Burlington Free Press: Comment & Debate
Deborah Richter, President, Vermont Health Care for All
Praise has been heaped on the 120-some page
report issued by the Harvard health economist,
William Hsiao, and his working group. Words like
historic, ground-breaking, and masterful are
used, and since I entirely agree I will put them to
use as well.
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 for 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
second, which is called the public option) is
hardly in the running because effectively it will
not achieve universal coverage.
The favored system designs have numbers.
Option No. 1 is a single-payer system. Option
No. 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 unsustainable rises 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 in fact 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. It is not
a template for other states. It is not a one-size
fits all. It is particular to our state.
Vermont has never before had anything close to
this to work with. It maps out routes to a goal
that can be abbreviated as "high-quality health
care for all Vermonters," and by affordable is
meant affordable to Vermont as a whole as well
as to individuals.
Comments after its release Jan. 19 no doubt are
pouring in. Because they are by post or e-mail
we can’t know what they are. But the usual
pattern is reservations, objections, gloomy
prognostications, alternative theories, quarrels
over details, complaints from idealists, self-
interested criticisms from the what-about-me
crowd, some valuable, some 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 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.
The Hsiao Report is a report, not a bill. It hands
the Legislature and the new administration an
historic opportunity.
The draft, or redraft, will be subject to the usual
practice in committees and hearings — the
standard back and forth of legislation — of
picking away at the details ("the devil is in the
details"). Not this time. This time the devil will be
found in our failure to create and implement a
system.