• Yeah, ’cause state-level plans never go national

    Andrew Sullivan quotes Kate Pickert arguing that Vermont’s single-payer system isn’t really a big deal:

    Vermont is not like the rest of the country. First, the state is home to only about 600,000 people. It’s not clear that the scale is large enough to test out a single-payer system and see if it could be instituted in larger states or nationwide. Vermont’s existing private insurance market is also unlike most other places. The state has very strict insurance regulation that has whittled down the number of private insurers selling policies on the individual market. Turning Vermont’s existing system into single-payer would be a huge change, but it’s not the same as a big state like California making the jump or a far less regulated state like Alabama.

    At first I thought this might be a joke. But it’s not.

    Let’s imagine I’d written this five years ago:

    Massachusetts is not like the rest of the country. First, it’s only home to about 6,500,000 people. It’s not clear that the scope is large enough to test out a mandate coupled with exchanges and subsidies and see if it could be instituted in larger states or nationwide. Massachusetts’ existing network of hospitals and insurers is also unlike most other places. The state already has a very low uninsurance rate, due to previous reforms, and a concentration of medical centers almost unparalleled anywhere else. Turning Massachusetts’ existing system into a universal one would be a huge change, but it’s not the same as a big state like California making the jump or a far less regulated state like Alabama.

    I’m not saying that as Vermont goes, so goes the nation. But, really, how silly would I look now, if I’d written this so declaratively just a short time ago?

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    • You would indeed look silly, but partly because MA is more like the nation than Vermont. Sure, we’re exceptional, but not nearly as much as Vermont.
      What the Vermont experience may lead to is other states, those that are larger and more representative of the nation, taking the single-payer plunge. Only then might we see a national single-payer plan get serious consideration.

    • I remember when MassCare passed being told that Massachusetts was the most liberal state in the nation (it was second behind Hawaii in the 2008 Presidential election) and THAT was the reason it passed universal health care. I was told it would never happen elsewhere.

      How’d that play out?

    • I guess it would depend on the context of why you hypothetically wrote these words five years ago. Did you write them to frame a test or as a proofpoint of something. For example you wrote:

      “It’s not clear that the scope is large enough to test out a mandate coupled with exchanges and subsidies and see if it could be instituted in larger states or nationwide.”

      Not surprisingly, no other state has tried any thing like Romneycare (I think California is trying something like it next year) and we’re still a few years away from the entire country trying something sort of like Romneycare (but only in the sense that the Patient Protection and Affordable Care Act uses many of the same words as Romneycare–mandate, subsidy, exchange, minimum creditable coverage, etc. )

      So assuming you were merely hypotthectially trying to frame a theory five years ago, the questions that we might be able to answer in another five or more years when the broader experiment concludes include:

      — How did a mandate do among a group not historically predisposed to healthcare insurance vs how it did in the state where healthcare insurance was invented and where people have always loved healthcare insurance (in the latter, Massachusetts, there was no statisitically significant change in the number of insured as a percentage of total population after five years)?

      — What was the effect of expanding a healthcare insurance subsidy program nationwide that had been underway in a demonstration environment under CMS waiver since 1997? (in the latter, Massachusetts, the demonstration had to be changed dramatically after the first seven years prior to Romneycare and the number of people that actually buy healthcare insurance that is not subsidized by tax dollars dropped by tens of thousands in the subsequent three years after Romneycare)

      — What was the participation by residents not receiving subsidies in heavily regulated exchanges nationwide vs. in the test environment? And what was the effect on their healthcare insurance premiums? (in the latter, Massachusetts, only about one-half of one percent of the population participated and the exchange idea did not appear to make premiums more affordable for the so-called merged market via grouped buying power as promised; the one half of one percent does not include those in the expanded Medicaid program allowed by waiver and mentioned in the previous question who also used the exchange to make their subsideized healthcare insurance policy choices even though they had to complete the traditional Medicaid means test and enrollment process, this group amounted to another couple of percent of the population)

      — How did these and all the other drastic changes to the market nationwide affect the 80% of people who had insurance but were not directly involved in the “reform” at first vs the 90%-95% who had insurance but were not directly involved at first in the test environment (in the latter, Massachusetts,
      – healthcare costs continued to soar
      – premiums continued to soar
      – co-pays and deductibles continued to soar
      – insurance choices were constricted
      – all other state-budget spending was decreased 20% while healthcare costs in the state budget increased 40%;
      – sales taxes were increased 20%,
      – doctors closed practices — literally and figuratively — and wait times increased;
      – doctors increasingly would not only not accept the subsidized insurance from the Medicaid expansion (called Commonwealth Care) but would not accept even full-price insurance sold on the exchange (called Commonwealth Choice)
      – the “most liberal state in the union” signed public-employee-union collective bargaining laws more constrictive than Wisconsin’s

      I guess we won’t know for years how that played out,