Ellen Oxfeld: We need a universal public system to solve our health care crisis

This commentary is by Ellen Oxfeld of Middlebury, a board member of Vermont Health Care for All.

In the past few weeks, the mess of Vermont’s health care situation has been abundantly documented by numerous commentators to this publication. Even members of the Green Mountain Care Board recently questioned executives from OneCare, asking them to show results to justify their high administrative costs, much of it funded by public dollars.

Commentators agree that Vermonters cannot get the care they need. One reason is high out-of-pocket costs, which now leave 44% of Vermonters under age 65 underinsured. 

There is also agreement that high prices, and not patient overuse, ail our system. How could people overuse a system they cannot even access? 

Indeed, many commentators also note that the only place in our current system that is overused is the emergency room — because people either do not have a primary care physician or because costs caused them to delay care until their condition became more critical.

But what is the solution to this problem?

We must acknowledge that 34% of every dollar in our health care system is administrative overhead. More than half of that is sheer waste, caused by so many middlemen — numerous insurance policies, byzantine experiments like the accountable care organization OneCare. These raise our costs.

We can bend the cost curve by creating public financing and universal access, thereby simplifying administration by cutting out these unnecessary middlemen. Without a universal system that is publicly financed, we will never have the tools to control prices, adequately reimburse primary care physicians, or ensure that all Vermonters can see a health care provider when they need to, without worrying about going into debt.

Indeed, in addition to the high cost of middlemen, another cause — rarely mentioned — of high costs is underuse. Expensive complications occur due to lack of access, especially as people defer or avoid treatment due to high out-of-pocket costs.

Sadly, many reform schemes are based on the erroneous idea that fee-for-service is the chief cause of our rising health care costs. Supposedly, providers offer services that are unnecessary and thus raise costs. 

In fact, health care systems around the world tend to use a mix of reimbursement schemes for providers, including fee-for-service. Yet none of these systems have the high costs that we do because of the simple fact that they are universal. Their administrative costs are much lower, and they avoid the high costs of treating people who ignored their symptoms for too long because they could not afford to go to the doctor.

We all know that a strong foundation in primary care is essential to treat people before their conditions are more expensive and land them in the emergency room. Health care reformers, regulators and even administrators sing the praises of primary care. Agreed! But then what? 

We must go beyond ritual recitation of the importance of primary care and ensure that primary care becomes a universal public good in Vermont. A universal primary care system would keep Vermonters healthier. It would also make life easier for our primary care providers, many of whom are not adequately reimbursed in our current multipayer system.

Our own Vermont statute, Act 48, lays out a roadmap for implementing a universal publicly financed health care system here in Vermont. If we cannot do this in one fell swoop, then let’s do this by sectors of care and start with primary care — the one sector of care that all of us need. 

Universal primary care would stabilize our primary care workforce by pooling our funds for primary care services and creating a fair reimbursement rate. It would attract primary care providers to Vermont, as it would involve less paperwork than other places, and they might see patients before their conditions were far less treatable. 

If primary care is a public good, like fire protection, then people will no longer avoid care as they are doing now. 

Vermonters need health care access and not more byzantine experiments. Bills will be introduced this coming session in both the Vermont House and Senate that propose making primary care a public good in Vermont. We should ask our senators and representatives to sign on. 

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Tags: Act 48, Ellen Oxfeld, overhead, primary care, public good, underinsured, universal public health care

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