Is Vermont’s approach to health care reform leading to “single provider” as well as “single payer”?

by Robert Maynard

I have long argued that the logic of the “health care is a human right” argument, leads not only to single payer, but to single provider as well. Single payer really is only a stepping stone in the eyes those who believe that government should control not only the paying for services, but the providing of services as well.  Back in May of 2011, TNR ran a story about a health care reform forum held by Burlington Democrats in which both Mark Larson and Dr. Deb Richter argued that the problem with the current health care system is that “no one is in charge.”  Dr. Richter lauded the push for health care reform because it would create “stewardship” over our health care system system.  Mark Larson complained that the current system is too fragmented and spoke about how centralizing authority in the Green Mountain Care Board will fix this problem.  We should keep this in mind when considering the creation of “Onecare Vermont,”  which is described as follows: “Fletcher Allen and Dartmouth-Hitchcock have created OneCare Vermont – an accountable care organization (ACO) that will work with a network of providers to coordinate the health care of approximately 42,000 of Vermont’s 118,000 Medicare beneficiaries.”

Here is what they see as its advantages:

An accountable care organization (ACO) is a coordinated group of health care providers who have agreed to share responsibility for the care of a defined population of individuals. The Medicare Payment Advisory Commission defines an ACO as: a group of primary care providers, specialists and/or hospitals and other health professionals who coordinate the full continuum of care and are accountable for the overall quality of care and costs for a defined population. (Medicare Payment Advisory Commission). ACO providers coordinate amongst themselves, and with each individual, to improve the individual’s quality of care, the efficacy of the care and to reduce the rate of increasing cost of care over time.

Coordinated care helps ensure that patients, especially those with chronic conditions, get the right care, at the right time, and in the right place. An ACO is not a health insurance plan or a health maintenance organization (HMO). An ACO doesn’t affect Medicare benefits or which providers a patient can choose to see. ACOs put the doctor and patient in charge of patient care, not insurance companies. Being part of an ACO is about better collaboration between providers and a shared commitment to improving the health of the patients they serve.

They see themselves as an integral part of our current reform efforts: “The development of ACOs like OneCare Vermont is a key component of health care reform and part of Fletcher Allen’s and Dartmouth-Hitchcock’s shared commitment to the highest-quality individualized care, delivered close to home, coordinated for safety, effectiveness, and lower cost, for the benefit of the patients and families we serve.”

Again, keep in mind that key figures in the push for Green Mountain Care see the problem with our current system as having “no one in charge” and see a need to gain “stewardship” over a “fragmented” system.  Here is how one of our readers reacted to the news of Onecare’s creation as part of a solution to the problem of no one being in charge:

Interesting…single payer advocates in VT are shaken up by the ACOs! ACOs swallowed up VT b/c of survival of the VT hospitals and providers under single payer. Most private practices are not under ACOs, BUT some are!!!

Passage of VT’s single payer made the VT ACO as an employed doc at RRMC recently told — (the doc is on his way out of VT..along w/ the entire dept at RRMC)! You have Dartmouth and FA controlling the state of VT w/ their ACO! VT is a tiny state only takes two major players to lock up the market!!! Congrats to Dartmouth and FA!!!

This is not good for VT’s health care system. You have to LOVE it (roll eyes)….Wallack and the GMCB were so busy chasing private practice docs to be bought up by the hospitals!!!!! Meanwhile….FA and Dartmouth took over the state! … has always said he is a “little fish” in a big sea for health reform in VT, but Wallack thought the private practice providers were the BIG fish!!!!

The comment about single payer advocates being shaken up over ACOs is a reference to this Vermont Digger article:

Vermont does not need another health reform trend called the accountable care organization. Vermont needs a not-for-profit, democratic, publicly financed health system that emphasizes the promotion of health. The Vermont Legislature has the opportunity to expand its open meeting law for nonprofit organizations to include hospitals and ACOs. Given our goal for a transparent and equitable Green Mountain health care system, this open meeting law is essential.

I find it hard to believe that all progressives are surprised that our push for government dominated health care reform is leading to a partnership with corporate medicine as most of the smaller players are squeezed out of what will become a monopoly health care system that will claim “stewardship” over our “fragmented” current system.  Some progressives naively think that this is all about limiting the influence of big corporations.  The notion that big corporations would be attacked always was a fantasy. Progressivism never really was anti-corporation, just anti-free market. As pointed out in this Freeman article, the central theme behind progressivism is that a society will operate more smoothly, or more justly, if it is run from the top down by experts.  Some progressives wanted those experts to come from the world of the business elite of Harvard Business School graduates, others thought that these experts should come from the social sciences:

The American economy after the Civil War became increasingly dominated by large organizations. I’ve written in The Freeman before about the role of the government in the growth of the centralized corporate economy: the railroad land grants and subsidies, which tipped the balance toward large manufacturing firms serving a national market (“The Distorting Effects of Transportation Subsidies,” November 2010), and the patent system, which was a primary tool of consolidation and cartelization in a number of industries (“How ‘Intellectual Property’ Impedes Competition,” October 2009,

These giant corporations were followed by large government agencies whose mission was to support and stabilize the corporate economy, and then by large bureaucratic universities, centralized school systems, and assorted “helping professionals” to process the “human resources” the corporations and State fed on. These interlocking bureaucracies required a large managerial class to administer them.

According to Rakesh Khurana of the Harvard Business School (in From Higher Aims to Hired Hands), the first corporation managers came from an industrial engineering background and saw their job as doing for the entire organization what they’d previously done for production on the shop floor. The managerial revolution in the large corporation, Khurana writes, was in essence an attempt to apply the engineer’s approach (standardizing and rationalizing tools, processes, and systems) to the organization as a system.

Big corporations, big government, big universities, etc., were to gain “stewardship” over our economy so that our society could be centrally managed from the top down by experts.  The real opponent of progressivism is  not big corporations, but free enterprise.  Free enterprise is see as chaotic and leading to a “fragmented” society.  The solution is for someone to gain “stewardship” over this fragmented society.  Of course that someone is to be experts, not the people themselves.

We could fix the mess that is being created out of our health care system by reversing course and initiating  patient choice oriented approach to reform.