To the Editor:
In discussing health care, the word “universal” is sometimes misused. If we are to have serious conversations about the direction of health care reform, and more specifically on the possibility of universal primary care, our terminology should be accurate. And we should ask candidates and public officials to explain exactly what they mean when they endorse universal care.
Let’s be clear. The concept of universality is distinct from hospital transformation and “payment reform.” The latter changes the way providers are paid, but does not address the problems identified by the Department of Health in 2025: 10,700 uninsured Vermonters and another 187,800 underinsured, meaning they were likely to delay or avoid care because they couldn’t afford the deductible.
Second, we should acknowledge that no universal health care bill advanced in the last legislature. S.197, entitled “An Act Relating to Reform for Primary Care” was amended late in the session to include a declaration of legislative intent to establish a program of universal primary care, but it remains to be seen if “universal” in this context means a program that covers everyone or one that merely pools insurance revenue to streamline care for a portion of the population.
Third, the idea of outfitting primary care as a public utility is also erroneously associated with universality. Public utilities are highly regulated because they offer a public good. When you flip a switch, the light goes on. Except for this: If you can’t pay your electric bill, and the power is cut off, the light does not go on. Translate that to health care. If you can’t afford the insurance premium, you will not have coverage when you go to the doctor.
Universal care means everyone is included; no one is left out. Period.
How then to ensure that everyone has access? For those who are concerned with political feasibility (pleasing all the “stakeholders”) it’s tempting to imagine a way to cover everyone without eliminating private insurance—some combination of insurance and public subsidies, as in the Affordable Care Act (ACA). The insurance companies will be happy and everyone will be covered, right? Actually, no, as demonstrated by the inadequacy of the ACA and its excessive enrollment cost.
The experience of Canada is also relevant here. In the 1960s, the movement for universal health care was picking up steam in Canada. Saskatchewan had already implemented universal publicly financed health care that eliminated private insurance. This infuriated the insurance companies and organized medicine and led to a concerted effort to achieve universality in other provinces through the private insurance system. It didn’t work.
Alberta’s plan, despite government subsidies, left 200,000 people uninsured out of a total population of 1.3 million. Ontario and British Columbia designed similar programs with means testing and benefit cliffs, resulting in disgruntled citizens and overburdened provincial governments. Then in 1964 a national commission released a report culminating three years of public hearings and research. The report recommended that each province establish universal coverage “regardless of age or condition, or ability to pay, upon uniform terms and conditions….”
The phrase “upon uniform terms and conditions” carried through to the federal legislation passed in 1966 establishing Canada’s universal health care program, and this meant that the private insurance/public subsidy model was dead, because if millions of Canadians were subject to a means test and others were not, the terms and conditions would not be uniform.
These are the principles that must underlie any definition of “universal” health care in Vermont: everyone included under uniform terms and conditions. By this definition, a system based on multiple private insurance plans is not universal.
On Town Meeting Day last March, eight towns voted in favor of a bill that would have phased in universal publicly financed health care starting with primary care. And on April 30, the House Health Care Committee held a public hearing at which many testified in support of universal primary care.
Given this groundswell of opinion, it is important to guard against applying “universal” to proposals that fall short of the definition. In the long run, that sort of bait and switch will only lead to political backlash. Furthermore, chimeric new models that take years to test and develop and then fall apart, (as did Vermont’s ACO/All Payer Model) can only add to people’s disillusionment, especially when such models add complexity and administrative cost.
We the public have been good patients. We have paid our premiums, our taxes, and our health care bills and have waited for promised reforms that never seem to bear fruit.
Now it’s time to move toward a health care system that includes all of us and is publicly financed. If we start with universal primary care, it will be a groundbreaking first phase, but let’s make sure the system we design is truly “universal.”
Ethan Parke
Montpelier, Vt.