[Rushtalk] Colorado Pushes for Universal Health Care That’s Governed by the People
lynux at keepandbeararms.com
Sun Nov 15 10:23:35 MST 2015
Colorado Pushes for Universal Health Care That’s Governed by the People
Oct 23, 2015
First pot, now health. In November 2012, Colorado voters approved a
ballot initiative that made recreational use of marijunana legal,
despite a federal ban. In November of next year, the state will have the
opportunity to lead the way again—this time, by opting out of Obamacare
and replacing it with ColoradoCare, a universal health care system
governed by those who rely on it. Proponents presented far more than the
requisite 99,000 signatures required to put the initiative on the 2016
ballot in Denver today, though they must be verified in the coming
ColoradoCare proposes a model that covers every Colorado resident. A tax
on income and employers would replace insurance premiums, but the
revenue wouldn't be subject to the whims of legislators; instead, it
would go directly to a fund overseen by trustees whom the recipients
choose. In this respect, it would be a cooperative-like system
accountable to everyone in the state, independent from the rest of the
government and enshrined in the constitution.
Proponents argue that ColoradoCare will mean better, more accountable
care at a lower cost. Opponents, including the Koch brothers-funded
Advancing Colorado, say it will be the Obamacare rollout on steroids.
But by combining conservative irritation with the Affordable Care Act
with liberal ambition toward universal coverage, it may actually have a
chance in a purple state like Colorado.
Colorado, also, has a history of building practical, cooperative
infrastructure. When energy companies failed to bring power to the
state’s rural areas quickly enough, communities set up electricity
co-ops to power themselves. Credit unions are plentiful. Cooperative
business models accommodate both community-mindedness and the state’s
Irene Aguilar, a physician and state senator, is the chief architect of
ColoradoCare’s unique cooperative approach and one of its leading
spokespeople. I sat down with her at an ice cream shop in Louisville,
Colorado, to learn more.
Nathan Schneider: What brought you from medical practice to the state
Irene Aguilar: I was appalled to see how much we were spending on health
care. I often think of one woman in particular who was about 42 and
working as a secretary when she first saw me. Every year I’d drag her in
to write her prescriptions, and she’d say, “I can’t really afford
these.” Because of this, her numbers showed that she was not doing very
well at managing her disease. By about 50 she had renal failure, and she
qualified for Medicare. I couldn’t help her take her medicines, and soon
we were paying $70,000 a year to give her dialysis. Because she was on
dialysis three days a week, guess what—she couldn’t keep her job, and
she ended up on Medicaid. This was a woman who had been working. She
went on, in her 50s, to have heart disease, and she had a leg amputated,
and at 60 she was dead. That is the real human cost of the backward way
in which we deal with our health care system.
It was so much more expensive to pay for her to get dialysis, to get all
those heart procedures, to lose her leg, and to be on welfare than it
would have been if we kept her on her diabetes medicines at the age of
42 and let her control her disease. It’s possible to have an alternative
that is both fiscally conservative and socially just; it would be
win-win in my mind.
Schneider: How did you start to entertain the possibility of an
alternative like ColoradoCare?
Aguilar: I worked for 28-years-plus at Denver Health, a county hospital,
doing primary-care internal medicine. In 2007, Colorado had something
called the 208 Blue Ribbon Commission for Healthcare Reform. The four
plans it considered included a single-payer health care plan, and the
commissioners created subgroups to consider how the plans would impact
certain populations. Since my daughter was disabled, I applied to be on
the vulnerable populations task force. We learned that if we adopted the
single-payer plan we could have everyone covered and decrease spending
by $1.6 billion a year.
Not knowing anything about politics, I assumed that of course the
commissioners would pick that one—and then quickly found out how much
money there is in health care and how many self-interested individuals
were in that pot. I began learning more about the political aspects of
this that I needed to be more aware of. In 2009 we tried to run a
single-payer bill through the legislature, but the governor managed to
kill it. I ran for office in 2010 in order to concentrate on this. Our
setbacks gave me motivation to listen to the feedback and see we could
to modify this and make it more consistent with Colorado values.
Schneider: How did the initial proposal begin to evolve into
Aguilar: In 2009, Atul Gawande published an article in The New Yorker
called “The Cost Conundrum.” He profiled the impressive health outcomes
in Grand Junction, Colorado, alongside those of McAllen, Texas. I went
and visited with people in Grand Junction to learn more about what they
were doing differently. There, [insurance company] Rocky Mountain Health
Plans collected all the payments and paid providers the same, no matter
who the individual patient’s payer was. They paid them about 80 percent
on fee-for-service and kept about 20 percent to be given on a reward
basis based on quality of care and patient satisfaction. Unlike my
experience as a provider, providers there did not have a disincentive
against seeing certain people because of the insurance they had.
ColoradoCare is sort of a blend of Rocky Mountain Health Plans and
Schneider: A lot of people seem afraid of entrusting health care to the
government—“death panels” and so forth. Does the Rocky Mountain model
get around that?
Aguilar: Rocky Mountain Health Plans, at the end of the day, is still an
insurer. In ColoradoCare, we’re all putting our money in, so in some
ways it’s a cooperative. But it’s different from a cooperative because
you don’t have to put money in if you don’t have a lot of money. The
pure cooperative people tell us to stop calling it a cooperative, both
because it’s mandatory and everybody doesn’t pay the same. But we like
to call it a cooperative because the board is accountable to and elected
by the people in the state.
Schneider: Tell me about where that money comes from.
Aguilar: You collect the funds through a premium tax—a 6.6 percent
employer tax across the board and a 3.3 percent individual tax. If
you’re self-employed, it’s the whole 10 percent, but because it’s tax
deductible it ends up being less than that. The funds are collected
through our taxes, but they’re transferred into a separate authority
that is run by its own elected board of directors.
Schneider: What does that revenue buy?
Aguilar: We had a fiscal analysis done by Gerald Friedman, an economist
at UMass, Amherst. He anticipated that with the Affordable Care Act,
health care would be about 19.4 percent of the gross state product, and
if we were to switch to this model, it would be closer to 15 percent. By
Obamacare standards, the level of care would be the very top—Platinum
Plus—covering 90 percent of your total health costs. We added in no
copay for primary care and low copayments that the primary-care provider
can waive if necessary to prevent longer-term costs. We also had it
priced for everyone in state, regardless of documentation status, under
the knowledge that we would not be turning people away for emergency
care, so it made more sense to have up-front preventative care available
for all the people who lived in the state. Vermont’s single-payer policy
imploded because it was way too expensive for them. It’s a small state.
But we have the numbers.
Schneider: Do you think Colorado’s more conservative voters will go for
Aguilar: There are people in the legislature, primarily Republicans, who
focus on what is and what is not government’s responsibility. They
really don’t want health care to be government’s responsibility. But I
was invited to present the initiative in Glenwood Springs on the Western
Slope, which is historically pretty conservative. I ate at a cafe there
where all the waitresses carry guns. I was impressed, though, with how
well people in small communities like that understand how the current
system works against them. Our rural areas have significantly higher
rates for their plans and lower benefits. When somebody in those
communities is sick and can’t get the care they need, it’s somebody
people know. They asked me a lot of questions, and they seemed to like
my answers. I didn’t sense any hostility.
Schneider: What will the strategy be for passing this initiative?
Aguilar: I think it will be really important to involve doctors and
nurses, making information available in their offices and ensuring that
they know enough about it to answer a few basic questions or refer
patients elsewhere. Of course, there are people who make billions of
dollars off of our dysfunctional system, and they will spend millions of
dollars trying to convince medical professionals that this will be more
harmful to them than what they have right now.
Schneider: Do you know who those opponents are yet?
Aguilar: I don’t. I would expect Big Pharma and for-profit hospital
systems—maybe all hospital systems. It’s hard to tell the for-profit
from the nonprofit these days. People often ask about what happens to
insurance companies. I answer, “What happened to vinyl record
companies?” It varies. An HMO like Kaiser could continue to exist
because they would get a monthly payment—it just wouldn’t be from an
employer, it would be from this premium tax. An insurer like Rocky
Mountain could continue to be an administrator for the system.
I actually had a lobbying breakfast with United Healthcare. They said to
me that when Vermont passed its plan, they spoke to the governor about
wanting to be the administrator for the Vermont health plan. So I don’t
think that insurers would go away, but they’ll have a different kind of
role, because there is still fiscal management to be done, just as with
Medicare. Estimates suggest that this kind of plan will create more jobs
in the health care industry in terms of delivering service, but it’s a
shift in what kind of jobs provided. The overall savings also means a
certain amount of extra income that’s available in the economy to do
things other than health care.
Schneider: What do you think the chances are that this plan will
Aguilar: Colorado is usually seen as a leader, as a state that is trying
to do the right thing. I think there’s sort of a sense that it wouldn’t
be unusual for a state like Colorado to try and do something new, since
we’ve been so proactive in other ways. I give it at least 50-50, and the
optimist in me gives it 52-48.
There’s this documentary that was done for PBS by T.R. Reid, who is part
of our coalition, called Sick Around the World. In one scene, he’s
talking with a former president of Switzerland, and she talks about how
in 1994 they passed universal health care by a narrow margin. There were
many people who were so angry that they said they were going to leave
the country. Ten years later, there were very few people who were not
thrilled with the program. Knowing what I do about health care, I can’t
help but hope that it will be the same in Colorado. There will be people
who put up a big fight, and when we beat them by the hair on our chinney
chin chin they’ll be furious. But in 10 years we’ll all be grateful we
took that step.
Editor's note: A previous version of this article referred to
ColoradoCare as "single-payer." While in some respects it is, in others
it is a hybrid that deviates from the standards many people associate
with single-payer. The phrase was removed to prevent confusion.
Colorado Pushes for Universal Health Care That’s Governed by the People
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