If Vermont is #1 in health care, this country's in big trouble

Mount Pisgah, diving into Lake Willoughby, way up noth

Vermont, my chosen and beloved place of residence, took the top spot last week in the Commonwealth's "State Scorecard" for healthcare, which ranks states based on access, quality, costs, and health outcomes.

For people who live elsewhere, this report adds one more thing to add to the list of Things That Make Vermont Cool. (This is a jump up from second place in the 2007 scorecard.) For people who live here, this report raises amazement -- and the feeling that it must be very bad indeed everywhere else.

Vermont's health system is a mess. Our costs and premiums are high and rising. Almost 15% of adults under 65 lack insurance, and many, many more are uninsured. As elsewhere, insurers here routinely obfuscate, bamboozle, delay, and just plain refuse to give requested documentation when questioned about denied claims. And the cost of insurance is driving businesses and homeowners to the brink of failure, even as they provide plans that pass more and more costs to employees who often earn low wages.

Some of the health-care reform measures passed in the last decade or so have helped -- if helping means slowing the damage. The most significant are a ban against cherry-picking, the requirement that people can't be refused insurance because they've been sick before, and better subsidies and access programs than most states have for the poor or not-so-well-off. This is the sort of patchwork approach that, say, the Baucus bill takes. And it is not working. We may be rising in the national rankings. But we're worse off now than we were 5 years ago.

The report spells out Vermont's strong and weak points pretty well. We rank in the top ten in prevention and treatment (3d), equity (2d), and "health lives" (8th).

The equity comes from programs that give the poorest access to fairly cheap health insurance, through the state's Catamount program, and, for children, through Dr. Dynasaur. Those programs, however, don't much help the expanding group of middle-class people and businesses. (Catamount, perversely, is not eligible to those who already have insurance or who have had insurance over the previous year, unless the plan deductible was over $10,000 -- a hugely risky plan for someone on limited funds.) And while coverage of children is good, at 93.4%, that's down from 95% three years eariier -- an alarming trend.

The percentage of Vermonters who saw their doctors for routine physicals in the last 2 years also dropped, from 87 to 84.4%. And 10 percent of Vermonters didn't make doctor visits they needed to at some point in the past year because they couldn't afford it.

Even in areas where we improved, we're doing poorly. A few:

Adults 50+ receiving recommended screening and preventive care: 49.3%
Adults diabetics getting recommended preventive care: 55.3%
Children 19-35 months getting recommended vaccines: 79.8%
Children getting both a med & a dental visit in past year: 79.4%
Children who received mental-health treatment they needed: 79.4%

Our premiums for enrolled employees, meanwhile are $4,900 -- 4th highest in the land, though our incomes rank in the middle. This partly explains the diminishing access. As premiums rise, fewer employees are covered, and their coverage leaves them responsible for higher deductibles, which makes them less likely to go to the doctor. The costs are rising, in other words -- and their power to discourage needed visits grows even more.

Finally, and most painful to consider, our infant mortality has risen from 4.4% in the 2007 scorecard (a number at least close to that of most European countries) to 6.5%. This is clearly not due to diminishing medical capacity or skill. It's due to reduced access to prenatal care and quality primary care.

Meanwhile, this is a business disaster. Both large-scale and small-scale business surveys make it clear that the rising cost of insurance is hurting Vermont businesses terribly. The Vermont Businesses for Social Responsibility found that -- our #1 Commonwealth ranking notiwithstanding -- the #1 concern of businesses in the state is rising health costs. A small, informal survey I helped do of Montpelier-area businesses found the same thing. As one merchant here put it, "The costs are rising fast and are beyond my control. It's a businessperson's nightmare." And this at a time when his revenue, like that of most small-business owners in the state, are falling or flat.

I don't mean to diminish Vermont's accomplishment in providing better health care and coverage than most of the country does. The steps we've taken, while half-measures to be sure, reflect the state's essential decency and civility. But they're not enough. Even here, the trajectory is toward less access, higher costs, outcomes that are flat or declining, and a cost burden that will drive businesses out of businesses and more individuals out of their policies and, in some cases, their homes. Vermont has many honorable distinctions. But curing the healthcare problem is not one of them. We're just better than other states at slowing the bleeding.