Ellen Oxfeld: We need a universal public system to solve the health care crisis

This comment is from Ellen Oxfeldt of Middlebury, a board member for Vermont Health Care for All.

Over the past few weeks, the mess in Vermont’s health care situation has been amply documented by many commenters on this post. Even Green Mountain Care Board members recently questioned OneCare executives, asking them to show results to justify their high administrative costs, much of which is funded with state dollars.

Commentators agree that Vermonters are not getting the care they need. One reason is high out-of-pocket costs, which now leave 44 percent of Vermonters under the age of 65 underinsured.

There is also agreement that high prices, not overuse by the patient, are making our system worse. How could people overuse a system they don’t even have access to?

In fact, many commentators have also noted that the only place in our current system that is overused is the emergency room—because people either don’t have a primary care doctor or because costs have led them to delay care until their condition becomes more critical.

But what is the solution to this problem?

We must recognize that 34% of every dollar in our health care system is administrative costs. More than half of that is pure loss caused by so many middlemen — multiple insurance policies, Byzantine experiments like the accountable care organization OneCare. This raises our costs.

We can bend the cost curve by creating public funding and universal access, thereby simplifying administration by removing these unnecessary intermediaries. Without a universal system that is publicly funded, we will never have the tools to control prices, adequately reimburse primary care physicians, or ensure that all Vermonters can see a health care provider when they need to , without worrying about going into debt.

Indeed, in addition to the high cost of intermediaries, another reason—rarely mentioned—for high costs is underutilization. Lack of access results in costly complications, especially when people delay or avoid treatment due to high out-of-pocket costs.

Unfortunately, many reform schemes are based on the mistaken notion that fee-for-service is the primary cause of rising health care costs. It is assumed that providers offer services that are unnecessary and thus increase costs.

In fact, health care systems around the world tend to use a combination of provider reimbursement schemes, including fee-for-service. Yet none of these systems have the high costs that we have due to the simple fact that they are universal. Their administrative costs are much lower, and they avoid the high costs of treating people who have ignored their symptoms for too long because they couldn’t afford to see a doctor.

We all know that a strong foundation in primary care is essential to treating people before their condition becomes more expensive and lands them in the emergency room. Health care reformers, regulators, and even administrators praise primary care. Agreed! But then what?

We must go beyond ritually reciting the importance of primary care and ensure that primary care becomes a universal public good in Vermont. A universal primary care system will keep Vermonters healthier. It would also make life easier for our primary care providers, many of whom are not adequately reimbursed in our current multi-payer system.

Our own Vermont statute, Act 48, lays out a road map for implementing a universal publicly funded health care system here in Vermont. If we can’t do this in one fell swoop, then let’s do it by sector of care and start with primary care, the one sector of care that we all need.

Universal primary care would stabilize our primary care workforce by pooling our funds for primary care services and creating a fair reimbursement rate. That would appeal to primary care providers in Vermont because it would involve less paperwork than elsewhere, and they could see patients before their conditions were far less treatable.

If primary care were a public good, like fire protection, then people would no longer avoid care as they do now.

Vermonters need access to health care, not more Byzantine experiments. Bills will be introduced next session in both the Vermont House and Senate that propose making primary care a public good in Vermont. We need to ask our senators and representatives to sign on.

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Tags: Act 48, Ellen Oxfeld, overhead, primary care, public good, underinsured, universal public health


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