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.

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.

Governor Shumlin’s plan for transitioning Vermont to a publicly funded universal health care system in 2017 is truly exciting and should be just the solution for our health care crisis. However, beginning January 1, 2014 (and running until our single payer system is in place) Vermont must have in place a Health Care Exchange as mandated by the federal Patient Protection and Affordable Care Act. How this Exchange is created will not only be an important foundation for Vermont’s universal health care system, but it will determine the quality and affordability of health care for small business owners and their employees, the almost 50,000 Vermonters in Catamount and VHAP and the estimated 47,000 uninsured Vermonters.

Even though 2014 seems like a long way away, the 2012 legislature which convenes in January will have to make several critical decisions about health care for the estimated 100,000 Vermonters who will be accessing health care through the Exchange beginning in 2014.

In the new Exchange, all health insurance plans will be offered by private insurance companies like Blue Cross Blue Shield and MVP. VHAP and probably Catamount Health will no longer be offered and these enrollees will have to purchase other private insurance. People in households under 400%FPL (about $90,000 for a family of 4 and $44,000 for a single person) will receive federal subsidies towards their premiums.

This brings us to a problematic issue: the affordability of the plans in the Exchange, particularly for the low and middle income Vermonters currently on Catamount Health and VHAP. Right now if you are on Catamount, you have an annual out of pocket (OOP) maximum of $1,050 in addition to your monthly premium; if you are on VHAP, the only OOP cost you have other than your premium are prescription drug co-pays of $1 or $2 and a $25 emergency room visit fee. In the Exchange any VHAP or Catamount enrollee who is over 133%FPL (about $1,230/mo gross household income for a single person and $2500/mo for a family of four) will have up to a $1,964 and $3,987 OOP limit respectively And this is on top of an increased monthly premium in the Exchange! The bottom line is that the federal subsidies aren’t nearly enough to make private health care affordable for low and middle income Vermonters.

Given that half of all the uninsured in Vermont are currently eligible for a public health care program and that high OOP costs are repeatedly identified as the number one reason people don’t enroll, the 2012 Vermont legislature needs to act to make sure health care is truly affordable in the Exchange. One option available to Vermont is to provide an additional subsidy on top of the federal subsidy people under 400%FPL will receive in the Exchange. Unless the state acts through an additional subsidy of its own, many thousands of Vermonters will either lose the relatively affordable coverage they had through VHAP and Catamount or just remain uninsured.

The other major issue after the affordability of health care through the Exchange is the comprehensiveness of coverage. All plans offered through the Exchange will be mandated by the government to offer similar benefit packages but what will largely differ is the cost sharing arrangement of each particular insurance plan, i.e. deductibles, co-pays, co-insurance etc. The federal government is expected to announce the list of mandated benefits for all plans in the Exchange sometime early next year. But since Vermont has traditionally mandated that private insurance plans covers services they typically don’t cover, it is the expectation that many benefits we are used to seeing in private plans offered in Vermont (such as naturopathic coverage) won’t be mandated by the federal government and therefore the state legislature is going to have to ensure are still offered. We need the 2012 legislature to act to make sure all plans in the Exchange cover a truly comprehensive range of services.

While the two issues mentioned above are the most critical for the upcoming legislature to deal with, there are several other very important flaws in the Exchange that must be address before 2014 including:

1. Reconciliation: If over the course of the year, household income turns out to have been greater than projected the government may have paid the enrollee more for premium subsidies than they were entitled to. In this case, the enrollee must pay the difference back and, if final annual income exceeds 400% FPL the entire tax credit must be repaid. Having to pay the government back money at year’s end for health care could be a serious financial hazard for many people causing them to drop coverage or suffer serious financial harm.
2. Limited open enrollment periods: The initial open enrollment period for plans in the Exchange will be from October 1, 2013 through February 28, 2014. Starting with the January 1, 2015 benefit year, open enrollment for the Exchange will be October 15 to December 7 of the previous year only. Though there will also be “special” enrollment possible for those newly eligible for the premium subsidy, who lose employer coverage, or whose household changes through marriage, divorce, etc, for most people this means they will only have a very short time in which to enroll, otherwise they will have to remain uninsured for the rest of the year.

Some have suggested that Dr. Hsiao’s plan to finance the new system will not work. But this is the wrong place to start. Dr. Hsiao submitted a proposal; it is not the state’s plan. Rather, it is a point of departure for further research and debate.

Dr. Hsiao recommended using a payroll tax to finance the new system. For a variety of reasons, including administrative convenience, the payroll tax should be part of the eventual funding scheme. However, using ONLY the payroll tax is both unfair and impractical.

For example, there are a number of Vermonters below retirement age that don’t work. Some of the non-working folks have substantial non-wage (“unearned”) income from capital gains, interest, and dividends. A universal health care system that does not require contributions from wealthy non-working Vermonters would be an insult to the rest of us.

And furthermore, if someone earns $100,000 in wages and an additional $100,000 from other sources, his or her effective rate would be half of that paid by everyone else. That is, assume the payroll tax is 8%. A person earning $40,000 would pay $3,200. The person earning $200,000 with only half from wages would pay $8,000, which is only 4% of total income. Does that seem fair to you?

In addition, limiting funding to payroll would exclude a substantial amount of taxable income. After subtracting wages for federal employees (who will not be part of the system), total Vermont payroll in 2010 was $11.1 billion. In contrast, total adjusted gross income in 2009 (latest year available) was $15 billion. Thus, even after subtracting federal wages, there would be well over $3 billion of income NOT taxed for the new system. This makes no sense.

Finally, the expected cost of the system is the predicate for conversations about financing. Unfortunately, the opposition has been trumpeting an “analysis” that assumes the system will cost much more than is expected (almost twice; see John Franco’s op-ed) and that it will be financed solely with a payroll tax. Not surprisingly, using these assumptions leads to substantial deficits and an unsustainable system. But the analysis is fatally flawed and is poisoning the discourse.

So let’s not get ahead of ourselves and let’s insist that all the parties stick to the facts.

When Governor Peter Shumlin signs the new health care bill into law on May 26^th, many people may wonder how we came to this point. Why is it that Vermont is the first state to pass legislation that acknowledges that health care is a public good, and that the best route toward universal access and cost control is to create a health care system that is publicly funded?  There are still many more steps to go before we reach this goal.  Nonetheless, it is worth pausing at this important juncture to ask what makes Vermont different.

One thing that makes Vermont different is that the campaign for single payer in this state has been broad based and involved multiple organizations and thousands of individuals at the grassroots level over almost two decades.

The Vermont Workers Center (VWC) is one of the groups that have done a superb job of organizing people from 2008 onwards – focusing on health care as a human right.   Their organizing built upon the earlier and still continuing efforts of many other individuals and groups — creating unparalleled energy around this issue. In 2009, for instance, public meetings were held all over the state on health care and for single payer.  Many were part of the VWC campaign.  Other meetings were organized by independent groups including religious and community groups. Senator Bernie Sanders also held many health care related events around the state.

These 2009 meetings followed on the heels of a 2008 campaign for H304 – a single payer bill for hospitals. Hundreds of people traveled to the statehouse for several large events to advocate for H304 in the winter of 2008, organized by Vermont Health Care for All (VTHCA). Additionally, Dr. Deb Richter of VTHCA traveled the state and spoke at over 400 forums between 2000 and the present, introducing the concept of single payer to numerous citizen groups.

Earlier in the decade, in 2005, former state Senator Cheryl Rivers, in coordination with Richard Davis of Vermont Citizens Campaign for Health organized for single payer on town meeting day, and succeeded in getting many towns to vote in support of the concept.

Large statewide demonstrations for single payer have been organized by VTHCA (1200 people at the Statehouse in 2002) and the VWC (over a 1000 people coming to their May Day rallies in 2009, 10 and 11).  Smaller demonstrations for single payer also occurred almost every year at the statehouse, and in other venues – such as a 2009 rally of several hundred people at the Obama administration’s regional health care summit in Burlington.  Unions and even business groups have also organized around the concept: several groups come to mind here including the AFL-CIO and other unions, Vermont Businesses for Social Responsibility, and even the League of Women Voters.

Because so many groups have been involved, and so many citizens have weighed in on the issue, this state was fertile ground for lawmakers and candidates who advocated for single payer. Not all of them won, but they helped make the issue prominent.  I don’t have space to list everyone here, but Anthony Pollina and Cheryl Rivers come to mind. And, of course, Governor Shumlin made single payer prominent in his campaign and won, and Senator Bernie Sanders has long advocated for single payer and helped legitimize the reasons for it to a broad public.  We should also not forget that it was Peter Shumlin, as Senate President Pro-Tem, who first contacted Professor William Hsiao in December 2009 for the express purpose of inviting him to testify in the upcoming legislative session.

All these efforts, and probably many more than space allows me to include, made for an ideal scenario in advancing the cause of single payer in the legislative agenda.  Because Vermont is a state where citizens really get involved in issues, it is still possible to see legislation pass that advances the common good.

Despite the politics and war of words, the health care proposal now before the Senate makes relatively modest steps towards a single payer health care system, while also taking steps to start controlling costs.

It is true that many questions about costs and financing are still unanswered. That is because the “plan” is not yet determined. I support a single payer system. It works in many places and can work here. But, I do not see this proposal locking us into a single payer at all. (Some will like this, others will not). Instead, the bill is designed to start controlling costs, to answer the questions we all have and to bring a plan to the Legislature, which we will accept or not. Here is what it does.

It establishes a Board to answer questions about what Green Mountain Care (the single payer) may look like. So, over the next few years a benefits package will be designed, costs and provider payments determined and a financing plan recommended. The Legislature will then vote to approve or disapprove it. This is expected in 2013 but may not happen until 2017, leaving much time for questions, answers and debate on the issues.

While this is a path to a possible single payer, it can only happen if certain requirements are met: there must be a comprehensive coverage plan, we must know the cost and how we will pay for it; the federal government must provide waivers and our Legislature must vote to approve it.

Certain values will guide the plan. It must cost less; with significant savings in the initial stages, followed over time by slower and lower cost increases than in our current system. It must include comprehensive benefits, including mental health and wellness; fair reimbursement for providers and protections for consumers. And, those on Medicare and other federal health care and retiree benefit programs (i.e. military programs) will keep their benefits. They will not see lower benefits.

It establishes a health insurance exchange as required by the federal government. The exchange is a way to help us comparison shop for health insurance and for some to receive subsidies to help pay. A variety of plans will be in it, including two new multistate plans required by federal law. Other plans will be available outside the exchange. It does allow us to move towards common administrative forms and other efficiencies. It should be operational in 2014 for individuals and small employers and for others in 2017.

And, it establishes pilot projects to start controlling costs by changing how health care is paid for and delivered. Costs will be lowered and outcomes improved by having physicians work with a team of others (i.e. prevention, mental health). They will be paid on a per-person – per month basis not the current fee for service method. And, be rewarded financially for keeping us healthier. This is already underway in our Blueprint for Health program.  Finally it makes better use of technology and electronic data to further cut costs.

The bottom line: there are a lot of questions to be answered. This bill only gets the process started.

My husband and I (61 and 62 years of age) had health insurance through  Blue Cross Blue Shield of VT. The only plan we could afford was the high deductible one ($5,000 stacked). We were paying  about $480 a month with no benefits. We decided to apply for Catamount Health coverage but in order to do so we had to be off  Blue Cross Blue Shield for 1 year. We took the risk and after one year got on Catamount’s Premium Assistance plan and finally were able to get good coverage. After one year on this plan we were notified upon yearly review that our income was $66.00 over the limit for premium assistance and that we would have to do a full pay of $830.00 a month.  That is unaffordable for us, (about 1/4th of our income), so we are now back to being uninsured.  Catamount turned out to be very disappointing for us. Single payer is the only true way to go for Vermonters.

March 14, 2011

Because of the recommendations in the Hsiao Report, funding proposals of the single payer health care system have focused exclusively on an employment tax to be paid by both the employer and employee. While it may be advantageous for some of the revenues to be levied in this way, to depend on a payroll tax as the only tax funding the system is not equitable.

Dependence solely on the payroll tax, is a blunt instrument that does not fairly distribute the costs of a universal health care system over the beneficiaries of that system. A flat tax rate is unfair to lower paid employees and potentially to families with more than one employed member. Working Medicare recipients may have to pay twice for both their Medicare premiums and the  payroll tax. The proposal does not deal with the cases of Vermonters who may be subject to double payments or those who will pay little or nothing.

Although a payroll tax is an improvement on the current regressive premium financing which is totally unrelated to ability to pay, a flat percentage payroll tax does not recognize the higher impact of these taxes on people with low incomes. In addition, most proposals put a cap on the total amount that an individual is required to pay. In effect, the tax is actually regressive since the average tax rate will be lower for the highest income earners—the higher the income over the cap, the lower the effective rate.

The strongest indictment of the payroll tax proposal is that it will create free-riders–trust-funders, coupon-clippers, wealthy retirees, etc–people who will benefit from the system and who can afford to contribute to its cost.

Although, there is no “official” financing proposal on the table yet, we have to make sure that when it comes, the funding system for our health care system is much more sophisticated and equitable than a straight payroll tax or it is never going to fly.

March 10, 2011

John Walsh, writing in Dissident Voice, a radical blog based in Santa Rosa, California, has delivered a scathing criticism of Governor Shumlin’s health care bill, claiming that its passage would not result in a single payer system in Vermont, and that therefore supporters are being hoodwinked.

Walsh is right that the bill is heavy on interim steps, such as the health care exchanges called for in the recent federal health care legislation. He is also right that many components of single payer (the financing mechanism being the most obvious) are left out of Shumlin’s bill. He’s also right that the bill gives a nod to “payment reform,” which could be interpreted to mean ACOs—a nebulous concept suspiciously like HMOs, which are currently all the rage among establishment health policy analysts.

But hoodwinked? No. Single payer activists in Vermont are fully aware that H.202 could be improved, and some advocates have been testifying to the very points made in Walsh’s commentary.

David Himmelstein’s pessimistic analysis, cited repeatedly by Walsh, is also not news to the leaders of Vermont’s single payer movement. Himmelstein’s indefatigable work for single payer at the national level has been extraordinarily helpful over the years. However, the Vermont single payer proponents have chosen to look at the Shumlin bill as a glass half full rather than half empty. In this light, the fact that not everything is spelled out in H.202 is an asset, not a liability.

Consider: If a financing package had been proposed this year, there is a good chance that the entire bill would be defeated. That’s because financing will inevitably stir a huge debate. And remember that Peter Shumlin was elected governor by a very slim margin. Better to have a framework in statute to begin with, and pass a financing package in a later year when more details of the system have been filled in and when Governor Shumlin has had more time to solidify a political base.

Consider: It’s a good thing that the benefit package, cost-sharing provisions, the health care budget, and many other details would be left to the new health care reform board. For anyone who has watched the Vermont legislature over the years ignore, obfuscate, water down, compromise, and/or destroy perfectly good health care legislation, a five-member board appointed by a governor who is a friend of single payer sounds like a breath of fresh air.

Finally, Walsh asserts that a less-than-perfect bill is a bad organizing tool. It would be if everyone was content to let it pass as is and go home. But the fight for single payer is a long haul, a very long haul. We are perhaps closer in Vermont than ever, but no one is breaking out the champagne. There are many issues remaining to be discussed and fought for. There are many strategic decisions still to be made and there will be plenty of criticism along the way, from the right and the left and everywhere in between. And so Walsh’s blog is no surprise.

Vermonters in favor of single payer are no dummies. We want H. 202 passed, and in the years to come we will fight for the other measures—the financing, the federal waivers, the global budgets—that will someday make single payer a reality.

Jan. 31, 2011

It has been several weeks since the Harvard health economist, William Hsiao, and his working group, issued their 120-some page report.  Praise has been heaped on it, describing it as historic, ground breaking, and masterful, words I entirely agree with.

I’ve studied it and thought about it. I’d like to offer this perspective.

The report is called “Act 128 Health System Reform Design: Achieving Affordable Universal Health Care in Vermont” but will forever be known as the Hsiao Report.

It does exactly what is was asked by the Legislature. It outlines the designs of three health care systems and offers the rationale behind the thinking for each, including facts, figures and the probable economic consequences. For Vermont, this is ground breaking.

Two of the three look good. One of them (the public option) is hardly in the running because effectively it leaves the problems – focused largely on unsustainable costs – untouched.

The favored system designs have numbers. Option 1 is a single-payer system. Option 3 is a single-payer system. What is the difference? Not a lot. Operationally there are differences. But at this stage, far more important is what they share. It is something of  overriding importance that we overlook at our peril, and in fact have overlooked at our peril for years. That peril can be described as an unsustainable rise in costs.

Here is the Hsiao Report: “Vermont will need to reorganize existing systems and develop new administrative capacities to manage an integrated, single-payer health system. In addition, the state will need to institute a regulatory apparatus to oversee the functioning of the system.”

This admonition appears about nine-tenths of the way through the report, but it is the key to everything. Our Legislature and new Administration are called on to create an integrated health care system. System is not an idle idea. Without a system the costs of health care in our state cannot be managed, contained, controlled, budgeted and will remain unmanaged, uncontained, uncontrolled, unbudgeted

The Hsiao Report is a masterful piece of work. It is specific to Vermont, to our health care, to our economy, to our political landscape, and to Vermont’s intersection with federal laws, regulations and, by implication, politics. Vermont has never before had anything close to this to work with. It maps out routes to a goal which can be abbreviated as “high-quality health care for all Vermonters,” and by affordable is meant affordable to individuals as well as Vermont as a whole.

Comments no doubt are pouring in. Because they are by post or email we can’t know what they are. There will be reservations, objections, gloomy prognostications, alternative theories, quarrels over details, moans from idealists, self-interested criticisms from the what-about-me crowd, some of it valuable, some of it a deplorable waste of time, but all more or less beside the main point.

As the Hsiao Report implies in its gentle way, if we don’t move to an integrated health care system that is uniform and regulated we are done. The costs are going to bury us. That is the essential main point.

A system oversees and coordinates. It integrates. At some basic level it abolishes the what-about-me chorus in favor of what-about-all-of-us. A system takes the fundamentally necessary step of grounding health care, and all of its elements, solidly in the realm of the public interest.

One of the great things about a system it is best to remember is that it provides a framework within which to adjust, adapt, change, confront new circumstances, deal with new problems, to fill in gaps, in other words to self-correct. To handle details in a systematic way you need a system. This is the opportunity the Legislature and the new Administration have been handed.

So the public comment period is drawing to a close (Feb. 4). The usual practice in committees and hearings – the standard back and forth of legislation – is to pick away at the details (”the devil is in the details”). Not this time. This time the devil will reside in our failure to create and establish a true health care system.