Coalition 21: Trying to find a solution for health insurance costs
The current state of the American health care system might be likened to lateautumn weather in Vermont: Everyone complains about it, but no one can do anything about it.
A wide array of Vermont interest groups is determined to show, however, that the health care crisis in at least one small state is not quite as impervious to improvement as a typical December day in northern New England.
Calling itself Coalition 21, this collection of business associations, advocacy groups and professional organizations has been meeting since mid-summer with the aim of drafting a comprehensive plan ensuring access to affordable, highquality health care for all Vermonters.
No proposals have been drafted to date, nor has the 28-member grouping set any timetable for reaching its goals. And even though the coalition faces some seemingly insurmountable obstacles, many of its members express optimism that this initiative will eventually succeed.
Some promoters of the Winooski Dome of yesteryear (putting the entire city under glass) were equally upbeat, however.
Coalition 21’s premise, according to its conveners, is that previous efforts to redesign health care, both nationally and in Vermont, failed because those proposals did not command sufficiently broad support.
State Senator James Leddy, a lead organizer of this latest quest, points to Bill and Hillary Clinton’s multi-faceted reform plan, which was stymied in Congress in 1994, and to Vermont’s own attempt around the same time to devise a system guaranteeing universal coverage.
Vermont’s ambitious undertaking collapsed because “some of the major players were not at the table,” Leddy recounts. He referred specifically to small business interests, which, he says, “suddenly realized that they were going to be asked to pay for health care.”
Leddy, the chairman of the Senate Health and Welfare Committee, says he spent much of the past two years consulting all the players about how to restart the effort to restructure Vermont’s health care system. He became convinced that any new initiative had to be “bottom-up rather than top-down.” He says he argued for a grassroots process that, initially at least, would have no direct government involvement.
Coalition 21 is the result.
The group is staffed by the non-partisan Snelling Center and meets under the auspices of the Windham Foundation, a sponsor of projects intended to benefit the general welfare of Vermont. The coalition can call -upon fiscal and legislative experts from state government, and it has studied plans developed in other states for reforming parts or the entirety of their respective health care systems.
The Vermont business community was willing to sign on to this endeavor, says co-convener Lisa Ventriss, because it has come to the conclusion that the current system is unsustainable.
Ventriss said even coming up with the formal name was difficult, which reflects the task ahead: “Coalition 21: Transforming Vermont’s Health Care System.”
She said it is very much a coalition of different individuals and groups; it must be relevant to the 21st century, inasmuch as the current system dates back to WWII; and, “This coalition is not about tinkering around the edges. So it wasn’t about health care RE-form, it was about TRANS-forming the health care system.”
Agreeing that a crisis point had been reached, members of the Vermont Business Roundtable, which Ventriss directs, “felt compelled to take risks in our own thinking,” she says. Ventriss recalls “a eureka moment” at one roundtable session a few months ago when participants decided in unison that new ways of addressing the perennial health care quandary had to be found.
Windham Foundation president Stephan Morse, the coalition’s facilitator, says it has come into existence as the result of an “awakening.” All parties now acknowledge that “we are indeed in a crisis,” Morse says, “and various players not used to sitting at the same table are coming together to address it.”
He himself approaches the issue from “the frustrated employer point of view.” Morse says he recently calculated what it costs to provide health insurance to his 45 employees at the Old Tavern at Grafton and 20 others at the Grafton Village Cheese Co. He says he was stunned to discover that the cost of health coverage equates to 1,600 room nights and 50,000 pounds of cheese.
Mark Neagley, head of Neagley & Chase Construction, affirms that the burden is too heavy for either his company or its employees to continue shouldering. Until about five years ago, Neagley recounts, his business paid the full costs of health insurance policies for its 40 covered workers. Relentless rate rises then required, however, that workers be asked to pay 10 percent of their premiums, Neagley relates, adding that the employees’ share has since climbed to 30 percent. Neither the company nor many of its workers can continue paying that much, he says, warning, “I think we’re right at the edge now.”
Concern over health care costs and gaps is so acute and widespread that Coalition 21 has had to expand beyond the size that was originally envisioned, Ventriss says. She and Leddy had wanted to cap the group at 13 members, Ventriss notes.
“But once people caught wind of it, they thought this grassroots structure was very promising and they wanted to be part of it.” Now there’s a danger of the coalition being too unwieldy to function effectively, Ventriss acknowledges.
The breadth of interests represented could also impede consensus, some participants suggest. But, they add, goodfaith attempts at finding middle ground are likely to be made by all concerned.
“We all agreed to check our guns at the door,” notes the Reverend Rick Neu, president of the Vermont Ecumenical Council and Bible Society. Neu’s group is represented on the coalition alongside such decidedly secular entities as Blue Cross/Blue Shield of Vermont, the Bi-State Primary Care Association, the Vermont Association of Hospitals and Health Systems, and the Vermont and Lake Champlain Regional chambers of commerce.
All 28 members have pledged to make room for facts that may not fit their ideologies, Ventriss says. While acknowledging that she holds some strong views on health care issues, Ventriss says she is taking part in the process with an open mind.
“I’m willing to be influenced by what the data says. I want to make rational decisions rather than emotional ones.
Even so, the gulf between coalition members’ positions does appear vast and perhaps unbridgeable, says Neagley. “What’s good about this is that everyone is able to express their true feelings and core beliefs. But it can be pretty shocking to realize that you totally and completely disagree with everything that someone is saying.”
Coalition members differ sharply, for example, on the emphasis that should put on consumers’ personal responsibility for maintaining good health – and thus reducing reliance on doctor visits, laboratory tests and some surgical procedures.
At a recent three-day retreat in Grafton, participants eventually agreed to use the phrase “pursuit of healthy lifestyles” rather than “personal responsibility.” Some participants had interpreted the latter term as “punishing to people who have no control over a disease,” says Richard Davis, director of the Vermont Citizens Campaign for Health.
Ventriss has a different position on this point of debate. In an interview prior to the retreat, she suggested that a reform plan might be impossible to adopt because “in some areas there’s not enough pain to bring about change. Consumers don’t get it,” Ventriss declared. “In most cases they’re not contributing enough to the system. They’re not seeing how challenging it is to maintain the system. There’s got to be consumer education and a focus on the lifestyle-behavioral element.”
A meaningful redesign of Vermont’s health care system cannot be carried out unless financing components are included, and Coalition 21 is committed to proposing ways of paying for envisioned improvements. That aspect of the group’s mission has already proven contentious, however, and will likely grow more so as specifics begin to be discussed.
In fact, the coalition will probably have to become broader as financing issues are taken up, Neu suggests. Legislators and the general public will have to get involved at that point, he says.
Some coalition members assume that providing coverage to Vermont’s 60,000 uninsured residents – 50 percent more than there were five years ago – will require state government to tap new revenue sources. Neu, for one, says, “There’s going to have to be taxes in some shape or form.”
But some coalition members are convinced that health care in Vermont can best be reformed by cutting costs rather than by putting more money into a system that has experienced an 88 percent increase in expenses – from $1.7 billion to $3.2 billion – in just the past eight years.
“More taxes are not the way to go,” says Neagley, who chairs the health care working group of the Vermont Business Roundtable. ‘That’s not going to attach a sense of ownership to health care. There are plenty of places where we can take costs out of the system.”
Coalition members agreed at the outset of the venture not to proceed in accordance with any timetable. “We didn’t want to set an artificial deadline,” Ventriss says, “because when people have a gun to their heads they sometimes do stupid things that they will come to regret.”
Leddy agrees that the coalition needed to establish “a process that does not link automatically to the political calendar.” But the group is also “acutely aware that there is pent-up political energy for change” in Vermont’s health care system.
Some members say they are not worried about Governor James Douglas and Democratic leaders of the Legislature drafting their own reform plan in the coming months while the coalition continues its methodical deliberations. Others argue, however, that it would not be inappropriate to infuse the coalition’s proceedings with a certain sense of urgency.
“If the Vermont Legislature does come up with its own plan and we don’t, you’d have to wonder what the point of our group was,” observes Davis, leader of the citizens’ health campaign.
For now, though, the coalition is moving step-by-step as it seeks to build consensus on key considerations. And members must still decide whether it’s feasible to strive for all-encompassing reform or whether it’s wiser to focus on one large segment of the system – hospitals, for example.
Advocates of a thorough restructuring, such as a move toward a Canadian-style single-payer approach, suggest that Coalition 21 could conceivably take that route, even though many of its members are skeptical, to say the least, about the costs and bureaucracy that such a system would entail.
At the recent retreat in Grafton, one working group recommended establishing a public trust, similar to a utility, to administer health care in Vermont. This proposal “wouldn’t take the insurance companies out the mix,” Davis notes, “but it would allow the state to set rules on costs and coverage.”
Such a framework would resemble a single-payer system, Davis says.
Even if the coalition’s final product falls short of his own goals, Davis says the exercise might still prove to have been worthwhile. He notes, for example, that the group could take the significant step of urging that health insurance be decoupled from employment.
But the coalition is far from endorsing any specific, or even conceptual, plan. It has only recently formulated a set of general principles to guide its work.
According to facilitator Morse, Coalition 21 is committed to helping Vermont achieve universal access to health care, comprehensive and continuous coverage, ongoing improvements in the quality of care, a system that is equitable and sustainable and one that also ensures accountability for quality and costs.
Translating those principles into a cohesive and detailed proposal will not be easy, concedes Morse. As a former Speaker of the Vermont House, he knows it is often impossible to satisfy all points of view – let alone achieve unanimity on controversial subjects.
“We’re not going to come up with a plan that will please everyone,” Morse says.
It’s possible that the coalition will produce a plan endorsed by most but not all its members, Ventriss notes. In that case, a minority report might be published as well, she says.
One big factor in the coalition’s favor, members say, is the small size of the state in which it is operating. Vermont’s manageable magnitude and sense of neighborliness are seen as major reasons why the effort just might prove successful.
The coalition has already agreed not to address issues that are largely within the purview of the federal government. It will not be proposing an overhaul of the Medicare or Medicaid systems, for example, although these forms of insurance for the elderly and the poor do have an enormous impact on health care costs and delivery in Vermont.
At the same time, according to various participants, the coalition is motivated by an understanding that the second Bush administration and the heavily Republican Congress are unlikely to initiate any sweeping national reforms. Fundamental change, if it happens at all, will have to take place on the state level, coalition members say.
“Vermont is small enough that we may be able to find workable solutions,” says Morse. “Sixty-thousand uninsured people is a big number, but it’s only a tiny fraction of the 45 million Americans who don’t have health insurance.”
A state with a population equivalent to that of a single midsized American city ought to be able to achieve a breakthrough, Neu suggests.
“If we can’t figure it out here, it’s not going to be figured out anywhere,” he says.
Maybe so, Davis adds, but he isn’t counting on it happening.
A registered nurse for the 28 years and a single-payer campaigner for the past 20, Davis says, “I’ve been at this for a long time, and I know you don’t get very far very quickly.”
Copyright Boutin-McQuiston, Inc. Dec 01, 2004
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