17 July 2007

Rocky presents to the 208 Commission

Bill Lindsay, chair of the Blue Ribbon Commission for Health Care Reform, couldn’t believe it.

The independent analysts had just informed the commission that Health Care for All Colorado’s single-payer reform proposal, which would bring universal health care to Colorado via a model similar to that found in other industrialized countries, would actually save money.

“Everyone in Colorado will have increased coverage — and we’re going to save $1.6 billion.” Lindsay said. “It surprises me that we’ll be able to do that.”

Those following comparative studies on health care systems would not have been surprised.

“The single-payer systems always do best,” says Dr. Elinor Christiansen, the past president of Health Care for All Colorado, a non-profit group advocating for single-payer, universal health care. “Why do you think other developed countries can care for all their people at half the cost we do — with equal or better outcomes? They use the cost efficiencies of a single risk pool, better prevention, and best practices.”

The Lewin Group, an independent firm offering actuarial analysis of four Colorado reform proposals, presented their findings to the Blue Ribbon Commission (also known as the 208 Commission) Tuesday. They work out complicated mathematical models — sometimes accurate to within a dollar of reality — that give insight into how much each of the four Colorado proposals will cost and how much good they’ll really do. It’s one thing for a reform proposal to say that doctors will continue to be well compensated and quite another to actually specify how much they’ll be paid; one thing to say that coverage will be expanded and another to say by how much. The Lewin Group’s analysts insist on detail in order to offer their educated guesses on what reforms will do.

John Shiels, a senior analyst with the group, told the skeptical commissioners that Lewin had always found savings when they modeled single-payer systems.

The four lead authors of the various proposals being modeled also had a chance to present to the commission.

Luckily, Dr. Rocky White from Alamosa, author of Health Care for All Colorado’s single-payer proposal, hadn’t been present when Lindsay had explained what the authors should discuss.

Lindsay had opened the day-long meeting by saying that the authors would talk about what modeling criteria had been problematic for them, and how they had arrived at their proposals’ assumptions. That’s pretty dry stuff compared to what Rocky offered.
The lanky 6’4” rancher physician told the commission that he’d been raised in an evangelical, Republican family in Nebraska, and carried those values with him when he moved to Alamosa to practice medicine and raise his family.

In 1986 he was one of 24 physicians to join together in a medical practice in Colorado’s rural San Luis Valley. “Only one of those 24 physicians was a Democrat,” Rocky told the commission. “We believed in the free market system.”

But they were paddling upstream with medical economics, in particular rural medical economics. “Fall of 2004, we went broke,” Rocky says. “We were working our butts off, seeing more patients than we could handle, and we still went broke.”

Part of the reason for that is because 23 percent of the San Luis Valley’s population is on Medicaid. Another 28 percent is on Medicare. Rocky’s practice loses 30 cents on the dollar with Medicaid. They break even with Medicare.

Worse, the uninsured population in the San Luis Valley is at 28 percent. “Everything that’s screwed up and wrong with our healthcare system is magnified there,” he says. “I began to study earnestly. Why were there so many uninsured? Why were we going broke? Believe me, the last thing I wanted to do was decide single-payer was the answer. But until we take away the profit motive from the financing of healthcare, we cannot fix our system.”

Rocky notes that he’s not a natural enemy of health insurance. He was, in fact, the medical director of an insurance company for four years.

But he also sees the system from the point of view of a provider, from the point of view of his patients, and from the point of view as a business owner. “I’ve seen all four sides,” he says. “I’ve seen people die because they delay their healthcare because they couldn’t get insurance. If we’re going to do this, we should do it right.”

A couple years ago, the Cortez area state legislator, Mark Larson, called Rocky and asked him to write a single-payer bill that Larson could take to the legislature — just to begin a dialogue. Rocky wrote a bill, and after Larson saw it he phoned Rocky. “Are you nuts?” he asked.

Larson didn’t want to introduce the bill after all, but he did want to establish a Colorado commission to study reform. Deanna Hanna and Anne McGihon also worked to pass that bill, Senate Bill 208 — thus the 208 Commission. “Instead of a commission to study single-payer, it became a commission to study healthcare reform,” Rocky told the commission. “I think that’s great. Between all of us we’re going to come up with a solution. The choice isn’t between right and wrong, left or right, but values. Do we value everyone having healthcare? Or are we going to continue to value Wall Street more than that? Don’t get me wrong — I value Wall Street too. But there’s something else that I see beyond my own 401k. Beyond that is the health of Colorado.”

The commissioners’ first questions were centered on profit. Barbara Yondorf, senior program officer with the Rose Foundation, asked if the Health Care for All Colorado Plan — which is titled the Colorado Health Services Plan — was like traditional Medicare for all.

“Absolutely right,” said Rocky.

Steven Summer, executive director of the Colorado Hospital Association, confirmed that profit was eliminate from financing but not from delivery of healthcare.

Summer also noted that if everyone were on Medicare, we’d have a bankrupt system. Rocky agreed that was the case, but only because Medicare dollars come out of general funds and because it has to work in our current flawed system.

Steve ErkenBrack, a West Slope commissioner with a non-profit health insurance plan, went back to the question of profit. “Do you envision removing all profit, so there would not be for-profit hospitals?”

Rocky reassured him that there would still be for-profit hospitals, providing a core set of benefits for every Coloradan. Those benefits were based on Medicaid benefits — which are actually very good, albeit with very bad funding. “I would say that most of you with private insurance don’t have coverage as good as Medicaid gives.”

Elisabeth Arenales, director of the Colorado Center on Law and Policy, asked about the benefits package. “My sense was that benefits might fluctuate, depending on the budget,” she said.

Rocky agreed that might be the case, but that the Colorado Health Services Plan had to begin somewhere. “We may find that we’ve saved so much more money that we can offer more benefits,” he said. “The point is that it won’t be the legislature deciding what the benefits should be, and we’re not going to have six board members of an insurance company deciding that they’re not making enough money, and cutting benefits.”

The Colorado Health Services Plan will be administered by a publicly accountable board.

Arenales asked what the thinking was on dental and eyeglasses.

Rocky agreed that those items should be in the plan.

Lisa Esgar, senior director of Operations and Finance, Colorado Department of Health Care 
Policy & Financing, pointed out that Medicaid benefits were good for children, but not good for adults.

The back and forth was lively and continued until Lindsay, the commission’s chair, urged the Lewin representatives to present their analysis on the plan, which would answer many of the group’s questions.

That analysis and the rest of the analyses aren't yet at the commission’s website, but baseline material is.

Commissioners did ask the inevitable questions about what if the federal government wouldn’t cooperate with the program. Lewin agreed that to make the Colorado Health Services Plan work, all the government dollars going to other plans would have to be captured.

ERISA came up as well. That’s the 1974 federal law that keeps states from requiring that businesses provide benefits for their employees — so that national employers wouldn’t have to offer a different set of benefits for worker in each state,

“We’re going to make an assumption that this will go forward,” said Rocky. “We outlined and addressed the ERISA concerns in the proposal. If we’re going to have a single-risk pool, we have to have a single-risk pool. To let large companies take their young healthy employees and carve out a place for themselves defeats that. We can’t be scared of the ERISA boogeyman.”

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