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SinglePayerTaxChanges
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Income
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CurrentIncomeTax
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HealthCareIncomeTax
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TotalStateIncomeTaxes
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EmployerPayrollTax
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$30,000
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$450
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$692
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$1,142
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$2,400
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$50,000
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$1,150
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$1,769
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$2,919
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$4,000
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$80,000
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$2,080
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$3,200
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$5,280
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$6,400
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$100,000
|
$3,000
|
$4,615
|
$7,615
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$8,000
|
$150,000
|
$5,850
|
$9,000
|
$14,850
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$12,000
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Green Mountain Care: Rationing by Any Other Name
Robert S. Emmons, M.D.
Duxbury, Vermont
Vermont lawmakers will soon get to the task of deciding how much your taxes must go up to fund a 2.5 billion dollar health care budget. That’s bad enough, but to add to your misery, you will also pay in the form of medical care withheld, thanks to the Green Mountain Care Board. At the update on health care reform delivered to the legislature on November 19, GMCB Chair Al Gobeille boasted that Vermont has more authority to regulate the practice of medicine than any other state: “That gives us the tools to do good work.”Documents available online at the board’s website detail plans for a system that takes decision-making power out of the hands of patients and their doctors, all in the name of cost containment.
The state’s health information technology plan envisions a database that will link your electronic record to all state departments and a federal data hub, with no provision for you to opt out of this data collection. Under Vermont’s plan for “payment reform,”your doctor will be monitored electronically to see if she is complying with state-approved clinical practice guidelines—selected for cost-containment purposes—and she will be penalized financially if your individual medical circumstances require a different treatment approach (“pay for performance”). Even if your care has been tweaked to meet all guidelines, if you are simply so ill that the cost of your care busts a budget set by state or federal actuaries, your physician will be expected to share the economic pain with third-party payers (“shared savings”and “episodic”payment). Green Mountain Care is Managed Care 2.0, a complex system of third-party financial incentives that undermine the independent professional judgment of physicians. It matters not to the patient whether the unwelcome intruder is a commercial insurer or the state.
On top of all that, a key element of the state’s plan to “bend the medical cost curve”is to reduce pay to doctors: the GMCB has unlimited authority to set fees for all clinicians and hospitals, including doctors like me who do not bill third-party payers. The target is Medicaid-level fees for all. If Vermont pays medical professionals less than their real value in a national market, then we cannot recruit or retain them, and you will have to wait longer for appointments when you are sick.
Practice guidelines, global budgets (either for the entire state or for individual hospital systems), and wait lists are all methods of rationing care, without calling it by its real name. In his recent presentation, Chairman Gobeille stated several times that appropriation of funds is a function separate from payment and delivery of services. I beg to differ. Here is how medical care will be rationed in Vermont, step by step: (1) public outcry and lobbying will pressure legislators to (slightly) lower tax rates; (2) lower tax revenues will lead to a (slightly) smaller appropriation for health care; (3) a smaller global budget will compel the GMCB to increase the financial penalties for hospitals and doctors when the cost of care overruns the monies available; (4) many of the physicians who are paid less will leave practice in Vermont and the ones left behind will increasingly find themselves diminished from deciders of optimal treatment to messengers of curtailed care; (5) fewer doctors means longer waits for shorter visits; and (6) as treatment is delayed or withheld to meet budgets, patients will get sicker and sometimes die. Green Mountain Care is rebranded managed care funded by a Medicaid-style appropriation process and administered by the folks who brought us Vermont Health Connect, so we need not look too far back in history to foresee our future.
Let’s connect the dots: if Green Mountain Care is implemented as planned under Act 48, then the pressure to restrain taxes today is inexorably linked to bad clinical outcomes in years to come. As a Vermont citizen, you can protest against higher taxes today, and you might even hold back the floodwaters for a while, but as long as you are corralled in Green Mountain Care, the state will still get you on the back end by reducing your medical care. Central to the execution of this plan is the abridgment of your right to spend your own money to get treatment outside the system. The solution to this problem is to fix it at the patient level, by restoring your legal rights that have been taken away by Act 48. I refer here to your rights vis a vis the state:
1) Just in case Vermont Health Connect continues to malfunction, and just in case plans available on the exchange use managed care techniques that degrade quality of care, give Vermont citizens the legal right to make real choices by purchasing their own individual health insurance policies outside the exchange. As it stands now, Vermont citizens do not enjoy that right.
2) Just in case it turns out that that quality, cost, and wait times get worse under Green Mountain Care, protect the legal right of Vermont citizens to spend their own money to get timely, excellent medical care from independent physicians outside the system. Don’t let the state set fees for private physicians, as that would have the effect of putting them out of practice, thus taking away choices for patients.
3) Just in case it turns out that health data mining is used in a way that ends up harming patients, give Vermont citizens the unrestricted legal right to say “no,” without penalty, to participation in Vermont’s health database, a right currently denied.
Some readers might ask, if patients are allowed to escape oversight and rationing by Green Mountain Care, then what positive alternative can I offer for reducing medical costs and improving the quality of the patient experience? In my private psychiatric practice where patients pay cash at the time of each visit, I already offer treatment at half the fees charged by the state’s premier Accountable Care Organization. I do not have a waiting list for new appointments, in contrast to who-knows-how-long a wait to see an attending psychiatrist at the Burlington hospital’s outpatient clinic. My friend Keith Smith, M.D., operates a direct-pay outpatient surgery center in Oklahoma City with fees posted online that run 1/5 to 1/10 the average at hospitals nationally. Cutting out the third-party payer saves patients time and money.
As it stands now, the GMCB, through the Certificate of Need process, can deny applications for larger, free-standing outpatient facilities like Dr. Smith’s that can offer high quality care at lower cost than hospitals. Amend the law to prevent state officials from blocking competition in Vermont’s medical marketplace. We in Vermont cannot repeal ObamaCare, but when we can, let’s get the third-party payer out of the patient-physician relationship, and it will not be necessary for the state to ration medical treatment.
Some readers will wonder about the fate of patients left behind in Green Mountain Care because they cannot afford to pay for private medical care. These are the patients I treat at my free clinic. A robust private sector that provides higher quality care will put pressure on the publicly funded system to keep up. Competition is the most effective corrective to the worst excesses of a small group of activists who are willing to trade off your access to optimal medical care in order to achieve their vision of social justice.
In 2013, Vermont Democrats in the House, in a nearly party-line vote, rejected H.331, an amendment introduced by Cynthia Browning that was designed to protect the legal right of citizens to make private financial contracts with doctors of their choice. An unwillingness to accept limits on the state’s authority to intrude with its fee-setting into private medical relationships signals a larger unwillingness to accept any limits on state power in medicine. If the majority party has been genuinely humbled by the results of the last election, then its leaders might look differently at patient rights in the next session. We cannot expect legislators to be able to raise enough taxes to meet the clinical needs of all Vermont patients, and rationing is the primary tool available to the GMCB to deal with the shortfall. Patient rights is the remedy: let’s empower individual patients to protect themselves from the fallible humans in state government who have their moments of grandiosity, calculated opacity, and erring judgment.
Dr. Emmons has maintained a fee-for-service private psychiatric practice in Burlington, Vermont for 25 years, and he is the founder and staff psychiatrist for the Franciscan Free Psychiatric Clinic in Moretown, Vermont. For two decades, he has studied financial conflicts of interest in medicine.
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Vermonters for Health Care Freedom
Health Care Reform Newsletter #41
Vermonters for Health Care Freedom continues our newsletter series on Vermont’s health care reform efforts. We dig deep through national and local media coverage, to bring honest reporting to our client businesses and newsletter recipients regarding Vermont’s push for a “single payer” health care system, and the problems inherent in such a system. We also report on the federal ObamaCare law and Vermont’s health benefit exchange. No other Vermont organization is dedicated solely to this work.
Grubergate: Shocking Revelations From VT. Single Payer Financing Guru
Jonathan Gruber, the Shumlin administration’s consultant hired to deliver a Vermont single payer financing plan in January 2015, has said this about American voters:
In this issue:
· Jonathan Gruber: Now Ready to Mislead the Vermont Legislature
· Why Does it Matter To Vermont?
· Gruber Fallout Is National
· The Gruber Report Will Not Meet the “Mullin Triggers”
Quotes of the Week:
“I was dumbstruck when I heard the comments that are surfacing from an economist named Jonathan Gruber, who was paid $400,000 to help shape the President’s health plan. First, he allowed as how the plan passed only because of a “lack of transparency” and – this is a direct quote – “the stupidity of the American people”.
Bob Schieffer, CBS News
“The problem is not that he said it. The problem is that he thinks it. I’m serious. The core problem under this damn law is that it was put together by a bunch of elitists who don’t really fundamentally understand the American people”.
Howard Dean, Former VT. Governor
“I would hope we would never spend one Vermont taxpayer dollar on someone that believes that we should mislead the voter. His belief that the ends justify the means is enough for me if I were governor to terminate his contract immediately. Transparency and open government are key to a well functioning democracy.”
Senator Kevin Millin, R-Rutland
Jonathan Gruber: Now Ready to Mislead the Vermont Legislature
Americans just found out in recent weeks that they were deliberately deceived and misled by MIT economics professor Jonathan Gruber, the architect of ObamaCare. Videos of his speeches reveal a man with an elitist disdain for American voters, whom he calls “stupid”. Gruber played a central role in the preparation of analyses and the selling of ObamaCare. He now proudly admits that he was party to a series of deceptions and lies necessary to hoodwink both Washington lawmakers and the Congressional Budget Office into passing ObacaCare under false pretenses. (see video at end of newsletter).
The same fate may be in store for Vermonters. Turns out that Jonathan Griber is the man Governor Shumlin contracted with to the tune of $450,000 to advise the Vermont legislature on how to finance Shumlin’s single-payer health care plan. Take a look at Gruber’s philosophy as seen in videotaped speeches on ObamaCare:
· “Lack of transparency is a huge political advantage. And basically, call it the stupidity of the American voter or whatever, but basically that was really, really critical to getting the thing to pass. Look, I wish Mark was right that we could make it all transparent, but I’d rather have this law than not”.
· “Politically you just literally cannot do….transparent financing, transparent spending. I mean, this bill was written in a tortured way to make sure CBO (Congressional Budget Office) did not score the mandate (for people to have insurance) as taxes. If the CBO scores the bill as taxes, the bill dies. So it was written to do that”.
· “It turns out politically it's really hard to get rid of (the exemption of health care from being taxed)," Gruber said. "And the only way we could get rid of it was first by mislabeling it, calling it a tax on insurance plans rather than a tax on people when we all know it’s a tax on people who hold those policies”.
· “It’s very clever, you know, basic exploitation of the lack of economic understanding of the American voter”.
· “We experimented with choice in public insurance – Medicare Part D. Typical senior has 50 PDPs (prescription drug plans to choose from). Seniors do a terrible job at choosing”.
· Gruber ‘s response in the Vermont State House to a Vermonter concerned about the ramifications of single payer: “Was this written by my adolescent children by any chance?”.
Overall, Jonathan Gruber’s remarkable arrogance and disdain for the intellect of American voters and Vermont’s citizens is breathtaking. His remarks are delivered in a gloating fashion, with much laughter, as he admits his deception of the Congressional Budget Office and Washington lawmakers.
In Vermont, calls to fire Gruber are coming in from every direction, including several Vermont Republican senators and representatives. However, the Shumlin administration thinks it has somehow solved Gruber’s credibility problem by capping his contract payments. Instead of $450,000, Gruber was asked to complete the work for only the $160,000 already paid. The state will continue to pay Gruber’s assistants at the rate of $100/hr. Lawrence Miller, Shumlin’s single payer point person, estimates that Gruber will probably be paid at least $280,000. Not much of a penalty there.
Miller explains that Gruber “pushed back some” , but that the state was looking to address questions about Gruber’s credibility. “Doing the work without compensation helps to address that, helps to mitigate that” (the credibility gap), says Miller. No, Mr. Miller, it doesn’t. Making money has nothing to do with it; Gruber has made multiple millions already. That’s not what motivates him; his arrogance does.
Why Does It Matter to Vermonters?
Even if Gruber worked for free, he can’t change who he is and how he operates. By his own admission, Gruber purposely distorted information about ObamaCare to make it palatable to the Congressional Budget Office. Additionally, he purposely misabeled another important tax provision necessary to fund ObamaCare.
This is the very same work Gruber is being asked to do for the Shumlin administration and the Vermont legislature. The clear language of his contract refutes the recent backtracking by both Governor Shumlin and pro-single payer legislator Sen. Claire Ayer that “Hey, Gruber’s only doing numbers; he’s not going to advise us on policy”.
Gruber’s Vermont contract clearly states, “The Contractor shall assist the administration and other consultants in the development of the final policy recommendations that form the basis of a comprehensive report to the state legislature ”.
Even the most ardent legislative single payer advocate will have a tough time explaining to his or her constituency why a guy who would lie and mislead the federal Congressional Budget Office will now tell the truth to the Vermont legislature, and why they should accept any of his recommendations. Reread his philosophy above.
Gruber Fallout is National
Others for whom Gruber has done similar work are now questioning their decisions. The November 19, 2014 Baltimore Sun reports that Maryland Representative Andy Harris, a Johns Hopkins-trained physician, is a member of the House subcommittee with oversight of health spending. Harris is questioning a $3.5 million National Institutes of Health (NIH) grant awarded to Gruber. Gruber has already received $1.5m to study how seniors choose Medicare Part D plans (“Seniors do a terrible job of choosing”). Harris said Gruber is on track to receive more than $2m. (Apparently Vermont’s pay freeze won’t hurt Mr. Gruber financially, although he did “push back” on it).
In a letter to the NIH, Dr. Harris wrote, “Recent developments related to Dr. Gruber raise questions about his objectivity and judgment, and thus the utility of his research. If NIH were to continue funding Dr. Gruber’s grant, would you recommend that Congress and others utilize Dr. Gruber’s study given his deporable views on the intelligence of Americans? If you do recommend using it, how would you justify that decision,, especially to seniors why rely on Medicare Part D?”.
Governor Shumlin and Vermont legislators will have to answer similar questions come January 2015.
The Wall Street Journal reports on November 20, 2014 that in Michigan, Republican state senator Tom McMillin sent a letter on November 19th to the State Department of Community health , seeking information on Mr. Gruber’s work, including how he was selected and paid. Michigan opted to go with the federal exchange rather than building a state-run exchange. (Mr. Gruber apparently works both sides of the street.) “He seems to have a proclivity for deception or fraud, so I’d like to dig into this”, said Mr. McMillin.
Perhaps the Vermont legislature should ask Reps. Harris and McMillin to visit in January and find out what they learned. Athough Gruber’s active participation in the obfuscation of facts that led to the passage of ObamaCare is not enough to dampen the ardor of Governor Shumlin and the Vermont legislature, this issue will not go away any time soon. The fallout will continue, more of Gruber’s contracts will be cancelled and more revelations will come to light.
Gruber’s Vermont Report Will Not Meet the “Mullin Triggers”
Remember the “Mullin Triggers” written into Act 48 to give Vermonters some comfort that a single payer system would not harm them? Many Vermonters were reassured that they were in safe hands beause no single payer system could be implemented without meeting these triggers. Not anymore. The triggers are not included in the scope of work outlined in Jonathan Gruber’s contract.
Mullin Triggers
· All Vermonters must have insurance coverage that pays at least 80 percent of their medical costs.
· Green Mountain Care, the single payer structure, will not have a “negative” aggregate impact on Vermont’s economy (Robin Lunge now says there will be “winners and losers”).
· The financing for Green Mountain is sustainable.
· Administrative costs will be reduced.
· Cost containment will result in a reduction in the rate of growth of per-capita health care spending.
· Health care professionals will be reimbursed at levels sufficient to allow Vermont to recruit and retain high-quality health care professionals.
Gruber Contract : “The Contractor and his subcontractor shall assist the state in analyzing the triggers set forth in Act 48 for future consideration by the Green Mountain Care Board:
· When implemented, Green Mountain Care will not have a negative aggregate impact on Vermont’s economy.
· The financing for Green Mountain Care is sustainable.
That’s it. What happened to the evaluation of the “80% medical costs” level plan? Or any medical plan? Any single payer analysis of the overall cost and whether it will be affordable and not have a negative impact on the economy, must, by definition, include an analysis of the underlying medical plan that will be the basis of single payer.
What happened to Act 48’s assurances about reduced admin costs? About cost containment resulting in reduced health care spending? And perhaps most importantly, about single payer’s ability to attract and retain high quality providers so our health care won’t suffer? Any response, Mr. Gruber? Governor Shumlin? Senator Ayer? Anyone?
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