By: Charles Gregory, Springfield (Charles is a single payer and Act 48 supporter)

The most effective tactic opponents of good health care have is FUD-flinging: Casting fear, uncertainty and doubt about them, much as monkeys in the zoo throw poo.  When you read an argument against health care for all, you can see which of the three they fling.

A recent example of fud-flinging was a Megan McArdle piece for Bloomberg in which she deemed Vermont too poor to be able to afford it.  However, I took the trouble to check CIA data on world GDP and health care rankings and found out that we are much wealthier than we would have tourists believe.

If Vermont were its own country, its would rank 20th in per capita GDP (PCGDP) with $38,198 (2005). Adjusted for parity of purchasing power (which equalizes currencies’ worth), it puts us right ahead of Belgium and 171 other countries.  Of all 36 countries which have health care superior to America’s, only 15 have a higher PCGDP than ours.

Those 21 countries below Vermont have health care outcomes which, dollar for dollar, are superior to America’s (2013 PCGDP, $52,800, ranking 8th in 2013) .

We per capita are richer than the citizens of France, Belgium, Denmark, the United Kingdom, Andorra, Japan, Finland, San Marino, Israel, Saudi Arabia, New Zealand, Spain, the United Arab Emirates, Oman, Italy, Cyprus, Greece, Portugal, Chile, Argentina, and Colombia (!).  Yes, the land reputed for narco-terrorism and well-known for fifty years of “la violencia” has better health care for all its people than America does!

There are people in the Legislature who think like McArdle.  Cynthia Browning of Arlington is one.  Maybe your representative is another.  Why don’t you send yours an inquiry and find out?  Using the image below might help firm up the resolve to do the right thing.

Vermont GNP Ranking

Vermont GNP Ranking

We wanted to share Felix’s story and observations of different healthcare systems around the world. It is long but well worth the read! Thanks, Felix.

Felix and his wife in Vermont.

Felix and his wife in Vermont.

My name is Felix, I am 26 years old and grew up in Germany. After graduating high school I traveled the world for over four years. I lived a year in Canada and ended up falling in love with an amazing US-American young woman while traveling down the US-west coast in my minivan. We married in September 2012, I got my green card and a few months ago we bought land in Guilford, Vermont to build a home for us there.

So you see, I know things about the world and I know things about getting sick and health care. I grew up knowing the German health care system. On my trip I had to get treated in India for a few serious health issues. I broke my wrist in Canada. I had to visit hospitals and doctors for various other problems in Greece, Slovenia and finally even in the USA. That’s just part of life. We live, we get sick, we hurt ourselves. Everyone does!

In (almost) all of those places healthcare was affordable. A visit to the doctors in India for an ear infection cost me just over $2 (including the medication). Emergency room care for a splinter in my eye in Slovenia was paid for through my German insurance (which at the time cost me 150 Euros/month, no deductibles) because it was valid all throughout the EU. In Canada I broke my wrist which cost me $750 including: a visit to the ER with x-rays, a cast, pain medication and follow-up appointments at private doctors offices with more x-rays and further treatment. I thought that was already a high price but greed has no limitations. The same injury would have cost me in the USA possibly tens of thousands of dollars when paying out of pocket. And there is no justification for such a price tag whatsoever.

When I slipped on ice in March of 2013 I thought I broke my leg. We rushed to a hospital in Keene, New Hampshire. I was in there for 20 minutes, out of which were 10 minutes waiting, 5 minutes for the x-ray, 3 minutes more waiting and 2 minutes talking to a doctor. She told me the diagnosis: “… Sprained ankle. Stay off of it for a few weeks. That’s all you can do.” No treatment, no medication, no nothing. That was OK with me. What was absolutely not OK with me was the bill for that diagnosis, about $1400. And that was with health insurance. Where in the world does so much money go for a service that should have cost a fraction of what it was? To the doctor? To the CEO of the hospital? To insurance companies that protect practitioners from law suits? I was outraged!

I always knew (generally most of the people in the rest of the world know, too) how depressing the health-care situation is in the USA. How come “the greatest nation on earth” is so far behind all other developed nations and many developing nations on planet earth? My theory is that it has to do with the Cold War. No other country opposed so viciously the Soviet Union and it’s ideology. Propaganda has been hammered into people’s minds that socialism is the most evil thing ever (as it was on the opposing side with the opposite view). To be fair, the form of socialism (specifically Stalinism) that was exhibited by socialist nations at that time should not be the role model. However, the downfall of that opposition is that it has led to a blanket fear of any and all things “socialist.” It seems that still these days people react absolutely allergic to any social behavior or social programs proposed by the government. I think that’s the most obvious reason why there is no affordable and effective health care system in the USA. Such a system has to be based on the solidarity principle which itself is rooted in socialist (social) principles. The strong support the weak. We will all be the weak ones at some point in our lives! There is no other way to get a society as a whole insured. I can already hear the outcry of critics. But guess what: America (and Vermont) does have socialist systems in place already and that is good! The school system is socialist. Everyone pays property taxes, no matter if you have children or not, which are used to finance the schools of your county. Fire fighters and policemen are paid through taxes which makes their employment socialist. You can’t run a country entirely within the private sector. The public just has to fund certain key services to make a society efficient, humane, fair and possibly even existent in the first place. If there is nothing that holds us together than we are just scattered groups of people that happen to live next to each other on the same continent. Choking down the Pledge of Allegience in school just doesn’t do it. More is needed to create a sense of unity. Caring for one another is the first and main ingredient to achieve that.

I don’t get it. Is it really so horrible to be social? Is it really so horrible that the strong in a society take care of the weak so that they can grow strong again and help other weak ones and themselves like in a single payer universal health care system?

Imagine you have to call the police because you get robbed. The police catch the robbers but leave you a bill for their services. Such a world is not governed by the people but by corporations and privatized monsters. That is a neoliberalistic world of completely unregulated markets where people get rich through the complete exploitation and downfall of other people without consideration for life or the planet. In such a world, we would all just be squeezing each other out for more money and more profits. Do you really want to live like a bunch of tics trapped in a jar sucking from each other’s last bit of blood you could get a hold of? This is how I see the current health-care system in the USA. It is a profit driven system where money is made through the suffering of many to provide some very rich with their sick lifestyle. That is perverted! Money is not charged to just cover the costs for treatment. Way too much money is charged to fill some very greedy pockets. Many other countries have proven over the decades that an alternative is possible.

But where should the money come from to implement universal health care for everybody?

Taxes, of course. And I can already hear the second outcry. Let’s not be naive. An increase in taxation would be probably the most likely scenario for the successful implementation of such a system. If there however would be a radical rethinking on a federal level on how the government spends it’s money then the country would be flooded with cash not just for a new health-care system but possibly all kinds of other good programs. For example:  A big chunk of all taxes is spend on the biggest earthly military to rage war once a decade in different parts of the world to protect US-American interests while killing people and destroying infrastructure and cultures. Instead of doing that we could actually use that money to help people right here where help is needed. Of course that is a very far fetched proposal. The military-industrial complex is woven into the identity of the country far too deep to go anywhere soon. So it is up to each state to come up with solutions.

I would be more than happy to pay a higher income tax for a government health insurance to compensate for all the ones who don’t pay into the pot but are still taking out of it. I would be happy to do this because there probably would be a day when I loose my job or get old and can’t work anymore and I would still be covered. And, who really wants to live in a society that says: ”Oh, you lost your job and you can’t pay your health bills? Too bad. Just lay down and die and don’t be a burden!”

In Germany we pay a 20% sales tax on everything. Luxury items are taxed even higher. Income tax is higher than the US average. And yes, people are complaining. But nobody complains about being taken care off when you get sick. They don’t complain that when they loose their job they automatically receive welfare until they found a new one. They don’t complain that when a mother has a child, three months before and a whole year after giving birth she can stay at home to nurture her child (how it’s intended to be) while getting paid by the government. She then gets her old job back (legally guaranteed). And they don’t complain that universities are almost completely free. After living in quite a few other countries, I realized how incredibly well off Germans are, how good they have it and what a crazy bad deal Americans get when it comes to the social network.

Not only are there good reasons individually for a single payer system but the whole country will benefit from it. Health care for all promotes a stable society. The more inequalities one finds in a society – like a disproportional distribution of wealth or health-care for the upper classes that can afford it but not for the underprivileged – the more tension appears within this society. Crime rates go up, a sense of community and unity is lost, the age old struggle of the classes and even civil war come out of it. Hitler got to power in Germany through the desperation of the people. When people’s basic needs are met and they feel secure, dangerous elements and forces have a harder time establishing themselves in society and government. From an economical point of view, healthcare for everyone makes sense. A healthy society is a productive society. Businessmen know that the fewer people get sick, the better it is for the whole company.

The real damage is when you can’t afford to go to the doctor for a little cold. When this cold turns into a full-blown pneumonia and you have to get care, you might be out of work for weeks. Too high health-care costs prevent people from going to the doctor when problems are still small. That damages the individual, the employers and the economy and drives up healthcare costs even more. It’s easier and cheaper to treat a cold than pneumonia.

I myself have had a rather annoying chronic cough for the last two years. I just can’t afford to go to the doctor right now. I’m too scared of the bill. Is it serious? Maybe. I don’t know. I should have checked it out long ago. Next time I fly to Germany I will go to the doctor. The air-fare will be pocket money anyways compared to an American healthcare bill.

I sometimes seriously doubt my decision to move to the USA. I feel like I am downgrading when comparing the quality of life between both countries. What keeps me here is the love for my wife and the hope that things get better. I think Vermont is moving in the right direction with it’s attempt for a single-payer health-care system that serves all Vermonters. Vermont could be an example of progressiveness once again for the rest of the nation if this idea gets enough support by the people.

So let’s do this and give back the country’s reputation: a place that’s worth living in. Wake up Americans – it’s time to catch up! Forward on the road of betterment is the only way to go!

On March 30th we asked our supporters to encourage key elected official to stick with Act 48, Vermont’s road map to a single payer health care plan. In less than 24 hours over 100 people had sent in letters. The responses were a powerful testament to the broad support of Vermonters to accomplish this historic task. Below are two letters that were submitted.

Vermont Can Lead the Nation

By: Steve Cota, Barnard

Once again Vermont can lead the Nation toward better living by instituting a Single Payer Health care system. The USA is the only Industrialized country in the world that doesn’t have some sort of socialized medicine available to all it’s citizens, not just the VA and people over 65. Why do we continue to let private Insurance companies rake in profits on younger insured’s and then use taxpayer money to pay for our care when we get old and actually need care? We need everyone to pay into one single system from their first paycheck on, and have that money grow until we need to use it in our old age. At the very least we need to get away from the absurd idea that somehow our Employers should be responsible for our healthcare! We can provide the template for other States, and the Nation to follow. Let’s get this done!


Please Support Act 48, Vermont’s road map to Single Payer

By: Dr. Jack Mayer, Middlebury

I am a Vermont physician, since 1976. I support a single payer plan and Act 48. I am writing to ask you to please support Act 48, Vermont’s road map to a single payer health care plan. I believe this is the only way to ensure all Vermonters have access to health care and that it is financed in an affordable and fair way.

Many of us have been working toward a single payer system for over 20 years. Since 2001, five official studies have all confirmed that there is no other way to provide guaranteed health care to all Vermonters and to contain costs than single payer. Please help us achieve universal health care by supporting Act 48 and the creation of Green Mountain Care as a publicly financed system available to all Vermonters.

Please, do not quit or compromise before we’ve started! Let’s move on and create a publicly financed, guaranteed health care system for all Vermonters. I support all elected officials in rising to this historic task.

I am writing to ask you to please support Act 48, Vermont’s road map to a single payer health care plan. I believe this is the only way to ensure all Vermonters have access to health care and that it is financed in an affordable and fair way.
I now have insurance because of Vermont Health Connect but it is very
expensive for my family. Yet it is less than the 1400.00 we would
have had to pay, for less coverage,before VHC. We fall in the middle. Not
poor enough
to get much help and not rich enough to be able to go it alone. I have
always been really healthy,as well as my husband, but we are both
facing surgeries in the near future. Gallbladder for me and a hernia
for him. Because it will cost us less overall we chose the platinum
plan. This will save us money in the long run. But it is way outside
our budget and we are struggling. We had to make a choice between
guarenteed ruin or trying to make the high premium payment. It
has quickly taken a toll on our budget. There is now nothing extra. No
savings left as well as no money to save. It’s tough.
My only hope is that this is temporary. That you legislators will stay strong
and not falter on your path to single payer. Please remember why you
started. The need has not changed!  It is still impossible to get sick
and not be financially devastated in our state and country. I implore
you to work harder than you ever have to see this thru. We are
counting on you.
The true test of bravery is before you now. You must find the courage to be brave!
We’re floundering out here. Do your best. Do your very best. We still need you
to fight for us. Please.
Many of us have been working toward a single payer system for over 20 years. Since  2001, five official studies have all confirmed that there is no other way to provide guaranteed health care to all Vermonters and to contain costs than single payer. Please help us achieve universal health care by supporting Act 48 and the creation of Green Mountain Care as a publicly financed system available to all Vermonters.
Please, do not quit or compromise before we’ve started! Let’s move on and create a publicly financed, guaranteed health care system for all Vermonters.  I support you and all elected officials in rising to this historic task.

by Ethan Parke

Single payer advocates and critics alike usually turn to Canada to see an example of what Vermont might look like if we are ever successful instituting a universal health care system in our small state. But Canada has over 34 million people and is vast geographically compared to Vermont. Canada is also comprised of semi-autonomous provinces, each with a slightly different health care system.

How about looking at four lesser known countries that are similar to Vermont in size of population, to see how each of them solved the problem of health care costs and universal access? Montenegro, Malta, Iceland, and Luxembourg all have universal, publicly financed health care. All are doing a better job of containing costs than the U.S., and all four score surprisingly well on indicators of health. Maybe there are some things we can learn from these nations as we get ready (it is hoped) to finance and implement a Vermont single payer plan in 2017.

Montenegro
Montenegro, a small, middle-income country on the Adriatic Sea, became an independent nation in 2006. Montenegro has 625,000 inhabitants, making it almost exactly the same as Vermont in size of population, though it is smaller than Vermont in geographic size by about half. The economy is based on tourism, services, agriculture, and manufacturing. Formerly part of the Yugoslav federation, the country had a tradition of a strong state sector, but since dissolution of socialist Yugoslavia in 1992, Montenegro began transitioning to a market economy.

Because it is a new nation, Montenegro was not included in the World Health Organization (WHO) World Health Report 2000, and therefore it is difficult to compare Montenegro’s health care system to other countries. Nevertheless, it is remarkable that in far less time than Vermont has spent debating health care reform, Montenegro has implemented a fine system of publicly-funded universal health care. This was accomplished despite a war-plagued recent past, a tenuous economy, and widespread government corruption.

All Montenegrin citizens are entitled to equal access to health care. The quality of service is good; medical personnel are extremely well-trained; and there are seven general hospitals and three hospitals offering tertiary care. However, hospitals and clinics often lack the top notch facilities and advanced technology that are common in wealthier countries.

Montenegro’s system is funded 100 percent by payroll and self-employment taxes. Employers pay 6 percent of salaries and employees pay 7.5 percent of salaries into the health care fund. Self-employed workers and farmers pay 13.5 percent of taxable income for health coverage. No other taxes for health care are levied. Workers’ dependents, the unemployed, the elderly, the disabled, and those on maternity leave pay no health care contribution, but are fully covered.

In 2010, Montenegro spent 9.1 percent of gross domestic product (GDP) on health care. This compares to 17.9 percent of GDP spent by the United States in the same year.

The Montenegrin national benefit package is very comprehensive. Most medical services are paid entirely by the health fund. This includes primary care, specialty care, hospitalization, rehabilitation, prescription drugs, pregnancy, and childbirth.

Dental care is mostly private, and is not covered by the government health fund, except for routine preventative dentistry. Prescription drugs are covered, as are some over-the-counter drugs if they have been specifically recommended by a doctor. Paradoxically, some over-the-counter drugs are more expensive than prescription drugs.

A few Montenegrin doctors practice outside the national system, catering to wealthy patients who can afford to pay out-of-pocket. But this sector is small and is not expected to grow.

In terms of health outcomes, Montenegro does better than many more highly developed nations in measures such as maternal mortality rate. It has fewer maternal deaths per 100,000 live births than the United States, Luxembourg, Canada, and Malta, according to the CIA World Factbook.

Malta
Malta, a tiny island nation in the Mediterranean Sea, has a population of 411,000. In 1964 it gained its independence from Great Britain and basically inherited the British National Health Service at that time. It has since tailored the system to fit local preferences and needs. In 2000 Malta was ranked number 5 in the world by WHO for the overall performance of its health care system, yet it was ranked only 37th in health care expenditure per capita.

Like Vermont, Malta has a diverse economy with a mixture of private industry, agriculture, and tourism. Malta also has a good public education system and a flagship public university with a medical school. The tourist industry on Malta includes medical tourism, in which people from around Europe, especially from England, travel to Malta to receive high quality medical care.

For Maltese residents, and for registered long-term visitors, the medical system is completely free at the point of delivery. Patients also have free choice of providers and have the option of going to a public or a private hospital. The benefit package includes all primary and specialty care, hospitalization, and rehabilitation. Prescription drugs, optician care, and dentistry are covered only if the patient is a member of a vulnerable group, such as the unemployed, low-income wage earners, chronic disease patients, and pregnant women. Dental care is offered free of charge to all school children.

There is no explicit rationing, except for services deemed non-essential, such as in vitro fertilization, and some types of cosmetic surgery. However, there are some waiting lists for common surgeries and other procedures which are not critically needed.

Malta’s health service is thus truly universal, though it does not fully cover all essential goods and services related to health. For those who want additional peace of mind, and who can afford it, private insurance is available to cover items not included in the public plan. Some providers are also allowed to operate outside the public system.

In Malta health spending is kept under control by the government. Public planning processes contribute to the development of spending guidelines for hospitals and other health care facilities. The guidelines are enforced by the Ministry of Health, which also imposes strict capital management and human resource management plans on health care facilities. Spending on physician care is limited because all doctors practicing in the public system are government employees who are paid a salary.

Malta’s health care system is financed by weekly payroll deductions and employer contributions. Dependents are fully covered by family members who are working. The unemployed, the elderly, and those on long-term disability, do not have to contribute directly to the system, though they are fully covered by it, and may be liable for income taxes. Parents on maternity leave also do not have to contribute. The self-employed pay a special income tax for health care that is somewhat higher than the standard employee deduction, and the self-employed must also pay additional amounts to cover family members.

Despite overwhelming reliance on the payroll tax, there is widespread consensus in Malta that the financing of health care is not excessive and is equitably distributed across the population.

Patient satisfaction surveys have shown that the Maltese people are very pleased with the quality of their health care system, with satisfaction rates running between 90 and 99 percent in most categories. However, a growing number of residents use private health care services in addition to the public system, as this gives them more options and sometimes quicker service. Many doctors also prefer to practice outside the national program, where they can earn more money catering to the wealthy. Malta thus faces the beginning of a two-tiered system that threatens to undermine the principles of fairness and equity upon which the system was founded.

Iceland
Iceland is more than 10 times larger than Vermont in physical size but has a population of only about 315,000. Iceland’s economy is based on fishing, agriculture, and financial services. It ranks as one of the wealthiest and most developed nations in the world.

From 1936 to 1989 Iceland had a patchwork of tax-supported health insurance funds, but these were abolished in favor of a single, more efficient and more equitable government administered health care fund that was implemented in 1990.

Today, health care in Iceland is universal. All citizens have the right, at all times, to access the very best health care services. Non-citizens who have been residents of Iceland for at least six months are also entitled to the full array of health benefits. Even short term visitors may be eligible for free or low-cost care. Hospitalization is guaranteed for as long as necessary and, except for outpatient cases and very short stays, involves no payment at the point of use.

Iceland’s health care system is financed 85 percent by taxes and 15 percent by out-of-pocket payments for services that are not covered or only partially covered by the national plan.

Uncovered services include basic primary care, outpatient hospital care, dental care, and some pharmaceuticals. However, there are many circumstances in which normally uncovered services are provided free or at reduced rates. For instance, children are entitled to free dental check-ups and partially subsidized routine dental care. The elderly, the disabled, and the chronically ill are also entitled to free or reduced rate dental care.

Prescription drugs fall into four categories: critical (matter of life and death) medicines, significant therapeutic drugs, lower significance therapeutic drugs, and short-term medicines, such as antibiotics or pain-killers. The national program pays 100 percent of the cost of critical medicines, 75 percent of the cost of significant therapeutic drugs, less than 75 percent for the lower significance therapeutic drugs, and pays nothing for short term medicines.

Despite the list of uncovered services, there is almost no private health insurance in Iceland. That may be because of Iceland’s high standard of living and the fact that charges for the uncovered services, such as primary care doctors’ visits, are tightly regulated by the government. And yet despite rigorous rate-setting, Iceland has more doctors per capita than any other country.

Iceland’s system is financed by an assessment on employers based on a percentage of wages paid out. Employees contribute through an income tax. This means that coverage continues even if an employee is sidelined by sickness or injury. Thus there is no need for separate workers’ compensation insurance. The government also pays disabled employees a flat fee to cover loss of salary and other expenses of being sick.

The WHO ranked Iceland’s health care system 15th in the world in 2000 for overall performance, and 14th in the world in per capita health care expenditures. WHO ranked Iceland tied for 12th in terms of the fairness of its health care financing mechanisms.

Iceland’s system has been criticized for lack of cost control on hospitals, which frequently raise charges and exceed their recommended budgets. The government has therefore moved to adopt a diagnostic-related group reimbursement schedule, similar to that used in the U.S. for Medicare. But this may not be enough to curb hospital spending.

On the physician side, strict controls on physician fees have led to dissatisfaction among the medical community, particularly among general practitioners, and the problem is exacerbated by the high numbers of doctors, particularly specialists, serving the relatively small population base.

While the health care system is not the only factor affecting the health of the population, Icelanders are generally well satisfied with the health services offered by the government-financed program. In surveys, Icelanders generally rate the health care system higher than they do other public services.

Luxembourg
Luxembourg is geographically very small (about half the size of Rhode Island) and is wedged between Belgium, Germany, and France. Luxembourg’s most recent population was estimated to be 515,000.

Luxembourg has a stable, high income, market economy dominated by manufacturing, banking, and finance. Unemployment in Luxembourg has traditionally been very low.

Since 1973 Luxembourg has had universal access and a health insurance mandate, requiring all workers and their dependents to be covered by employment-based insurance plans. Originally there were 11 fully private “sickness funds,” each catering to a separate category of employers. In 1974, to keep the funds solvent, the state injected money into the funds, providing up to 40% of their revenue, and standardized the payroll contribution levels by law.

By 1978 there were only 9 funds left and they joined together in one union that negotiated standard rates with providers. In 1992 the funds morphed into mere agents for administering reimbursement of public funds, and therefore they no longer bear much resemblance to U.S. style- insurance companies.

Rising health care costs triggered yet more reforms in 1995, when Luxembourg initiated global budgeting for hospitals. Each hospital now has to negotiate an annual budget with the Union of Sickness Funds, which reimburses hospitals in lump sums rather than for individual services.

The payroll assessments are shared half and half by employee and employer, and the revenues from these assessments are placed in the Union of Sickness Funds. All dependents of employees are covered. Non-working children are covered to age 27. Self-employed people pay a tax that is roughly equivalent to the full employer/employee assessment, with some adjustment according to type of self-employed business. The average self-employment tax is 5.44% of gross income, subject to a cap. Vulnerable groups get free care or variable state subsidies in the form of tax credits.

All medical necessities are covered, including prescription drugs and dentistry. Amazingly, Luxembourg spent only 7.8 percent of GDP on health care in 2010, according to the CIA World Factbook. This compares to 17.9 percent of GDP spent by the U.S.

Although Luxembourg is a wealthy nation, it has not fallen into the trap of allowing health care costs to escalate. Some of this is due to very strict government rate setting. Fees are fixed by the government and all providers must comply. Over-billing is not allowed.

Most doctors are in solo, private practice and almost all are paid on a fee-for-service basis. Primary care doctors do not act as gatekeepers, and in Luxembourg you don’t need a referral to see a specialist.

For doctor’s visits, dental care, and prescriptions, patients have to pay a fee at the point of service and then request reimbursement from the Sickness Fund, which pays 80 to 100 percent of the fee. Vulnerable groups are exempt from having to pay the upfront fee. Free medical care is provided for prenatal care, for children, and for maternal health. The government also runs a free health service for children that is implemented right in the schools.

One interesting fact: Doctors in Luxembourg often make house calls, preferring that sick patients stay at home rather than bring their germs to the clinic.

All hospitals in Luxembourg are public, and each hospital has first, second, and third class wards. Third class wards are free. Patients contribute a co-pay out-of-pocket for the higher class wards, which have more privacy and more spacious rooms. However, emergency care is free even if you have no insurance or are from a foreign country. Luxembourgers occasionally buy private insurance to cover co-pays and the few services that are not covered by the national plan.

Overall, Luxembourg’s health care financing is 93 percent public. The rest is out-of-pocket or from private insurance. The government finances approved capital construction projects at hospitals and clinics at 80 percent of costs, with the balance coming from capital reserves or special fundraising drives.

Luxembourg’s publicly funded system allows the government to implement integrated public health measures aimed at reducing the incidence of cardiovascular disease, cancer, accidents, diabetes, and communicable diseases. The government is also making concerted efforts in mental health, environmental health, and occupational health. The government’s popular school health program also remains a top priority.

ParkeTable

Lessons for Vermont
Universal access was achieved in each of these four countries with relative ease. There was no handwringing about whether the country could afford an “entitlement program.” In each country there appears to be widespread acceptance of the role of government in guaranteeing universal health care as a public good, and widespread acceptance of taxation as the most equitable way to raise money for it. This is good news for Vermont as we head toward single payer in 2017.

The two richest countries in the comparison (Luxembourg and Iceland) are spending less than the U.S. on health care as a percent of GDP and per capita. But the country with by far the lowest per capita spending on health care in 2000 was Malta, which also ranked the highest in overall health system performance. This would suggest that a country that combines a single payer with a mostly public delivery system stands the best chance of delivering high quality health care at a reasonable price. Vermont would therefore do well to look at ways to make our private delivery system more transparent and publicly accountable as a cost-control and quality measure. Robust public health programs, such as Luxembourg’s school based clinics, also seem to have potential for lowering costs and improving population health.

Montenegro, with its small size, modest income levels, and tumultuous political history would seem at first glance to be a poor model for Vermont, especially in terms of health care quality. But Montenegro has achieved very high quality primary care, and good basic hospital care at a reasonable price. Again, this suggests that health care can be universal, high quality, and cost efficient, but government must play a central role in both financing and delivery in order for this to be achieved.

The financing of health care in the four countries is similar in that all rely most heavily on payroll taxes or payroll “assessments”, with self-employment taxes or income taxes secondary. Vermont should follow the same pattern, and should consider how to duplicate these countries’ efforts to include disability insurance (workers’ compensation) in the single payer plan, so that employers are relieved of this as a separate burden.

Among the four, Iceland has the highest level of private out-of-pocket financing. While Iceland’s system provides 100 percent public funding for hospitalization and catastrophic care, physicians’ fees in outpatient settings are funded privately out-of-pocket. However, the government very tightly regulates these fees, a situation that pleases consumers but displeases doctors. This suggests that if Vermont is to preserve fee-for-service physician reimbursement in a single payer system, it will have to adopt a standardized rate schedule that will hold costs down and still maintain an appropriate number of physician practices in the state.

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Ethan Parke is a board member of Vermont Health Care for All

By Marvin Malek, MD

Vermonters are now being subjected to the most intense, well-funded propaganda campaign I have ever seen in Vermont.

Beginning in January of this year, the group, Vermonters for Health Care Freedom (VHCF), began to carpet bomb the airwaves with a media campaign targeting Act 48, the health reform law signed into law last May. The campaign uses the standard propaganda techniques of fear-mongering, distortion, and appeal to conspiracy theories.

Reality Check

The ads allege that a secret cabal of health reformers plan to raise our taxes by $5 billion to fund the new single payer system, that these conspirators already know how they plan to impose these taxes, and that they are hiding this information from the public.

Every element of this message is nonsense. Here’s the reality check:

$5 billion represents total health spending in Vermont currently. As is the case in most states, over half of Vermont’s health care money comes from federal sources. This includes funding for federal employees, the military, the VA, Medicare, and the majority of Medicaid funding. And Act 48, the reform bill, has been designed to ensure that we continue to receive all of the federal funding we normally receive. Furthermore, most of the remainder of the $5 billion is money we’re already raising. This encompasses out-of-pocket spending, health insurance premiums, and local and state taxes that are already funding health care for state and local employees, teachers, prisoners, VScript, Catamount, and Vermont’s portion of Medicaid spending.

So whatever additional revenue is required will represent only a small fraction of total health spending—not even close to $5 billion.

The ads never mention that Green Mountain Care—the proposed single payer plan– does not go into effect until 2017.  Think about it: Is it realistic to expect those who are just beginning work on the reform effort to have already determined its entire funding structure—five years in advance? And that there is some sort of conspiracy related to Green Mountain Care’s funding for 2017? Next thing you know, they’ll claim a conspiracy if the Agency of Transportation or the Corrections Dept are unable to announce their 2017 budgets five years in advance.

Get real.

The truth is that the reform effort we are undertaking is a major change, and it is refreshingly honest and appropriate that Act 48 obliges our lawmakers to identify a funding mechanism 4 full years in advance of its implementation—in 2013. This timing allows us to speak with legislative candidates in the coming election season and share our opinions on how our future health care should be funded.

Will the propaganda campaign succeed?

While the assertions of these propagandists are ridiculous, this does not mean that the propaganda campaign will fail. Reality doesn’t matter when the microphone available to the propagandists is so loud, and when the message the microphone is blaring is incessant. Prior propaganda campaigns have taught us that if you repeat a lie often enough, people will come to believe it.

And based on what we’ve seen in the last month, there appears to be no limit to the amount of money this organization has available to spew its disinformation. While many Vermonters may oppose or have doubts about the health reform effort, the scale and costliness of this media campaign make it quite unlikely that the campaign is funded within Vermont. My bet is that almost all of the funding is coming from pharmaceutical and health insurance companies. For these companies to spend all it takes to prevent single payer reform from succeeding—even in one state– is far less expensive in Vermont than it would be in most other states.

But we’ll never know. The key information that is being very consciously hidden from the public has nothing to do with what VHCF is alleging. What is being hidden from all of us is this question: Who is funding this propaganda campaign?

Green Mountain Care will bring all Vermonters into a system of health care they can access throughout their lives. And as is the case with single payer systems across the world, only this type of reform has the ability to control health care costs and provide care to every single citizen throughout their lives. The international track record is crystal clear:  Single payer systems control costs, and they are very popular – far more popular than the nasty game of musical chairs that passes for a health care “system” here in the U.S.

But this reform threatens those powerful corporations who are quite content with the health care system just the way it is. And now we see them fighting back using the technique that usually works: Throwing unlimited amounts of money to create a propaganda offensive.

How can Vermonters respond?

1.  Local media outlets should not air any media spots by organizations that refuse to disclose their funding sources

2.  Local media outlets should provide airtime free of charge to local organizations and individuals who are able to provide sensible balance when such media campaigns support primarily the interests of well-funded corporate conglomerates whose media buys are orders of magnitude greater than what regular Vermonters could possibly afford.

3.  If they are willing to air ads from such mysterious organizations, then local media outlets should severely limit the number of times the ads air so that they are not serving as passive conduits for disinformation campaigns. Effectively, they become complicit when they profit from propaganda that is harmful to the public interest.

4.  If our local media outlets continue to serve as conduits for a propaganda campaign—and this definitely includes this case—then concerned citizens around the state should organize pickets and call-in campaigns directed at these stations. Media outlets have a duty to serve the public in an ethical and balanced manner. They need to respond appropriately to this new development in a manner that demonstrates their role of service to the public.

5.  Host a public forum or public debate. Supporters of health reform are available around the state who are ready to speak publicly on the issue. I have personally offered to debate the opponents of reform in any suitable venue. I made this offer on WDEV’s Mark Johnson show last month—and Mark agreed to host such an event. Unsurprisingly, there has been no response so far.

Every Vermonter who wants to create an affordable and humane health care system for our state has a stake in this effort.

Marvin Malek, MD is a physician who practices internal medicine at Central Vermont Hospital.

by Rep. Chris Pearson (P-Burlington)

As a member of the House Health Care Committee it has been a tough few weeks. H.559 puts into state law the requirements set out by the Affordable Care Act (ACA) passed with great fanfare by Democrats in Washington. I summarize the ACA as Catamount on steroids. It will help make health coverage more affordable for many Americans. It won’t attack the underlying problems within our system. That is especially true in Vermont where we already have community rating and guaranteed issue – two features copied and put into the ACA (both good things).

The Shumlin administration has taken the ACA and tried to make it work as a stepping stone for our larger health reform efforts. There are a few good pieces that will help us, although on balance the timing is certainly frustrating.

As passed by the House last week, the Federal Health Exchanges will help us separate employment from health coverage and draw down more federal money (in the form of refundable tax credits) so that health care is more affordable. Estimates range from $100-300 million of subsidies, no small sum. These tax credits are only available to individuals buying insurance if they earn up to 400% of the Federal Poverty Level (almost $90,000 for a family of four). It is our assumption that many businesses will drop their high-deductible coverage and help employees buy coverage as individuals by setting up pre-tax accounts to be used for health expenses. Let’s hope this will become the most amicable divorce ever seen.

In the end the most controversial part of the bill was the inside/outside question: that is, would small businesses (50 or fewer employees) have the option to buy outside of the exchange or not. The administration kept saying the exchange would be a good deal for people, so I reasoned we could keep it voluntary so people come in by choice. It wasn’t until I was called into the Governor’s office that I saw the flaw in my logic.

After wondering why I was making such a stink about this point, Gov. Shumlin explained the timeline for seeking a waiver. Under Federal law, the date waivers can take effect is January 1, 2017. What I didn’t know was that we can apply much sooner. And we should, so we are early in the queue. When we submit that application we need to demonstrate that Vermont is getting $x million in tax credits because that becomes a baseline amount as we move forward under a waiver. We don’t have the luxury of waiting for people to slowly come to the Exchange if we want to move forward as quickly as possible with Green Mountain Care.

That was the piece I needed. Green Mountain Care is the goal and any interim steps must advance us toward that goal. H.559 isn’t our dream plan, but it doesn’t hurt our larger efforts. And in fact, it begins the cultural shift necessary to make a truly universal system possible at the same time giving us a good deal of new Federal money so that health care becomes more affordable for low and middle-income Vermonters.

by Ellen Oxfeld, Middlebury

There has been a lot of discussion about the Exchange – about “bronze,” “silver” and “platinum” plans. Vermont is required by federal law to implement the Exchange in 2014. How can Vermont’s legislature best configure the Exchange?  Many people are wondering what this all means for them.

Let’s remember that the Exchange is just about a format to purchase private insurance. It is not the same as the single payer system that Vermonters will be allowed to implement in 2017.  Single payer is about financing health care for all Vermonters directly – without the waste and overhead of insurance company middlemen.  A single payer system guarantees health care, divorced from employment, funded directly by the public.  If you lose your job, you will still have health care in a single payer system.  If you are a small employer, you will not have to spend hours shopping around for different plans.  

We all know that if the Exchange was able to deliver health care to all Vermonters when they needed it, and to control costs, we wouldn’t need a single payer system in Vermont.  However, we can’t establish a single payer system until 2017, because we can’t get a waiver from the Exchange until then.  Therefore, we  have to think about the Exchange as temporary, and try to take advantage of the one thing the Exchange does have to offer, namely federal dollars to help people purchase insurance premiums and to subsidize some out of pocket costs.   Once Vermont establishes a single payer system, we will be able to access these same federal dollars, but put them directly into our new single payer system.

In the short run, we will have to devise rules for the Exchange that do the least harm.  We know that having plans with different levels is not what health care is all about!  But, we also know that many small employers are well meaning, and if they could afford private insurance plans with more coverage, they would have purchased them in the first place.

The House Health Care Committee and the Shumlin administration have been trying their best to wrestle with these issues.  I suggest that they let two guiding principles help them through this morass, and that they keep in mind that the Exchange is temporary.  First, despite the inclusion of bronze plans, there should be ways to create maximum incentives for “silver” plans.  I agree, you cannot force a small business to purchase a plan they can’t afford.  However, incentives can maximize the choices of silver plans, and this may bring in more federal dollars, as well as keep to a minimum the number of people who are left holding the bag with high out of pocket costs.   Second, it will be very important to make sure that people currently on VHAP and Catamount experience as little deterioration in their experience of cost and coverage as possible.  If the Exchange results in a sharp deterioration of coverage or increase in cost, this will create real hardships for people.  Such bad experiences with the Exchange may also poison the well for single payer, because people will be turned off to the very idea of reform.

As we go through this process, however, let’s remember that single payer is based on completely different principles than the Exchange.  With single payer we will no longer be talking about “bronze,” “silver” and “platinum” plans, but guaranteed health care for all Vermonters without the excess cost of the insurance company middlemen.  Single payer is the only real solution for individuals, for businesses, and for all Vermonters.

by Ethan Parke, Montpelier

Partisan politics, not sound statistical analysis, underlies recent attacks on Vermont’s plan to create a single payer health care system. Rutland City Treasurer Wendy Wilton has attracted media attention with her off-the-cuff number crunching. Bruce Lisman (a retired investment banker at JPMorgan Chase) and Lieutenant Governor Phil Scott have both been warning that single payer health care is too risky in these difficult economic times. And Robert Letovsky (a business professor at St. Michael’s College) has maligned the Canadian system in an attempt to discredit Vermont’s initiative.

Wilton’s curious refrain has been that single payer revenues do not match single payer expenses. She asserts that by 2019 Vermont would be $2 billion in the red if a single payer plan is adopted. The allegation is odd because to date there has been little attempt to formulate a revenue plan for the single payer program, and estimates of costs and savings are usually given as ranges. There are simply no hard numbers to debate. However, Wilton uses the lack of a financing plan as the basis to attack the whole premise of universal health care.

I agree with Wilton that it would be nice to have a complete picture of health care reform all at once.   As Rutland City treasurer she must certainly gain satisfaction from analyzing the cost of a new dump truck, calculating its return on investment, and pinpointing the effect of the purchase on the city tax rate. Unfortunately, changing the health care system of an entire state, providing coverage for all its residents, and controlling costs is a much more complex task. Since no state has yet made this move, there is no fixed price tag, no iron-clad quantification of savings and health status improvements, and no perfect comparison models.

Furthermore, as much as we would wish it, single payer in Vermont cannot happen in one fell swoop. The Legislature has taken a cautious approach, commissioning a thorough study and enacting a framework for future action. The Green Mountain Care Board has recently published a study of expected single payer savings, as required by statute. The next steps may include development of payment reform models, outlining a benefits package, and working out the ways that federal health care reform can provide a transition to single payer.

Wilton raises the specter of “the largest tax increase in the history of Vermont.” This was the same fear tactic that was used to defeat health care reform in the 1990s. Yes, if you replace private health insurance premiums with taxes, the increase in state revenue will be huge. It would be irresponsible for the Legislature to levy such taxes without also eliminating the waste, fraud, and redundancy in the current system, and creating a transparent and accountable means of administering such revenue. It would also be irresponsible to saddle businesses that currently provide excellent health benefits to their employees with taxes exceeding the projected costs of private insurance. Preliminary studies indicate that such challenges can be surmounted, but we must be patient.

Truth be told, we do not currently have a transparent and publicly accountable system. We do not now have adequate ways to control costs or to prevent personal bankruptcy from health care bills. And Vermonters die because they do not have access to affordable medical care. Ms. Wilton admits the current system is unsustainable, but if she has a better idea how to solve these problems, I have not heard it.

One final point: It is easy to pull out tiny pieces of the health care puzzle and say this or that should be changed. Ms. Wilton intimates that if people behaved in a healthier manner, health care costs would be lower. She also cites Vermont’s chronic disease management program (the Blueprint for Health) as a way to reduce costs. But if Vermont were perfect in both these areas, overall health care costs would still be too high. Institutional fixed costs would remain the same and would rise with inflation. Providers would continue the insane chase of paperwork involved in billing and insurance reimbursement. And costs would continue to shift from one area to another without any overall rationale. In the absence of unified financing, we will never be able to keep the lid on our health care spending.

If we want to give our businesses a break, if we want to rescue our economy, if we want to be a society that has the decency to make health care available to everyone, regardless of assets or income, then, despite the uncertainty involved, we must continue on our present path toward single payer. We know that a public process and legislative action will be necessary at each step along the way. We must not be distracted by those who would derail reform in order to score political points.

by Ellen Oxfeld, Middlebury, Vermont

What are the potential savings from a single payer system in Vermont? A recent report from the Joint Fiscal Office and the Department of Banking, Insurance and Health Care Administration (JFO and BISHCA) has led some single payer opponents to claim that significant cost containment can occur without single payer.

This is a spurious claim that misinterprets the report and challenges the fundamental precepts of the study the Legislature commissioned last year by Harvard health economist William Hsiao. The Legislature should invite Professor Hsiao back to Vermont at his earliest convenience to analyze and clarify the findings of the BISHCA report, which in fact reaffirms that a single payer financing system is the only way to simultaneously control costs and provide comprehensive health care coverage to all Vermonters.

Indeed, since 2001, the state has commissioned four official studies of our health care system and tested the proposition of whether a single payer system would be able to cover all Vermonters and contain costs.  Every single time, the answer has come out in the affirmative, whether it was the Lewin study of 2001, the Thorpe study of 2006, the Hsiao study of February 2011, or the follow-up that was just released by the state of Vermont last week under the auspices of JFO/BISHCA (Joint Fiscal Office and Department of Banking, Insurance, and Health Care Administration).

It is true that the latest study is more conservative, but even this study concludes that with a single payer system we can provide an equitably financed system with comprehensive coverage for all Vermonters (something that is not the case now), and contain the rise in costs while doing so.   Let us not lose sight of this important insight – we can cover everyone with a comprehensive package and contain costs.  Isn’t this better than the current situation?  Right now, by everyone’s admission, costs are uncontainable, and 200,000 Vermonters are either uninsured (43,000) or underinsured (160,000) according to a March 2011 report prepared for the Vermont Office of Health Access.

That said, some important questions have been raised about the latest study and they should be addressed.  First, the study concludes that fraud reduction and clinical reform will actually save a much greater percentage of health care costs than administrative savings from the implementation of single payer.   This might lead some people to conclude that single payer is the least necessary piece of the reform package.  However, this would be a misreading of the evidence.  We should remember that fraud reduction and clinical reform will never be truly effective if they are not part of a unified financing system – that is single payer.  Also, fraud reduction and clinical reform on their own can never get us to universal coverage for all Vermonters – again, let us not lose sight of this goal!

Second, the study’s definition of administration included such things as billing, personnel management, and even hospital laundry.  But did it have a measure of costs to the system as a whole for having the complex financing  [structure or non-system] which we have now?  For instance, did it count the costs to the system now that arise when people delay treatment because they have inadequate coverage, or when people have to fill out (and others have to process) mountains of paperwork each time their incomes rise or fall to apply to different programs.

Still, let’s not forget the bottom line.  With single payer all Vermonters can have access to comprehensive coverage, equitably financed. Every study has validated this, and no other alternative to comprehensive cost effective coverage for all Vermonters has ever been put forth.  Professor Hsiao, who is a world renowned expert at examining the way different parts of a health care system interact and affect  one another,  should also come back to shed light on the latest study.