Catamount Health offers little in the way of reform

MARVIN MALEK, MD
From the May 21, 2006
Times Argus

Observers of the lovefest at the state capital over the recently passed Catamount Health reform bill might think we'd found the Holy Grail or invented an improved wheel. Unfortunately just because a Republican governor and Democratic Legislature can agree on a bill does not mean that good legislation lies ahead.

As an internist in Barre, I frequently undertake the difficult task of providing care to people who have no health insurance — those the Catamount health bill is designed to help. So I want to believe that the Catamount Health bill will really serve as the "historic reform" that Sen. Jim Leddy called it in a commentary on these pages on April 30.

But I'm really worried about the bill. As a cost-control measure, improving the care of those with chronic illnesses is completely unproven. The research supporting it is dubious. The Democrats' consultant, Ken Thorpe, has grossly overstated the ability of chronic care programs to reduce the cost of medical care. He ignores the findings of a thorough review conducted by the Congressional Budget Office, and also research conducted by Kaiser-Permanente, the country's largest nonprofit health plan, which indicated there is no evidence chronic care management programs lead to cost savings.

In fact, far from allowing an expansion of public coverage to a new population, I worry that the growth of Medicaid costs will be unsustainable if the chronic care initiative fails to meet the most optimistic projections. The Medicaid program will be under sustained pressure because it serves as the bottom of the safety net. The sickest — and most expensive people to insure – end up insured through the Medicaid program when they become too ill to work and exhaust their savings.

While you're adding a new population for the state to insure by not taking on the insurance and pharmaceutical industries, you are leaving aside the best tactic to reduce costs. The current system of multiple private health insurance companies adds enormous amounts of administrative expense. I see it every day as we contend with complex insurance company policies which attempt to avoid paying any and every medical bill, and I can only imagine the parallel expense taking place at the other end of the phone line at the insurance company. And by not consolidating into one large insurer for the entire population, we fragment our ability to get serious about negotiating down the prices of medical supplies and prescription drugs — and to create a better coordinated system of care for those with chronic illnesses.

It's clear that Gov. James Douglas' close-minded insistence on preserving the privileged position of the private health insurers has set the limits on the legislation. So we're instead stuck with modest, band-aid reform – with no secure funding for the bill, and no action to do something meaningful about the ongoing meltdown of our health care system. Here is a snapshot of just a few of the problems the new reform bill does not address:


The Medicaid deficit;

Labor strikes over health benefits;

Poor access to primary care as middle class and poorer families contend with ever-increasing deductibles before their insurance coverage kicks in;

Big businesses continuing to relocate to Canada and other countries where they can fulfill the promise of health insurance to their employees at far lower cost;

Small businesses struggling to find affordable health insurance for their employees;

Massively higher administrative costs in the United States compared to other countries. H.861 actually adds to our administrative burden, especially since the governor succeeded in insisting that multiple private insurance companies administer the program.

What does that mean to me? Yet more sets of rules for our practice to contend with. And I can only imagine the administrative burden the chronic care initiative will place on primary care practices.

Worse yet, I fear the passage of the Catamount bill will sideline the push for more meaningful health reform. We'll all be asked to give the new program a chance to work, likely putting the brakes on effective health reform for at least three, and maybe four or five years. Meanwhile, there will be ever more underinsured patients, ever higher health costs, ever greater Medicaid deficits.

It is inappropriate for Sen. Leddy and other legislators to portray this bill as a major, landmark achievement. Believe me, it is anything but that. You would do better to portray it as a small step that will have some immediate beneficiaries, but a bill that cannot provide long-term health security for the citizens of Vermont.

Every legislator asking for our vote should be obliged to come up with a coherent answer to the question: Why does every other developed country have universal health insurance and vastly superior health outcomes while spending only 50 percent to 60 percent of what Americans spend on health care? Our legislators — and our governor — ought to show enough curiosity to really grapple with this fact.

Vermonters should expect the same health security that citizens of every other developed country have come to expect. In all these countries, every citizen has full health coverage that is stable and stays with them throughout their lives — no matter what.

By contrast, the Catamount bill is a small, tenuous step that is dependent on an infusion of extra Medicaid dollars in the next two years and relatively good tax revenues that have gone along with the current favorable phase of the economic cycle.

Beyond two or three years, we can expect the new Catamount plan and the Medicaid program to both face enormous deficits — and we'll probably be forced to cut back on both programs.

Dr. Marvin Malek is an internist in Barre and a member of Physicians for a National Health Program.

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"What will it take to achieve real health care reform?"

Richard Kirsch, Executive Director of Citizen Action of New York has written an insightful, detailed analysis "If Wishes Were Horses: The False Promise of the Massachusetts Health Plan." Especially because the Massachusetts legislation was widely hailed across the country as a 'miracle' and a 'model' of bipartisan cooperation, as well as 'universal health care' and a 'solution,' etc., thoughtful criticism of the plan helps us all; I hope people take time to read it closely.

Kirsch dissects the Massachusetts plan thoroughly. He identifies the provisions that will help the poor, aspects we should celebrate, and also exposes the roots of the "false promise." He places the plan in contemporary context and reviews the history of similar efforts as well his own efforts in New York. He offers his honest reflections and recommendations.

Yet Kirsch discounts, rather than returning to embrace, the single payer national health insurance proposal. He resurrects the phrase that single-payer is not "politically feasible," which is by now an old saw. But where this once sufficed to dispense with the idea, and thus ignore it, discussion of a public national health insurance system can be dismissed no longer. We see this when Kirsch asks:

"If the fundamental flaw in the Massachusetts plan is that it maintains the private insurance system and accelerates the pressure toward consumer driven health care, does that mean that the only solution is a national health insurance plan?"

Significantly, he answers his question by striking a reluctant, not dismissive, chord: "Not necessarily." Kirsch elaborates:

"The advantages of single-payer are clear and go well beyond the elimination of excess administrative costs that is too often the prime rallying point of single-payer advocates. National health insurance provides the basic structure for universal coverage: everyone is automatically covered in one large pool. It provides the tools for systemic affordability: setting prices; controlling supply; limiting out of pocket costs; directing funds towards high quality care. But these goals, all of which stem from the concept that health care is a public good rather than a private commodity, can be achieved in various measures with systemic changes that don't require a single-payer system."

And yet, while Kirsch acknowledges crucial strengths of the single payer proposal, he retreats to a position in defense of private health insurance:

"So in proposing a public program that fits the American experience, and therefore has some chance of becoming law, I recommend a system that utilizes Medicare and regulates private insurance. Under such a system every American would be guaranteed health care from Medicare or private insurance."

Is this really how we might avoid "more false promises" like the ones in Massachusetts? Even in the best case scenario, won't the preservation of our private health insurance corporations lead to more health care injustice, with inequalities of care accelerating, polarizing and ultimately crystallized in a two-tier system? Can the American profit-driven health insurance industry really be regulated into treating health care as a "public good?" If that were to happen, wouldn't that industry, at least as we know it, cease to exist?

In other words, if one sees, as Kirsch does, that selling health care as a private commodity is a fundamental flaw for social policy, as it is in the Massachusetts plan, then it really is time to come back to single-payer. There is no right way to do a wrong thing.

Kirsch suggests that one can find examples of developed nations where private health insurance coexists happily alongside public health insurance, thanks to heavy government regulation of the health insurance industry. Besides the question of whether it might be "politically feasible" for American insurers to be regulated into changing their spots -- or perhaps their souls -- this idea seems, at best, lost in translation.

Mostly, "private" insurance companies in other countries are actually non-profit firms which are not only highly regulated but which exist only because government finds it advantageous, and efficient, to work through them. They are not politically powerful agents, as are insurance companies in this country. In countries like France private insurers are sidelined. In a few nations, like Switzerland, regulation means that the government has the power to dictate how much each insurer may charge for premiums as well as the amount of profit it may make on basic coverage -- none. In Britain, parallel private insurance spurs the underfunding of the NHS, undermining it. In Canada lately there is a lawn sign that sums it up: "Don't Privatize Medicare!" With Medicare "Part D" - D for debacle - those signs apply just as well here in the US. Like Medicare Part D, and just as Kirsch finds in the Massachusetts plan, for most developed nations, treating health care like a private commodity remains the germ of the problems.

This gets back to the point about what is "politically feasible." Consider what we're up against this way -- a profitable, powerful private insurance industry, alongside behemoth pharmaceutical and medical technology industries -- a three-headed Cerberus. Kirsch identifies what nourishes the monster (health care as a private commodity) as the source of our ills. He identifies basic health insurance coverage for all as the necessary next step toward reorganizing the American health care system along the lines of a public good. He then proposes, like Hercules at his twelfth labor, that if we keep private health insurance, there is a way to tame the beast and harvest from it the public interest. Well, OK -- but a great myth.

If Kirsch's recommendation seems logically contradictory, even more curiously, he contemplates the Herculean social force that it will take to change the American health care system in order to organize it around the best interests of its patients. Surely that force would be capable of delivering single payer reform. Even further in line with the single payer demand, he wants to see sweeping change, real strides instead of baby steps. Kirsch concludes transcendently, reiterating the theme of health care as a public good:

"What will it take to achieve real health care reform? It will take a major shift in the nation's politics. As long as our political agenda is dominated by the champions of privatization and the opponents of government regulation, we will have no chance of enacting reforms that realize the objectives of universal coverage and systemic affordability. Instead, we will get more false promises like that of Massachusetts, a law that has some positive provisions based on the concept that health care is a public good, but is flawed and doomed to failure by its core assumption that health care is a private commodity."

Ultimately, working my way through Kirsch's analysis seemed a bit like observing a dramatic exploratory surgery -- the sick patient rushed to the OR after failing medical treatments -- where the surgeon masterfully dissects, keenly exposes the malignancy, proposes the instruments to resect the tumor ... and then hesitates, wishing he could give the medications one more chance. Nevertheless Kirsch's closing words return to his deep conviction that the patient can be saved:

"There are no shortcuts. Wishing won't make it so. Winning real health care reform requires a clear vision, a persistent, strategic energy and a belief in the miracle of change."

A major shift in American politics is well underway. We should see the Massachusetts plan as a result of its shift, as well as a driver. Not a "miracle in Massachusetts" but a measure of a struggle in which real reform can be won -- a process that has the power to yield the "miracle of change." Massachusetts gives us a measure of acceptance of the idea that health care is a public good. That idea is winning the day. Yet Massachusetts also shows us that the insurers retain the capacity to hijack that idea, co-opt it and use it to reinforce the status quo.

The demand for single payer national health insurance -- which leaves no role for private insurance companies to treat health care as a private commodity -- is the clear vision with the strategic power to realize the change we all need.

Richard Kirsch, please come back.

Andrew D. Coates, MD

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Download our WAMC Forums

All four forums in our series "Reforming Our Health Care System: The Pros and Cons of Medicare for All" can be heard via the internet at the WAMC Performing Arts Studio archive page.

Capital District Physicians for a National Health Program would like to thank all who participated in the forums as well as our co-sponsors -- the League of Women Voters and especially WAMC, Capital District Alliance for Universal Healthcare, Hunger Action Network of NY State, the Labor-Religion Coalition, Albany Medical Center, Albany Law School, the MBA Program in Healthcare Management of the Graduate College of Union University, the Medical Society of Albany County, the New York State Nurses Association and Rekindling Reform.

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