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.