Opinion: Focus on universal primary care

This Community Forum was written by Ellen Oxfeld of Middlebury, and Montpelier residents Dr. Deb Richter, Ethan Parke and Marjorie Power, who are members of the organization Vermont Health Care for All.
Every election season legislative candidates campaign on the issue of health care access. Yet once in office, our representatives quickly learn to keep silent on this fundamental issue. Vermonters deserve better.
According to a recent official report, 36 percent of Vermonters under age 65 are underinsured. Forty percent of those with private insurance are underinsured. This means their “medical expenses are more than what their income could bear” and they “delay care at higher rates than those with adequate insurance.” High out-of-pocket costs associated with many of today’s health plans make people avoid going to the doctor until it is too late. Delays can be fatal in cases of pneumonia, cancer, heart disease, and other serious illnesses.
Why must we tolerate a situation in which people only seek care when their conditions become acute and expensive? Why has our legislature done nothing to move us toward the goals of universal health care articulated in the sweeping health reform legislation passed in 2011 as Act 48?
This session neither the Vermont House nor the Senate health care committees seem interested in health care access. Instead, they’ve spent hours on something they call “insurance market stabilization,” ignoring the fact that the market has never worked in health care, no matter how stable. The market always excludes those who cannot pay, and always results in health care injustice.
In defiance of economic realities, last year the legislature mandated that all individuals have health insurance. Now lawmakers are proposing stiff penalties on those who do not purchase it, despite the fact that the Department of Health says the main reason Vermonters don’t have insurance is that they cannot afford it. The assumption behind the individual mandate is that by broadening the market, premium increases will level off. Not likely. The real reason for premium increases is the high cost of hospital care.
Forcing someone to purchase a private, high deductible insurance plan only moves that person from uninsured to underinsured status, and many people who purchase such plans are still likely to defer necessary care due to cost. It’s evident that looking for solutions only within our market-based system does little to solve the underlying problem of access.
Consider that a Blue Cross bronze plan costs almost $500 month for a single person and almost $1,400 month for a family. After paying the premium, a single person still has a $5,500 deductible. The family’s deductible is $11,000. The plan includes another deductible on drugs ($900 per member), and an array of other items not included in the out-of-pocket limits. The bronze plan also requires significant co-pays for primary care and specialists. There are premium subsidies for those under 400 percent of poverty, but this leaves many middle-income people out. Additionally, the subsidized premium does not change the plan’s high out-of-pocket exposure.
If we want Vermonters to have access to health care, why not make primary care a public good as laid out in H.129, a bill with 48 co-sponsors in the House of Representatives? While making a transition to a universal publicly financed system all at once — as envisioned in Act 48 — proved too difficult for a variety of reasons, H.129 would achieve the first step on this roadmap to universal care.
Primary care is only 6 percent of total health care costs. By making it publicly financed and free at the point of service, the legislature could remove the roadblock to health care many Vermonters face. The cost of primary care could be equitably spread across the population, and because everyone would be covered, there would be no benefit cliff where coverage ends.
Nations with universal access to primary care have higher life expectancy numbers and better health care outcomes than the U.S. If primary care was universal we’d also be controlling costs, as people would not delay seeking care until their conditions become very expensive to treat.
A universal primary care system would also cut red tape. In the U.S. we spend about 31 percent of our health care dollars on insurance administration and billing. This amounts to $1.86 billion per year in Vermont and means we spend nearly $3,000 annually per Vermonter — not for medical care, but for a complicated bureaucracy whose purpose is to collect money. A system that serves everyone would greatly reduce administrative waste.
Legislation now under consideration in the House includes a study of a multi-state regional universal health care system. This is more worthy of discussion than “market stabilization” but strikes us as far more complicated and futuristic than simply going ahead as a state to enact universal primary care.
Act 48 set a goal of making health care a public good. That goal is still embedded in Vermont law, and should still be the benchmark for legislative action. It’s time for the legislature to listen to Vermonters and refocus.

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