Editor’s note: the following piece has been available on Randy Brock’s campaign website for a while now, but it is being republished here again at TNR because of the importance of Randy’s insight linking Vermont’s past tradition of self-reliance with the reality of our 21st Century Information Age. This is not just about health care, but the fundamental dividing line between a freedom based vision of Vermont’s future vs. the the progressive vision that is stuck in the Industrial Age model of society being run from the top down by a select few. (See the highlighted section)
As Governor, one of my highest priorities will be to ensure that every Vermonter – 100% – has access to quality health care at an affordable cost.
I do not believe that health care is a human right. But I believe it is the right thing to do.
There are two pathways toward achieving that goal. One path leads to a system in which our entire $5 billion per year health care system – one sixth of our economy – is placed in the hands of unelected, unaccountable bureaucrats in Montpelier. Down that path lie higher taxes, reduced choice, price controls and rationing of services. That’s the path we are on now and the road ahead makes the future for our children less bright and less prosperous.
The other path leads to a system in which patients and their doctors, not bureaucrats, are in control. In that system, individuals can decide on the health plan and the medical care that best meets the needs of their families. There, the power of individual consumers and the free market can drive the transformational change needed, just as they have done in every other aspect of the American economy. And it is transformational change that is needed, not just small tweaks to a system that has grown increasingly dysfunctional and costly.
Vermonters have a long and proud tradition of independence, self-reliance and maintaining control over our own lives. That is the thread that joins today’s Vermont from its founding more than two hundred years ago. But we are living in a new century. Look around us: products and services are moving us even more toward a culture of personal responsibility in which we take charge of our lives and futures in a way never before achieved. From the adoption of new personal technologies (iPhones, Facebook, Google) to new personal services (Expedia, EBay), consumers are empowered on a personal and at the same time global scale. Extending that power to the individual has made every Vermonter smarter, more independent and more capable of managing complexity than ever. That is a tradition in which Vermonters want to control their own lives, make their own decisions, and not be bound by rules, bureaucracy, strictures and one-size-fits-all mandates from Montpelier. In health care, Vermonters don’t want bureaucrats – either from Montpelier or from faceless insurance companies – getting between them and their doctors. So let’s look at another vision.
Imagine a Vermont where prudent regulation, free choice and abundant competition have made the high quality and low cost of Vermont health care the envy of the nation. That’s my vision of health care and it is a vision within our grasp. Here’s how to create real health care reform. And while you’re reading this, notice how many items cost nothing to implement!
ESTABLISH COMMON-SENSE PRINCIPLES
To begin developing a real-world framework for health care in Vermont, we need to first set down the basic principles and values upon which a transformed health care system will rest.
- Patient-Centered and Patient-Directed
- Strengthen the Safety Net and Leave No Vermonter Behind
- Robust Choice
- Competition and Collaboration Among Providers
- Enhance the Already High Quality of Vermont Health Care
- Personal Responsibility
- Positive Incentives to Make Healthy Choices at Least Cost
- Individual Ownership and Portability
- Evidence Based
- Information Intensive and User Friendly
ESTABLISH MEASURABLE MILESTONES AND RESULTS
Here are some of the things we should be able to see and to measure as we implement a health care system developed using these principles:
- Increased choice of plans and options
- Increased choice of doctors and medical therapies
- Better protection for the seriously ill
- Greater affordability to Vermonters
- Shift of control from insurance companies and government to individuals and families
- Greater ease and more informed individual decision-making
- Positive change in behaviors: Greater individual responsibility for wellness
- Lower system cost
BEGIN THE TRANSFORMATION
Next January, we can begin the true transformation of health care in Vermont.
We don’t need to succumb to the siren song of undefined budgets, unknown costs and a Governor who repeatedly says, “Trust me. I know what’s best for you.” That will be replaced with a hard-headed, common-sense, but humane, approach that proposes real change, in steps that we can see, price, measure and prove. We’ll continually adapt as new ideas and proven strategies evolve, systematically look at what is working in other states and adopt those proven, evidence-based solutions that have worked elsewhere. Of course we will continue to innovate, but we will no longer expect Vermonters to “lead the way” as guinea pigs in someone’s grand, unproven social experiment.
Here are five key strategies that point the way forward:
ADOPT CONSUMER-DRIVEN HEALTH CARE
- Provide a pathway for every Vermonter, regardless of income or employment, to get affordable health care
- Reestablish the principle that the primary responsibility for maintaining wellness and paying for health care rests with the informed individual and family, not with the government.
- Promote policies that put informed consumers, with incentives to control costs and real choices, in charge of managing their health.
- Recognize that the federal Patient Protection and Affordable Care Act may be repealed if there is a change of Administration in Washington. Vermont’s decisions now must allow for that contingency. Don’t tie Vermont’s future to the vagaries and uncertain funding promises from Washington. Remember Special Education? Remember Medicaid? Remember FEMA?
- Provide positive incentives to create behavioral change.
- Reduce the cost of defensive medicine by reforming medical malpractice law to provide safe harbor protection to physicians who practice defined evidence-based medicine, while ensuring that patients who are harmed are adequately compensated. Eliminating needless tests will have a significant impact on reducing health care cost.
- Allow individuals the same state income tax deduction that employers have for health insurance purchases.
- Further incentivize providers to invest in health information technology, including electronic medical records.
- Allow Vermonters, like residents of Maine, to buy insurance from licensed insurers, in any state in New England.
- Aggressively seek out and invite insurers to enter the new Vermont market. Expand the number of health insurance companies willing to operate in Vermont by removing unreasonable legal and regulatory restraints.
- Reduce the current strict age-based community rating for small group and non-group insurance, which requires healthier young families with children and mortgages to subsidize the premiums of their older, sicker, but sometime much wealthier parents, to the 3:1 cost ratio allowed by the federal health care law. Protect the uninsurable or those with serious, high cost preexisting conditions through targeted reinsurance and high risk pools as described below.
- Allow insurers to offer discounts for healthy lifestyles (weight management, no excess alcohol, tobacco or illegal drug use, etc.) just as auto insurers do for seatbelt usage, airbags, and no moving violations.
- Establish a mechanism to allow portability of insurance policies so that changing employers does not have to mean changing insurance policies.
- Pilot choice for low-income families on Medicaid, as has been tested in Florida and Indiana with significant cost savings and high patient satisfaction.
- Reduce the number of Vermonters on state-assisted coverage by making private insurance more affordable.
- Reward consumers for shopping wisely for health care by allowing them to keep some of the savings
- Lead a collaborative effort between Vermont health care providers and Vermont’s tourism and recreation industry, to throw out health care capacity controls, and allow providers to expand capacity, especially in selected areas such as orthopedic and cosmetic surgery, to make Vermont the preeminent medical tourism destination in America.
- Create a targeted reinsurance mechanism (as in Maine and Idaho) or high risk pools to provide protection for and to insulate from high cost that small number of traditionally uninsurable Vermonters. Provide mechanism to cover preexisting conditions.
PROTECT PATIENTS WITH REASONABLE RULES
- Spend public funds to educate Vermonters on how to stay healthy, and how to access information on shopping wisely for insurance and preventive and chronic care (which consumes on the order of 70% of America’s health dollars).
- Educate Vermonters on the content, risks and rewards of multi-state and other New England state policies offered for sale.
- Review every government mandate and repeal those that needlessly drive up the cost of health care. Continue to offer some former mandates as options that consumers may choose if they want them.
- Allow consumers to purchase coverage “a la carte.”
- Consider a mechanism to encourage captive insurance plans for groups of businesses.
- Gradually reduce and eventually eliminate the vicious cycle of the cost shift under which government programs (Medicaid, VHAP, Dr. Dinosaur, Catamount) systematically underpay providers, who in turn shift the uncompensated costs to private insurance customers. This shift makes private insurance less affordable, creating more uninsured individuals, and driving more people into underfunded government health care programs. Providers would need to agree to reduce the present cost shift to private insurance by the approximate amount of the increased state payments.
- Encourage Vermonters to choose Consumer Directed Health Plans, based on lower-cost high-deductible major medical coverage coupled with tax-deductible Health Savings Accounts. When informed consumers themselves pay more of their health care expenses, their pressure will drive efficiency, innovation and affordability among providers.
- Allow Vermont carriers to offer individual and small group plans tailored to the needs of their customers outside of the Vermont Health Benefits Exchange (although PPACA tax credits would not be available). This would allow continuation of the popular association plans offered by such organizations as the Vermont Association of Chamber Executives (VACE) and Business Resource Services of Vermont.
- Bring together providers and impress upon them the need to achieve industry-wide administrative and claims processing unification and simplification. Despite potential changes in federal law, maintain a state-level anti-trust exemption in this area.
- Examine the effectiveness of Vermont’s efforts to deal with fraud, waste, abuse and error. Determine the return on investment of deploying additional resources in this area.
- Adopt point-of-service reimbursement. Enroll eligible low income uninsured in programs on the spot.
- Adopt technology, such as patient smart cards, for speeding administration, for more efficient exchange of medical information and to help combat waste, fraud, abuse and error. Taiwan, Germany and France use similar technologies.
- Keep state government’s hands off Medicare. Resist Governor Shumlin’s attempt to ensnare Medicare into Green Mountain Care.
MAKE HEALTH INSURANCE UNDERSTANDABLE
- Ensure that the Health Insurance Exchange, established under the federal health care law, is easy to use, clear and has an abundance of choices.
- Require providers to develop a process to post competitive prices on selected procedures or services.
- Conduct independent performance audits to examine every cost and the health-effectiveness of every mandate.
PROMOTE AND ENCOURAGE CLINICAL REFORMS
- Explore creation of a multi-provider purchasing mechanism, with competitive bidding, to lower cost of medical equipment, pharmaceuticals, diagnostic testing and supplies. Market forces should be used to drive down the cost of commodities across-the-board.
- Move to full price transparency, published so that consumers can see the price at various providers for similar services. New Hampshire and other states have models. Provide consumers with web access to this information, as well as comparative pharmaceutical prices at Vermont, mail order and web-based pharmacies.
- Make better use of non-physician providers, promote telemedicine, encourage telephone consultations and similar innovations, and recommend regulatory changes to ensure fair compensation for these services.
- Form a consortium of providers who, along with government, will examine how Vermont could establish around-the-clock non-emergency room access to basic health care within one hour of every Vermonter. Encourage and provide incentives for evening and weekend urgent care clinics, clinics in grocery stores and pharmacies and similar facilities (some possible staffed in part using non-physician providers) to cut down on use of emergency rooms for non-emergency services.
- Stop requiring duplicate medical tests, especially when a patient transfers to a tertiary hospital. If we cannot trust testing in community hospitals, we shouldn’t allow them to test in the first place.
- Intensify case management for the small number of high utilization patients, especially those with multiple unnecessary emergency room visits, who drive high heath care costs. Focus on identifying and resolving the social, psychiatric, behavioral, system access and administrative issues involved. Examine the model successfully being used by Northwestern Medical Center.
- Review the potential of adding additional functionality to the prescription drug database to prevent fraud, waste, error and abuse.
- Engage providers to help develop protocols to minimize the use of testing that has minimal value, and to cut down on waste and abuse of the health care system.
Governor Shumlin’s Green Mountain Care Single Payer plan will lead to rationing through global budgets, will drive up the cost of medical care, discourage physicians and dentists from moving to Vermont, make it difficult for businesses to add jobs and put critical health care decisions in the hands of five unaccountable government appointees, none of whom, however well-meaning, has ever managed a health care system, a hospital or an insurance company. Worse yet, it will saddle Vermonters with enormous new tax burdens, burdens so large that Governor Shumlin won’t make the costs known to Vermonters until after he and his friends are reelected. And it will place in jeopardy the high quality health care in Vermont that we have all come to depend on.
There is a better way forward. As Governor, I will move toward that better way with five key strategies to expand choice, reduce cost, provide more affordable access to and improve the health of all Vermonters.