Devil in the details

One of Gov. Peter Shumlin's signature pieces of legislation that passed the state Legislature during this past session was healthcare reform. Deeming adequate access to healthcare a "right, and not a privilege," he has set the state on a course to develop what would be the nation's first single payer system, which will employ public finding to allow such access for all.

His Republican opponent, State Senator Randy Brock, has countered with a different kind of health care proposal, one which relies much more heavily on market-based incentives to achieve the cost savings all agree are needed, while maintaining an element of choice by consumers. There are good arguments to be made for both points of view, and both sides might benefit from keeping minds open and considering the alternative approach. That's a skill that seems all but lost in Washington D.C. at the moment, but hopefully still survives, in some way, in a small state like Vermont.

Vermonters, if the polls are any judge, seem to be as fed up with private insurers as people in other states are, and the availability of good health care at an affordable cost weighs heavily on the minds of those who may need it. Given the ever-aging and older demographics of Vermont, that is an increasing number of people, and perversely, there is much concern that Vermont may not be able to attract enough doctors to come and set up practices here.

It's not really going to be possible to make a judgment on Gov. Shumlin's health care plan, or more precisely, the one that the five-member Green Mountain Care Board produces - which is expected sometime next year, conveniently after the election. Health care may be a right, or a least one that should be universally available at some minimum, basic, and effective level, but neither can it cost more than the state can generate in taxation to pay for it. That is the driver, after all, of replacing the current system with something else, be it single or multiple payer - as things stand now, present cost trends are unsustainable. So something has to give. But if the Green Mountain Care board is not careful, the state's fragile economy could be burdened with a new round of expenses that aren't sustainable either.

We'll part company with Senator Brock over comparing buying healthcare to purchasing a TV set - quality of life is a tough category to put a price tag on or comparison shop for - but we do confess to liking some of the pieces of Brock's still evolving health care package. The notion that someone who minds their lifestyle choices to minimize the likelihood of contracting lung cancer, for example, by not smoking, or exercises regularly to avoid illnesses associated with obesity, should get a break on their insurance premium as a result, is very attractive. The "community rating" idea gets trickier. Under state law, insurers must charge the same for an 80 year-old as it does for a more likely to be much healthier 20 year-old. Should the younger person be charged less? The controversial federal Affordable Care Act, the health care overhaul that passed Congress in 2010 allows for up to a 3-1 spread. There's a case to be made that younger, less likely to need healthcare individuals are also less likely to be able to afford good healthcare insurance. But there is also community aspect to this market as well, where the economics only work if everyone is contributing, and young people could suddenly and unexpectedly find themselves needing treatments as well. That's a harder call.

One advantage to Brock's plan, and one lawmakers should consider, is that it is inherently more flexible that the global single-payer approach, and could be more easily tweaked if later on, consumers are behaving differently than expected.

In this day and age, it should be possible to ensure that all people get an affordable and effective, if basic, level of quality healthcare. For those who want more, they should expect - and most seem willing to - pay more for it.

There is a lot of change needed in the health care scene. If we as a nation were creating a health insurance system from scratch, we probably wouldn't create one that resembles the historical patchwork that we've evolved into. Linking health insurance to work, and making it a benefit businesses can offer employees in exchange for a tax credit, seems particularly ripe for plucking and replacement.

But on the other hand, as people live longer and expect to live healthier lives, at some point personal responsibility does kick in. That doesn't mean that someone who smokes two packs of cigarettes a day shouldn't get health care when they need it - but perhaps they should expect to pay more for it. Meanwhile, we wait for the numbers from the Shumlin administration. When we know those, and how their plan is proposed to be funded, we can have an intelligent discussion.


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