by Hamilton E. Davis
One of the most vivid memories I have of serving in the Vermont House some 25 years ago was the afternoon that a man came into our committee to present his case for passage of some bill whose subject I cannot remember, but which in any event had little chance of passage.
He sat in the witness chair without ceremony and began his testimony this way:
I once actually saw, in a foreign country, a man beating a dead horse.
I couldn’t help thinking of that as I sat through a three-hour hearing last week in which Governor Peter Shumlin’s three top single payer health care reform experts laid out, in excruciating detail, all the reasons why they couldn’t recommend any of the financing options they had developed over the previous three years.
The governor had pulled the plug on the financing section of his single payer reform initiative on Dec. 17, and followed that by releasing just before New Year’s Day a vast heap--hundreds of pages--of reports and appendices concerning the financing of a shift from private insurance to state financing.
The governor’s decision to kill off the signature measure of his four years in office left much of state flabbergasted. Supporters of single payer ranged from heartbroken to angry, while conservatives exulted, although wondering whether the governor who has dominated state politics for years was planning some slick maneuver that might resuscitate the dreaded single payer plan.
In fact, the Shumlin administration will spend additional time this week explaining to legislators why they had no choice but to do what they did. These dispiriting recitals should end this week, however; and both the lawmakers and the Shumlin health planners will have to turn to the really important question: where do we go from here?
The future is now
The key indicator to the future track of health care reform will be Governor Shumlin’s budget address Thursday afternoon. Shumlin mentioned health care only in passing in his inaugural speech last week, but his planners have put together a package of proposed legislation and other steps to affect the course of health care reform.
What is a mystery at this point is whether Shumlin wants to, or can, say anything that will breathe life back into the financing side of health care reform. For serious health care reform is a war fought on two fronts.
The first front is cost containment and the restructuring of the health care delivery system so as to make its quality much higher and its spending rational and sustainable. That task lies within the purview of the Green Mountain Care Board and the war on that front is already going very well. Indeed, the GMC board doesn’t really need any new legislation. Its legal framework is the single payer law passed in 2011, and that statute, arguably the best such legislation in the country, gives the board all the powers it needs. Shumlin could come up with legislative proposals in that theater of operations, but if they are more than housekeeping stuff, they could do more harm than good.
At this point in Vermont’s reform effort, the key theater is the financing front. The question there is how to move from health care financing based on employment status to financing based on residence in the state. That is the front where, on Dec. 17, Shumlin broke and ran.
It is important to note that even though the governor abandoned the field on financing, the cost containment effort will continue at the GMC board. The difficulty lies in the fact that the political momentum behind the cost containment front could be dangerously eroded by the failure on financing.
The ultimate question, therefore, is whether Shumlin can recover enough substance and credibility on financing to provide at least some support to cost containment. What might that look like?
One thing he could do would be to reverse his Dec. 17 declaration. He could present one of his 15 potential financing scenarios to the legislature and invite the members to join him in trying to find a road forward. That would require a dramatic shift in approach from plans developed basically in secret to plans developed in a real partnership with another branch of government.
I can’t imagine such a thing happening. Shumlin personally does not have enough credibility with the legislators, the press or the public to get away with it, even if he would consider it, which he almost certainly wouldn’t. So then what?
He could try one of the many step-by-step proposals on financing that have been floating around in the policy ether for the last four years.
One of those would be to try to extend insurance coverage to the 23,000 or so Vermonters who remain uninsured. Senate Finance Chairman Tim Ashe has expressed interest in that area. There are problems with it…but there are problems with just about everything. If it could be done, Vermont would be the first state with universal coverage, and Shumlin could be known for that nationally, instead of his current role as the father of failure.
Another would be to figure out whether a sector of the delivery system—hospitals say, or primary care—could be shifted to public financing. Problems there also, but moving a piece of the cost into the public arena would be cheaper than moving the whole system in at once.
He could try to add something to Medicaid financing, a step that would draw down more federal dollars and achieve some incremental benefit.
Another possibility would be to build a piece of infrastructure that could be used for public financing, without committing big money at this point. Shumlin’s report to the legislature has a sort of sleeper element that could serve as the framework for such a step. The language refers to a management “entity” that could operate as a public utility for health care. Although Vermont Blue Cross is not mentioned by name it would be the obvious “entity.”
Just having such a hunk of machinery in place would ameliorate at least somewhat the political burden the Shumlin administration has had to carry owing to the failures of the federally financed insurance exchange. The mere association with Blue Cross could confer some political benefit on the administration.
Whatever the individual merits of the list that Shumlin produces Thursday, the question will be whether, taken as a whole, the list can move single payer financing from “dead”, which it is now, to at least “critical but likely to survive.”