by Hamilton E. Davis
In his January 24 budget address, Gov. Phil Scott took one of his most significant steps in support of the Vermont health care reform project since he took office in 2016. Scott said in his speech he was confident about moving ahead with the project based on reports showing that the state’s hospitals had spent well under the contracted level for 2018 for a piece of the Medicaid population. The providers working under the terms of fixed price contracts performed markedly better than those hospitals and doctors did in the fee-for-service reimbursement system in the past. Every word in Scott’s statement was true, including the punctuation. VTDigger’s response was to call him a liar.
Digger didn’t use the word liar. Its report said the Scott statement was “Mostly false.” And you can’t check that out because Digger took its report down after three or four hours and replaced it the next day with a new claim that the Scott statement was only half false. What are we to make of this mess?
The first thing to understand is that the Digger reporting is just as bad now, or worse, than it has been since it began its newest phase last October. It is also becoming clear that Digger is determined to remain on its current course in reporting on the health care reform project. What is new in the last week or so is that Digger now has an association with PolitiFact, a national organization whose mission is to test the veracity of statements by politicians and public officials. The Digger article is cast within the PolitiFact framework that establishes five categories—True, Mostly True, Half True, Mostly False, False and Pants-on-Fire. You have to wonder about PolitiFact’s due diligence taking Digger into its tent, but that’s a story for another time. Anyway, let’s look first at the Scott move.
The Significance of the Scott Move
The Governor said that in 2018 providers working under fixed price contracts spent $7.7 million less than they would have if they had been paid under the fee-for-service system that had been in effect previously. The same under-spend showed up on a much smaller scale in 2017, the pilot year of the reform effort. Scott also said the 2019 figures, which are not yet fully available, are trending in the same direction.
“The challenge,” the Governor said, “is changing the way we pay for something that is 20 percent of our state’s economy without making it harder to access care, adding new costs or reducing quality. For these reasons, many Vermonters are skeptical,” he continued. “I know I was—and still am, somewhat, because we’ve seen firsthand that there’s no quick fix or political promise to make healthcare more affordable. But the early results give me reason to be cautiously optimistic.”
The Governor didn’t provide much context, and I’m not sure whether he could have without turning a couple dozen sentences into a health policy seminar, which would have taken up the whole budget address and probably several other addresses as well. So, here is what I believe my tiny corps of brilliant readers need to know: the dynamic he was welcoming was limited to the Medicaid population in the state; Medicaid is the only payer now prepared to take advantage of fixed price contracts. Medicare is not there yet, and neither is the private insurance industry, although Vermont Blue Cross is discussing it with OneCare Vermont.
The fixed price contract for Medicaid in 2018 was set at $75 million, and the actual spending was $67.3 million, $7.7 million under that. That number is known because both payers and OneCare Vermont are keeping records of what the fee-for-service payments would have been under the old system—shadow payments is the buzz phrase. The state didn’t save the $7.7 and Scott never said it did.
The significance in the finding lies in the prospect that future fixed price contracts can come in at savings of 10 to 11 percent, or more, less than fee for service. That savings can amount to several hundred million dollars a year. And that is just a start. Extending the new payment model to Medicare and the private insurance system would save Vermonters billions of dollars out into the future and would constitute the first sustainable delivery system in the United States.
The barriers still to be overcome, however, are formidable. That fact is what lends added significance to the Scott comments in his budget address. When Scott took office in 2017, he treated health reform like a ticking bomb; it had cost his predecessor, Pete Shumlin, his promising political career and Scott wanted no part of it. Within a year, however, Scott had come to believe that reform could work and he began to lend his support. But quiet support is not the same as political leadership, so it was important that the Governor stepped out from behind the curtain.
The importance of that cannot be overstated. The progress of reform has been strikingly good, given the intrinsic difficulty of the task. But the political environment has been toxic, with powerful opposition from many quarters, most notably the Vermont Senate; and the opposition has been amplified by the coverage from VTDigger, Vermont’s only active daily press organ.
Fact Checking Digger’s Performance on the Scott Statement
Is Scott a Liar, Half a Liar or an Innocent Victim?
The central issue in the Digger coverage was reporter Katie Jickling’s claim that Scott had falsely told the public that OneCare Vermont had saved the state $7.7 million in health care costs in 2018. That was the claim in the first Digger story on the Scott budget address. That story went up sometime during the day Sunday, Feb. 2. By the end of the Super Bowl game, it was gone, only to appear in rewritten form on Monday afternoon. The judgment in the PolitiFact lexicon had changed from “Mostly false” to “half true.”
In an editor’s note, Digger said that its previous article had been revised after the governor’s office had reached out “clarifying his statement as focusing on the Medicaid patient pool. This made the statement more accurate—we changed the ruling from mostly false to half true—but Scott still left out important context about overall costs associated with the One Care program.”
In the recast piece, Jickling picked up the thread of Digger’s thinking: referring to the putative $7.7 million savings, she wrote, “That savings figure jumped out at us,” she wrote. “Our research on OneCare has found mixed results—and an open admission from health care officials that the program has not yet created the savings they hope to achieve, Did we miss something?”
Did they ever! The whole mess is a tissue of mistakes, sleazy writing, and deliberate misinformation. Too extreme? Here are the facts:
The whole modern reform movement in the United States, under the general rubric of “Obamacare,” was launched in 2010 with a clearly defined track. There was a sort of warmup period from 2013 to 2016. In 2017, ACOs like OneCare would be allowed to pilot new reimbursement systems, with the first fully operational year coming in 2018. The target results were supposed to be achieved by 2022—a five-year span. Given that reality, let’s consider the Digger claim that OneCare hasn’t achieved the results it had hoped for. Keep in mind that that under federal law the first full reform year was 2018. The Digger claim here is pure garbage.
The fact is that no one knows what the performance track is because it is impossible to tell that from one year’s results. No one will know even the most preliminary results until we see the 2019 results, and they aren’t available yet. Even then, it will be difficult to project what is likely to happen in 2020, 2021 and 2022. And what really indicts the quality of the reporting here is the statement that it’s based on “an open admission” from health care officials.
There was no such “admission”—everybody involved in the reform project has been bending over backwards not to claim more than can be fully justified. The so called “admissions” were simple statements of fact, and describing them as admissions is just sleazy writing. Moreover, the results so far, while less than fully proving the validity of the reform concept, have been good, not bad. The system performance on Medicaid was positive in 2017, and even better and more encouraging in 2018. We don’t have the 2019 results, but Scott has access to the figures for most of that year, and he said they look good too.
What’s left of the Digger judgement is that Scott did not include the administrative cost of OneCare in the savings figure of $7.7 million dollars, and that he had implied that the Medicaid performance also covered the performance of the other contracts, the ones with Medicare and the insurance carriers. The whole admin cost stuff is just silly, and not worth time. The issue of whether Scott was clear about the scope of the performance, however, is clearly substantive, although basing a half-true rating on that alone seems overdone. For me, the more interesting element there is what it reveals about the Digger style, as well as its editing performance.
The whole piece is predicated on the call that a Scott spokesman made to Digger in the wake of the first, erroneous piece, the one that got taken down on Sunday night and rewritten. The spokesman “reached out with additional information clarifying his statement as focusing on the Medicaid patient pool.” That sounds both reasonable and innocuous. Based on my 60 years in the journalism and policy world, I would urge my tiny corps to look behind to see the real weaseling by Digger.
Jickling’s reporting was based on an interview with Ena Backus and Alicia Cooper of the Agency of Human Services staff weeks before the two stories went up. Backus and Cooper are seriously credentialed specialists in the health policy biz. Backus has a masters degree from Brandeis University, and Cooper has a Ph.D in health policy research from Brown. No serious person could talk to those people without learning that the 2018 results were from Medicaid only, not Medicare or Blue Cross. Nor that the results were encouraging, without being fully dispositive. The reason I know that is because I talk to them about the same stuff myself, and that’s what they told me.
What obviously happened here is that once the Diggers figured out that they were turning a guy who hadn’t spoken a single false word into a liar, they realized they had to climb off their original judgment and try to cobble together enough other stuff to avoid total embarrassment by calling him only half a liar…After all, it was Digger’s maiden voyage on the good ship PolitiFact.
Sound too contentious? Possibly. If so, my tiny corps should suspend their own judgment on their faithful correspondent. My next post will demonstrate an even worse performance by Digger, one that poses a threat to the whole reform process itself.