costs are the lousy nutritional and exercise habits of our citizens compared with other developed countries."

This statement is symptomatic of the way right wingers attempt to argue issues: they make false claims which are factually refuted, so they simply move to another false claim - in this case, expensive healthcare can be laid at the feet of our citizens who eat poorly and don't exercise.

Bull. But typical blame the victim rhetoric. As well as completely overlooking numerous other influences on people's health, such as tainted foods, poisoned air, poisoned water, incompletely tested drugs that have been allowed on the market; a medical system that emphasizes medication, thus creating a population taking multiple drugs with interacting negative side effects, etc. But since the (rigged) free market must be worshiped, well, so long as some company is making money then the public can pound sand.

People suffer health problems and accidents for a number of reasons and reducing illness is certainly worth trying to do. But it's a separate problem from the issue under discussion which is how best to handle the fact that some amount of illnesses and accidents are irrefutably inevitable -- how, as a society, shall we deal with them when they happen?

Posted by: Melinochis | February 10, 2011 1:58 PM | Report abuse

Are nutrional and exercise habits so different between nations as to explain the huge differences in rates of infant mortality? Does that even make sense? Are the "root causes" our historical reliance on more-market-based approaches to health care versus the rest of the world? Maybe insurance, and its costs to the healthy/young to fund the expenses of the sick/old necessitates a large pool or strict government regulation (explaining the differences in placees like MN to places like TX).

Also, Singapore is wonderful. I mean, "**Compulsory** savings and price controls"?!? http://en.wikipedia.org/wiki/Healthcare_in_Singapore
Grafting market style mechanisms onto a UK-style system?!?! http://healthaffairs.org/blog/2010/11/12/how-do-you-solve-a-problem-like-health-reform-has-singapore-got-it-right/

All that sounds great to me....

Posted by: Chris_ | February 10, 2011 2:11 PM | Report abuse

@Melinochis,

wait a minute are you really trying to say that obesity is NOT a major factor in healthcare costs are you? You have seen studies right that shows that 75% of healthcare costs come from diabetes, heart disease which in many cases have a direct correlation to obesity.

If obesity is such a "right wing trap" then why (rightly so) is the First Lady attacking childhood obesity? She must be a right wing plant or something!

Time to bring up this chart again.

http://www.nationmaster.com/graph/hea_obe-health-obesity


I'll gladly agree with you that obesity levels in the US are much higher than the rest of the world because of our dependence on high fructose corn syrup as well as our addiction to fast food and lack of exericse as compared to other countries but you can't reasonably say that they don't exist.

Posted by: visionbrkr | February 10, 2011 2:17 PM | Report abuse

It'l be interesting to see how this unfolds.

There are many problems with "States Rights":

-- Human rights are vastly more important. No American State should have the right to not maintain minimal standards for American citizens in education, health, safety, and more. Remember; "States Rights" was used as a reason to permit slavery and discrimination.

-- It can create massive diseconomies of scale and simplicity. It can vastly increase costs, measured and unmeasured in GDP.

-- It's much harder for the public to monitor and hold accountable 50 of each little kind of official (or 5,000, when we get to local rights -- how many people make an informed vote for their local judge, or drain commissioner?)

and I could go on.

But a problem here is some states free riding on other states -- adverse selection. Texas let's its poor and middle class without insurance die in the streets, so the sick in that state move to Vermont. There are steps you can take to diminish this, but it may still be a substantial problem. This, among other important reasons, is why many things like this are best done Federally.

Posted by: RichardHSerlin | February 10, 2011 2:21 PM | Report abuse

visionbrkr -

I remember reading in "A walk in the woods" that Americans walk something like less than a mile per week. This is all walking - grocery store, mall, parking lot, around the house, around work, etc. That's beyond shameful. I've moved around a fair bit in my adult life in urban, suburban, and rural settings. And I'll say that when I've moved to cities, I've always noticed a soreness in my calves for the first month or so. Public transportation = more walking = less obesity = better health = lower healthcare costs. I'm sort of amazed that no one has said this before. Maybe it just isn't polite to say in public unless you hide behind a ridiculous moniker like "willows1".

Posted by: willows1 | February 10, 2011 2:26 PM | Report abuse

Melinochis - I'm not a right winger in really any sense of the word, and I tend to agree that our lousy eating and exercise habits are a major contributing factor to healthcare costs. The ironic part is that these features of American life could probably be addressed by much less intrusive remedies than a health insurance mandate, etc. For example, reducing corn subsidies, raising gas taxes, and investing in public transportation are probably all things that would improve the overall health (mental & physical) of our society.

Posted by: willows1 | February 10, 2011 2:33 PM | Report abuse

@ justin84: Your final question (about sick people taking up residence in Vermont because they can't get insurance elsewhere) illustrates why most efforts at health reform have tried to do it at the national level rather than the state level. Vermont can afford to make its health care system better than that in other states, but not so much better that Vermont becomes flooded with people who move there just for the health care. So it is the Affordable Care Act, by improving the health care system nationwide, that gives Vermont the freedom to think about a plan like Shumlin's.

Posted by: KennethAlmquist | February 10, 2011 2:48 PM | Report abuse

The most dramatic demonstration of how difference in morbity rates affects healthcare costs is Cuba in the 1990's. After the Soviet Union collapsed, Cuba lost subsidies, and the population had meat rations and overall caloric intake cut, and were forced to ride bicycles instead of using cars as gasoline costs soared.

I'll quote from the study published by the Johns Hopkins Bloomberg School of Public Health in October 2007:

During the end of the Cuban economic downturn and the years following it, there were substantial declines in cardiovascular disease, type 2 diabetes and all-cause mortality. The researchers report a plateau in the number of deaths from diabetes during the food shortage of 1988-1996, when physical activity increased and obesity decreased.

"Future steps towards prevention of cardiovascular disease and diabetes should focus on long-term population-wide interventions by encouraging physical activity and the reduction of caloric intake," explained Franco, who is also affiliated with the Johns Hopkins Welch Center for Prevention and Epidemiology."

Also, Professors Ken Thorpe and Robert Woodruff of Emory University published a study the compared morbity rates between European nations and the US to explain a large percentage of the healthcare cost differentials between the 2 sides of the Atlantic.

So Melinchos is the typical Left winger who refuses to look at empirical evidence. Ideology triumphs over facts. More government must equal a better life, and other fairy tales they like to believe.

Sorry to burst your bubble!

Posted by: ElGipper | February 10, 2011 2:50 PM | Report abuse

visionbrkr: "wait a minute are you really trying to say that obesity is NOT a major factor in healthcare costs are you?"

We are talking about 2 different things here: your question is "why do people get sick?" and my question is "how do we help people when they get sick?"

Certainly one way to help reduce overall costs is to engage and educate the public on healthy lifestyle choices, etc. Indeed, one of my favorite bloggers is Canadian and she talks about how, in Canada, the public has a sense that they owe one another to do their best to be healthy since they all share in the costs of medical care. She also writes about how wonderful it is not to have to live in a crouch of fear of getting sick or hurt and having it financially cripple you...but I digress.

HC costs have been rising for years due to a number of factors that are completely unrelated to what actually ails people and what treatments they do/don't receive. I guarantee you that, with the current system, you could reduce American obesity by 100% and medical costs will still go up.

Posted by: Melinochis | February 10, 2011 2:52 PM | Report abuse

willow1: you make the same mistake as visionbrkr: you're conflating why people get sick, and/or the fact that people DO get sick, with why it costs so much to treat them when they do. Those are two different issues.


Posted by: Melinochis | February 10, 2011 2:57 PM | Report abuse

@Melinochis,


I don't think we can say that (at least in the long run) you can reduce obesity to zero and costs will still go up. I don't think that's correct but there's no way to prove that because obesity is not going away.


And they're not two different issues. They're not the same obviously but they are related. The fact that we're treating so many more people for conditions relating to obesity is a factor involved in how we as a country have seen the overall healthcare costs rise so substantially.

As an example i'm a regular watcher of the NBC show "The Biggest Loser". Have you ever seen it? Ever seen how when the morbidly obese contestants start there they are on usually 10-15+ medications and near the end of the show they bring the doctor back in and he tells them that their diabetes is gone, their heart disease is gone they're off their meds. Its a breakthrough for them but what you don't hear is that they won't end up in the hospital and have a $100k hosptial stay for a heart attack. They won't be on $1000+ monthly medications. Add that up on 30% of the population and you may be ignoring the subject as it doesn't fit the goal of your post but its certainly a huge part of the problem.

Posted by: visionbrkr | February 10, 2011 3:22 PM | Report abuse

http://thinkprogress.org/wonkroom/2008/08/12/mccain-veterans-care-access-card/
http://thinkprogress.org/2009/06/10/coburn-va-healt/
^3 studies show VA has better health care than private hospitals, and costs less even though it treats older, and sicker patients.
^VA heath care delivers about 30% better quality care than private heath care.
^This is despite the fact that the VA Costs 40% less than private health care.
http://angrybear.blogspot.com/2008/11/relative-efficiency-of-public-and.html
==Canada gets 1:.71 amount of health care compared to america.

http://www.dailykos.com/storyonly/2009/7/13/753063/-A-Secret-ExposedMedicare-Works-Better-Than-Private-Insurance
^medicare has better quality health care than the private sector.
-Medicare is accepted by 70% more physicians
-40% more medicare patients report excellent care.
-37% more medicare patients report getting
needed care. This is despite Medicare costing 45% less then private insurance.
http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf

Posted by: mynameisblehbleh | February 10, 2011 3:28 PM | Report abuse

http://thinkprogress.org/wonkroom/2008/08/12/mccain-veterans-care-access-card/
http://thinkprogress.org/2009/06/10/coburn-va-healt/
^3 studies show VA has better health care than private hospitals, and costs less even though it treats older, and sicker patients.
^VA heath care delivers about 30% better quality care than private heath care.
^This is despite the fact that the VA Costs 40% less than private health care.
http://angrybear.blogspot.com/2008/11/relative-efficiency-of-public-and.html
==Canada gets 1:.71 amount of health care compared to america.

http://www.dailykos.com/storyonly/2009/7/13/753063/-A-Secret-ExposedMedicare-Works-Better-Than-Private-Insurance
^medicare has better quality health care than the private sector.
-Medicare is accepted by 70% more physicians
-40% more medicare patients report excellent care.
-37% more medicare patients report getting
needed care. This is despite Medicare costing 45% less then private insurance.
http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf

Posted by: mynameisblehbleh | February 10, 2011 3:30 PM | Report abuse

Here's the thing: who is representing the interests of the road builders, the automotive industries, the farm subsidies, etc? Who is currently against high speed rail and mass transit generally?

I think those of us living in the DC area, despite how often we gripe about its various problems, can nevertheless vouch for the health-promoting impact that Metro provides, in addition to promoting attractive, successful economic growth along the trains' lines and reduction in aggravation over sitting on the beltway.

These sorts of programs need help to get off the ground, though. Who will help them?

Posted by: arm3 | February 10, 2011 3:43 PM | Report abuse

I don't think that this approach would work in my state (CA), but let Vermont experiment with it. It should be interesting and we may learn something. I have my doubts about its being successful, but experimentation is the best way to convince folks that something does/doesn't work.

Vermont is tiny, not very diverse and doesn't share a border with Mexico. Maybe it's approach will work in some of the other northeastern states.

Posted by: Beagle1 | February 10, 2011 4:12 PM | Report abuse

*visionbrkr: I don't watch TV so I haven't seen the show you mention. However your point appears to be that when people successfully lose weight they get to stop taking a lot of medications. Good for them.

And then what? My reaction would be that if there's some kind of successful program out there that helps morbidly obese people lose weight in a healthy way that lasts, then all morbidly obese people should be able to enter such a program.

But gee, lots of these folks don't have medical coverage or other resources that would enable them to take advantage of treatments that exist. Hmm, now what?

Where do we go from there? What is your solution?

I stand by my point: people get sick or have health conditions for lots of reasons, some of which can be argued are under their control, but some of which are not under their control. We also have a HC delivery system that is unsustainably expensive. A big part of that (to wind back to the whole point of Ezra's post, single payer HC) is that a whole slew of people profit from the system that we have currently. People losing weight by walking daily and managing their diet doesn't profit anyone in particular - but people being overweight and being prescribed drugs to deal with weight-related problems most definitely profits several stakeholders. The system needs sick people. (Consider how Pharma companies keep finding new mental illnesses to treat. Are you feeling anxiety? Our pill will help you.)

If you remove one category of sick people our system, as is, will find a way to make up those lost profits. Just like in the banking industry. Gee, we have to stop charging exorbitant fees for overdrafts? Well we'll just start charging people for their formerly free checking accounts. As a start. Meanwhile, YOUR costs will not noticeably drop.

Why people get sick is one problem. Paying for their care is a different problem. Solving one doesn't solve the other. It may influence it but it's only one of many factors.

I'd like to actually do (or see done) practical things that improve all of our lives (except as seen through the lens of corporate and shareholder profits). Though, ultimately, of course, HCR is just a proxy for the real question facing America, which is, is profit the final, ultimate goal of everything? Are all aspects of life reducible to their supposed financial value? Are things that are priceless, such as health, love, caring for our neighbors, actually valueless? Expendable? To be sacrificed so that some people can get more dollars?

Healhcare is not, should never have been, a commodity.

Posted by: Melinochis | February 10, 2011 4:50 PM | Report abuse

--*Healhcare is not, should never have been, a commodity.*--

Sorry, but there is no choice about what things are. If it can be sold or traded, it's a commodity.

The thing is, someone has to produce or provide health care. It isn't just hanging from trees on every corner. And you don't get to say to someone: "The service you provide is not a commodity so you have to give it to me." They will disagree.

Further, if you are so far off on this "commodity" thing, you might want to stop and wonder what other simple things you don't know as you proceed to attempt to force your fellow citizens into ill-conceived and expensive schemes that will probably do more harm than anything else.

Posted by: msoja | February 10, 2011 5:44 PM | Report abuse

"Are all aspects of life reducible to their supposed financial value? Are things that are priceless, such as health, love, caring for our neighbors, actually valueless?"

Do you support setting speed limits to 5 mph on all roads? If health is priceless, it stands to reason that such a policy would pass a cost benefit analysis.

Posted by: justin84 | February 10, 2011 6:05 PM | Report abuse

Melinochis,

Don't confuse average cost of a treatment with the aggregate national expenditures on health care. If we could reduce obesity rates to zero, then the US expenditures on healthcare would be closer to Singapore's 3.8% of GDP than our current 17%.

Being overweight is not a failure of the healthcare system nor is it remedied by greater expenditures using doctors. It's a failure of personal responsibility rooted in all kinds of factors. But the biggest failure is the lack of social stigma and sanctions against obesity. Obese people should be treated worse than smokers. In the long-run, they cost our medical system a lot more money.

However, the Left likes to coddle obese folks. Blame it on Korean store owners who don't stock enough fresh produce, rather than on their customers who prefer malt liquor and cheetos to a wholesome diet.

Posted by: ElGipper | February 10, 2011 6:28 PM | Report abuse

*ElGipper: Well the hate and scorn always outs itself eventually. No doubt you are a flawless being with perfect habits and as such are justified in throwing stones as much as you feel like. Evidently perfection excludes compassion, but let's not quibble. After all, there are all kinds of people we should be stigmatizing because life just isn't worth living if you can't hate, or cause others to suffer.

*justin84: no, I don't support reducing the speed limit to 5mph, but that's exactly the kind of meaningless, irrelevant pretend argument that rightwingers always resort to when they can't actually make an argument. If what you are trying to say is that you believe that health should be given a monetary value and that people who—for whatever reasons—dont't at the time, have the dough, should suffer and die, say so. I would disagree with you and think it was an ugly way to think, but it would be honestly ugly instead of dishonestly self-righteously ugly. The problem with rightwingers is they are dishonest to the core of themselves. They use a lot of good-sounding words and concepts to hide the actual nastiness underneath.

*msoja: "If you can buy it or sell it it's a commodity." We can decide as a society whether health can be bought and sold on a commoditized basis. We once bought and sold people too, then decided it was wrong. These are decisions that are within our power to make, they are not some kind of laws of nature handed down by God.

I'm not suggesting that no exchange of money for service should take place - another non-argument. I'm saying that health care services should not be subject to the supposed free market forces that place ever-growing profits in front of every other consideration. It is not acceptable to me that people should die so a corporation can have higher stock prices. That may be acceptable to you. It isn't to me.

One of you illustrious trio mentioned Cuba earlier as an example of how HC costs are low because people have been forced to have healthy diets. You don't mention that they also have state provided healthcare and that some Americans have traveled to Cuba to get healthcare they can't get in their own country.

But for all that you right wingers are supposedly pro-American, you accept that America must fail to do what all other developed nations in this world have succeeded in doing: providing universal healthcare to their citizens, for less money. America can't do it. America must be second-class. Americans just aren't smart enough, apparently. Not resourceful enough. No problem-solving ability here. Nope, we're just stuck with what we have and, instead of finding solutions, we should spend our time blaming fat people, and poor people, and brown people, and any people not lucky enough to be rich or evolved enough to have perfect health.

You guys are truly inspirational and your collective logic has convinced me. I'll abandon my Christian principles and sign on to your survival of the fittest worldview.

Posted by: Melinochis | February 10, 2011 7:21 PM | Report abuse

Melinochis,

The Cuban medical system sucks. I've been to Cuba and the average Cubans get horrible treatment in 3rd world facilities.

The Party Cadre and foreigners like Michael Moore get different treatment. Cubans are healthy inspite of, not because of, their medical care. The exercise more, dance more, walk more, have more sex, and eat better than Americans. That's why their health statistics are so stellar.

But that's beside the point, even conceding your ignorant praise of Cuba's medical care, the fact is that the study I cited proved that radical changes in their diets and exercise habits brought tremendous improvements in their health outcomes! These improvements had NOTHING to do with their medicare care! Doctors and nurses didn't play a part. It was all as a result in changes at the personal level.

That what Leftists simply cannot abide. Real change must come from changes in personal behavior. Sorry comrade, you will not save the poor and disenfranchisement with a government program.

I suggest that you search "24-hour Ghetto Fitness" on YouTube for an example of how change could be effected among our most impoverished.

I have no scorn or hate. I have tremendous belief in the power of people to change. If you've raised 2 kids to adulthood, you'd understand what it means to set expectations high to encourage achievement. None of this coddling, left-wing pandering gets exceptional results from individuals.

Posted by: ElGipper | February 10, 2011 7:43 PM | Report abuse

Hmm, so the Cuban medical system sucks but the people are healthier, sexier, more active..oh, in spite of, not because of their system. Good to know.

I completely agree that people's health can be dramatically improved as a result of diet and exercise changes.

My argument is that you are selecting a group of people - the obese - and hanging all the flaws of our healthcare system on them. You are implying that the offering of HC to these people IS the problem and that if those people were not part of the system all would be well. And as long as you can fight that straw argument you can conveniently avoid dealing with 2 realities:
1. our system is riddled with problems that increase costs and reduce availability (for which you've offered no solution)
2. a large part of our population has obesity related conditions that aren't going to disappear next year just because you think they don't get enough exercise. It's all very well to say that someone just shouldn't have diabetes, but guess what? they still do.

So if you want to cut all people off from healthcare services if their problems--in your opinion--"are their fault" say so. Make your argument.

We'll cut all fat people off the insurance rolls and they don't get Medicare/Medicaid. Tough love. Some of them will die, some will go blind, some will lose limbs (or die since they probably can't cut the limbs off themselves successfully) and some of them might even get better. Societally we are to stand by and watch this happen and rejoice as our healthcare costs go down, right? Coz they will, right? All will be well, right? Because that's the only thing that's wrong with the system, right?

All the corporate interests that paid millions (or was it billions?) to lobby against single payer and the public option will just sit back and say "great!" Reduce our customers by whatever percent and we'll just eat the losses. You bet. That's what we always do, right? You can count on us to do what's best for the country first, and our bottom line second. Yessiree!

The free market will take care of everything, just as it has to date! It's not the system, it's fat, weak human beings who happen to live here and leech off everyone. They're the problem! And lefties who just won't wake up and smell the coffee! They think the system is rigged to benefit corporations and shareholders at the direct expense of citizens. What an idea! Just how could they possibly think that?

Posted by: Melinochis | February 10, 2011 9:42 PM | Report abuse

Hah! The "ElGipper" thinks that if Americans would just stop getting fat and stop using drugs, our healthcare costs would suddenly be in line with the healthiest countries of the world. If only it were that simple. Look, sure, the overall health of Americans will have some effect on costs but remember, we pay a third more as a percentage of our GDP than other developed countries. That is a lot of money. The main reason we pay more is that the technology we use here is very expensive (mainly because the government does not set the prices of health care services as they do in most of the developed world). There are other reasons we spend more money (high administrative costs, defensive medicine, etc.) but it certainly does NOT boil down to a simple "let's stop shooting heroin and eating hamburgers" prescription.

Posted by: parkwoo | February 10, 2011 10:00 PM | Report abuse

--*We once bought and sold people too, then decided it was wrong.*--

Have you ever heard of Temp Agencies? People are still a commodity, and they are still bought and sold.

The distinction being the voluntary nature of the transaction.

--*It is not acceptable to me that people should die so a corporation can have higher stock prices.*--

Then you need to shut down the fast food industry, the tobacco industry, and the auto industry, for starters.

The corporations you want to neuter are the one's working to save people's lives, and when you get done neutering them, people will die.

Posted by: msoja | February 10, 2011 10:32 PM | Report abuse

Well done Melinochis! You've made a very compelling argument. Too bad the same can't be said for your counterparties.

Posted by: co8906 | February 10, 2011 11:59 PM | Report abuse

The Left is too stupid to understand that you only incur medical costs when you get sick or injured. Over 3/4's of our medical costs are related to morbidity: cancer, heart disease, arthritis, ostepororsis, Type 2 diabetes, etc. Research has demonstrated that these ailments are related to dietary and exercise habits.

If someone receives Medicaid, what's wrong with conditioning that aid to meeting certain biomarker targets? Have you ever walked into a doctor's office that serves Medicaid patients? The obesity rate is shocking and inexcusable. There's no compassion in giving out medications to someone without addressing the "root causes."

All the Left cares about is making government bigger. You don't care about really caring for people and improving their lives.

We don't use 17% of our GDP dispensing flu medications, fixing broken bones from sporting and car accidents and delivering babies from mothers who don't use drugs and eat like pigs.

We have tremendous inefficiencies due to state regulations (why can't I buy insurance in CA that doesn't cover psychiatric care or some other ailment I don't need coverage for) and the tax code that favors over-consumption of medical insurance and its use for routine care instead of unforseen catastrophic events (like car insurance). But these government-driven inefficiencies are the tip of the iceberg.

Posted by: ElGipper | February 11, 2011 10:55 AM | Report abuse

Let's not forget our high school geography. Quick, America (especially for single-payer nay-sayers..), what city is the closest to the Vermont border with a population over 1 Million? Answer? Mais oui, c'est Montreal!! (oh, a terrible third world hellhole! ;)

Vermonters know how good Quebeckers have it and they want the same. C'est Super, M. Shumlin!

An American physician

Posted by: stmay | February 11, 2011 11:39 AM | Report abuse

El Gipper, what do you propose then? Regulating food sales and marketing of things that are bad for us? Isn't that what the nanny state that conservatives tend to rail against does?

I agree that these society-wide behaviors need changing. I disagree that this is possible outside of the intervention of some actor capable of transcending the free-riding, "rational" individual's normal decision-making that has led us to where we are. I think the notion of absolute personal responsibility is a myth, but that does not mean that it's 100% the other way. We all have the power to make determine our own course to an extent, but this is based on the information and resources we have on hand combined with our own biological drives. The typical rational actor as a result is too short-sighted to consider the long term benefits of eating and exercising when faced against the constant onslaught of televised advertising and our bodies not regulating well how much sugar is enough. There is a reason the advertising industry is as large as it is, and makes as much money as it does: people are fairly easily influenced.

Maybe you don't buy that, but nevertheless we find ourselves in this situation. Do you have an alternative explanation? Do you have a solution?

Posted by: arm3 | February 11, 2011 11:43 AM | Report abuse

Arm3,

I propose raising the Medicare tax rate and raising deductibles and co-pays for Medicare recipients over 65.

In addition, I propose a schedule of discounts on the Medicare tax rates, deductibles, and co-pays that is linked to biomarker measurements that are almost completely under an individual's control. The 4 I have in mind are: body fat percentage, cholesterol count, and blood pressure, and presence of nicotine in system to detect smoking. These are low-cost tests.

Someone can refuse to take the tests and be stuck with the higher taxes (under 65)and greater cost burdens (over 65). Presumably, these will be the people who are too unhealthy or too rich and lazy to bother taking the tests. The vast majority of the population will presumably want to get measured so that they qualify for the discounts. I'm open minded about the frequency for cost considerations, but annual basis should be fine. Any doctor's office could make these measurements.

Suppose Medicare tax rates increase from 3% to 8% of eligible income. We'd develop a matrix of tax rates ranging from 8% to 1% based on the combination of biomarker measurements. I'll let the experts construct the matrix based on sex differences and other factors, but you get the idea. Ditto for the co-pays and deductibles in Medicare plans.

The whole point is to provide individuals with immediate financial pain that is somewhat correlated with the additional expenses they will incur due to their unhealthy lifestyles. As car insurance rates are higher for younger and more reckless drivers, so should health insurance taxes be higher for those with behaviors that lead to higher costs.

In addition, I would have rules requiring Medicaid recipients to improve their biomarkers in order to qualify for continued benefits or larger benefits.

Very simple. You inculcate a sense of personal accountability for health, instead of pretending that physicians and drug manufacturers are responsible for making us healthy.

Posted by: ElGipper | February 11, 2011 1:29 PM | Report abuse

We have a single payer systems in several different forms. Medicare, Medicaid, SCHIP and VA Hospitals. Might as well bring the whole population into one system. Mainly the healthiest part of the population are insured by Wall Street health insurance companies. People and business are mobile, so single payer will be the only solution. I don't understand the fight back on who will pay your or my doctor bill. It works in other less wealthier countries, so it can work in America. Thanks Gov. Shumlin for not sticking to the status quo.

Posted by: reginaldjohns | February 12, 2011 5:05 AM | Report abuse

Single payer will work because money is tied up in premium payments to for profit companies. Just pay into one system and it's done. Hopefully The Supreme Court will strike down the individual mandate in the new law. Then we can fight for a real national universal health system.

Posted by: reginaldjohns | February 12, 2011 5:10 AM | Report abuse

Yeah, let's take the profit out of every economic activity in the US to wring out the waste going to Wall Street profiteers! That will solve our health care and every other problem.

Except that idiocy has already been tested, and failed in every society. Healthcare is screwed up in this country because of state and federal policies. To blame the private sector for working within a screwing system created by government is sadistic.

Posted by: ElGipper | February 12, 2011 7:40 PM | Report abuse

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