 Dr. Deb Richter, it's just a pleasure to have you here with us in the Zoom world. Thanks so much for joining us. I'm happy to be here, Lauren Glenn. So the other day we got a press release which said non-profits ask the state to end one care affiliation and urge resources to be shifted to basic health care needs. And so I wanted to talk some more about that because as just kind of a regular person, I'm really not that in tune with what one care is and why this is important, but I thought that if we talked, I would be able to understand better what some of the issues are. So maybe we can just start with just that kind of the very beginning, you know, you're an active doctor working during this period of time trying to help a variety of different kinds of people. What kind of challenges do you find that the health care financing system puts in your path as you try to do your work? Well, the biggest problem I see is the insurance coverage that people have. And the studies actually show us that 40% of remoners, four and 10, they're basically, they're so poorly insured that they're effectively uninsured. So they have deductibles of some of them, five, 10, I had one patient with $12,000 deductible, which means they pay $12,000 before they get a dollar's worth of care. And what they do, these patients is they tend to avoid coming in early in their disease and preventively to prevent complications because of cost. And so that is to me the biggest problem that we have right now. In addition, 7% have no insurance at all, and that's rising. And particularly with COVID, we certainly want to see people earlier in their disease. We certainly want to help prevent, for example, people to come in and get flu shots. We want them to get flu shots to help prevent them getting pneumonia from the flu during the winter and complicating the whole emergency room situation. So that to me is the biggest issue right now is the cost to the patient and the lack of adequate insurance. Well, it's interesting you say that because I think we're under the impression that most Vermonters are covered and we have affordable health care, but it sounds like that is not the case. Right. And the thing is being covered. There are a lot of people that have insurance in quotations. But does that really cover you if you have to pay $5,000 every single year, the first $5,000, and you don't have $5,000? You're effectively or functionally uninsured. So we're assuming that we're basically categorizing those folks as having insurance, but their insurance is they're effectively or functionally uninsured. So that really is about 47% of the population. And is that largely because we're insured through our businesses and businesses offer, you know, the basically policies that they can afford to their employees? Yes, that is one of the main reasons that which, you know, essentially if an employer pays for health insurance for their employees, the cheaper policies are one with higher deductibles. And those are the ones that that they can afford at this point. I mean, years and years ago, many, many businesses, I think it was 66% had pretty generous policies that covered almost everything that a patient would need. And now you've seen over the years, insurance policies getting slimmer and slimmer and slimmer in terms of what they cover in terms of first dollar coverage. So there are very few people that have decent health insurance policies at this point, including labor, their policies are getting slashed as well. And this is not going to get any better. This effectively forces the patients to ration their own care. And I suppose that's the point that the less the insurance companies have to pay. But downstream, what ends up happening is people are sicker and they die younger of preventable causes. We know this, we've been compared internationally as one of the worst in terms of dying of preventable illnesses. And that's because other countries cover most of the care that people need, particularly primary care, which by the way is the least expensive best investment a society can make. When we know that when people have primary care and they have, everyone has access, they live longer, the costs are lower, the quality is better, there's fewer hospitalizations that are unnecessary, there's fewer ER visits. All those things are paid for in general in other countries and they spend half as much as we do per person. So what is one care Vermont and why should the state sever its relationship with that private organization? Well, one care is a for-profit entity that receives money from essentially three payers. So Medicare, Medicaid, and Blue Cross. And what there are a certain number, tens of thousands of attributed lives. So in other words, people who are part of this one care, they receive a monthly payment that eventually goes to the provider. So essentially what it is, I guess in their own self description, is a group of providers that are there to hopefully keep people healthy and are responsible and take on risk for the health care of the people that are attributed to them. So one of the reasons that I think this isn't being discussed enough is because it's incredibly complicated. Most people I ask what one care is, they have no idea. And that is, I suppose, one of the reasons that there hasn't been more publicity about this. But one care's goals are probably, they have good intentions. Their claim is they want to lower overall costs. They want to improve quality. They want to reduce the fee for service. So in other words, they don't want doctors and hospitals getting fee for service any longer. They attribute that to the reason that we have high costs in health care. And their goal is to keep people healthy out of the hospital and then hopefully lowering the cost so that those savings can trickle down and then we'll be able to ensure more people. That is sort of the overall goal, which is again laudable. Seems like the good intention. The problem is we've had one form or another of an ACO or an accountable care organization since 2013. The newest version started in 2017 and it's a five-year contract. They signed with Medicare with the feds. And then the state signed the Medicaid contract. And then Blue Cross has another contract. So there's three different payers feeding into this ACO. And then the ACO pays the doctors in the hospitals and the other providers who are part of it. The problem that the organizations that signed on to this press release that we have is, first of all, it doesn't address access at all. So if you have a $5,000 deductible and your provider is part of one care, so your doctor or your nurse practitioner, it doesn't change your $5,000 deductible. So it still keeps people rationing their own care, keeps people from going in and getting being seen. So if it doesn't do the one thing that we know that improves the population's health, which is access to primary care and access in general, then what is the point of it? So it doesn't address that at all. So it doesn't improve your insurance. It doesn't change your deductible. It doesn't change anything. And it doesn't even include the uninsured. So that is sort of the main problem that we have with it is that, first of all, it doesn't address the most important thing was the patient being able to see their physician, especially their primary care physician and nurse practitioner. So understand it now? Yeah, I understand it now. So one care is a, if I'm just to paraphrase, it's a vehicle for the distribution of the states and the feds and the private insurers health care resources. Yes, it's basically a fixed payment. Again, this is a lot like HMOs back in the 90s. What they gave was a fixed payment to the, well, at that time it was to insurers. But in a fixed payment every single month for the 120,000 or whatever the number of attributed lives that they have right now, and they get a fixed payment and they're supposed to pay for most of the health care for those who are attributed to it. And that is sort of that fixed payment is supposed to go up at 3.5% a year. So the thinking is that if you get this capitated payment that you will, will doctors and hospitals will work harder to keep people healthy because they're getting this fixed payment and they get to keep the savings. So if they're getting, if they're getting a certain person, you know, dollar figure every single month and they spend less of it taking care of you, trying to keep you healthy, then they get to keep the savings. So the goal apparently is this all payer model, which again means that these payers pay on this fixed payment that goes up 3.5% a year and then puts this money into this one care ACO and then the one care pays out to the doctors and hospitals. So again, it's the thing to remember as well is that this ACO has an administrative cost on top of what we already spend in health care in the health care system, which by the way is one in three dollars goes for administrative cost in the U.S. health care system. That's actually 34%. So what's the benefit of having an ACO if it just adds another layer of cost? What was the thinking behind having these in the first place? Well, the thinking was that the problem in health care, the reason that costs were so high was that doctors were doing unnecessary procedures because they got paid for every procedure they did. That is the thinking. It was the thinking behind HMOs back in the 90s. And again, it's not a great way to pay doctors. It's not a great way to pay hospitals. I would admit that. But the problem is that if you look at other countries, Canada, Germany, France, Spain, all those other countries pay their doctors a fee for service reimbursement. And they are cost are half what ours are. So it's hard to make the argument that the fee for service is really the problem. So this fixed payment is supposedly going to give a fixed payment to the doctors and hospitals every month. And that fixed payment is fixed. So in other words, they won't get more money if they do more procedures. This is the theory behind it. The problem is that the reality hasn't matched the theory. And they have not lowered costs. The savings have not trickled down to average Vermonters who have $5,000, $10,000 deductibles. They have not shown that they've improved quality. And they definitely have not improved access. So we're really three and a half years into this. Should we continue, and essentially what's a failed experiment, is really the question Vermonters need to ask. What are they benefiting from it now? Because if you ask Vermonters, they're all saying, I need help now. I can't wait five or 10 years to see if this experiment will work or not. I need help now. I can't pay for my kids shoes. I can't pay for my mortgage because they're paying for healthcare. And so we need to fix the problems systemically, not just sort of this piecemeal approach. The other problem is, is that we put public money into this private for-profit entity and really can't trace where the money is going. And that should be a problem for Vermonters as well. So is there also a problem that the payments to the doctors themselves is, I mean, you said there's been a, you know, there's a steady payment that increases by a percentage. But in your press release, you said that one care is severely reduced reimbursement for primary care physicians. So that's happening also. Right. So the important thing to know is that the fundamental basis for one care was based on primary care. And their theory was that if people got good primary care, that they would then have lower costs and be healthier. And that's actually true. We know that. Again, the problem was that it didn't improve the person's health insurance. So it didn't, it didn't end up doing that. The money that was reduced was initially they had a number of independent doctor organization or practices that received a certain payment per month to participate in one care. Those payments were vastly reduced recently. And some of those primary care doctors actually dropped out. So the thinking was, in fact, I remember going to a lecture from one of the former CEO of one care, Todd Moore, who said this is going to be wonderful. We're going to increase payments to primary care, which will help encourage them to take care of their patients and give higher quality care, reduce overall costs, reduce complications. And in fact, this most recent move does exactly the opposite. So tell me about the other organizations who have signed on to this press release. It's quite a variety. The League of Women Voters, the Vermont Worker Center, Physicians for National Health Program, Justice for All. How did you get together? What's sort of, I understand that you share this in common, but what brought you together to make this statement and call for this? Well, we, we've all recognized how much that our, our attention to this one care is taking away attention to the fundamental flaws of the healthcare system right now. And the fact is, again, when you look at organizations, Physicians for National Health Program is advocated actually. And this is a, you know, a Vermont chapter of a national group advocated for a publicly funded single payer healthcare system for all Americans. And this is the Vermont group. Again, caring that everyone needs to be included, healthcare needs to be a public good. And we need to pay for it publicly, like every other industrialized country. The Worker Center has long advocated for actually single payer at the state level, and is recently advocating for expanding Medicaid. So again, it's about access. It's about people doing without people suffering now, not having to wait five or 10 years from now. Again, this is all about access in general. The fact is that the people are paying into the healthcare system vastly. Two thirds of healthcare is already publicly funded. So a lot of these folks who have these terrible insurance policies are paying into healthcare, paying for other people's healthcare and not getting the healthcare services themselves. So again, like legal women voters has been advocating for a publicly funded, they were advocated for the single payer act 48 that was passed in Vermont in 2011. So these organizations have all been about everyone being included. So everybody in nobody out everybody being included in healthcare and regarding healthcare as a public good. So is that the alternative position as a single payer system? The alternative position is essentially a publicly funded universal healthcare system. Our organization, Vermont healthcare for all advocates for starting with primary care and making that publicly funded for all Vermonters. So paying for it, which is a very, very small investment with a big payout. As I said before, we know that when primary care is available to people costs are lower, quality is higher, people live longer, they're in the hospital, they're hospitalized with preventable illnesses less. They have fewer ER visits. It's the best investment. It's the best bang for the buck. In fact, if it were a drug, we wouldn't hesitate to invest in it. And that is one thing that again, people are tending to avoid right now, because it's the one thing that everybody needs, whether you're healthy or sick, everyone needs a tetanus shot, everyone needs certain preventive screening services. And when something goes wrong, it's the first person they do call and they should call. How does the state extricate itself from one care? You've made this call to do so, but what actually are the steps to decommission this model and then pursue an all-payer model? Right. Well, the Green Mountain Care Board was originally the ones who signed the agreement with Medicare. So we're asking the Green Mountain Care Board to not re-up that. Essentially, this has been a failure. We need to go back to the drawing board. And we do know what does work. We have to stop doing what doesn't work and start doing what does work and helps for monitors now. So that is the one thing that we can't, as legislators, have no effect on what happens with Medicare. That is through the Green Mountain Care Board. But legislators have the effect of being able to say that we're no longer going to have Medicaid involved in this experiment. They do have, they hold the purse strings on that. Private insurance, they still can do it if they wish. We don't have any, you know, we don't have no sway over that. So those would be the steps. Essentially, legislators say no more. I mean, because the other thing to remember, too, is that who is paying for the administrative burden, essentially, of one care? Who's paying for that is actually the hospitals, which you may say, well, okay, you know, that's them. But when they can then charge more to private insurers, who pays for that? We do. Our premiums go up. So we're paying every single penny of this. This is all Vermonters healthcare dollars. It's coming from us. So when hospitals have to pay a couple million dollars each into one care's overall administrative structure, we end up paying that cost that comes from us in our premiums. And again, we end up with cheaper and cheaper policies, as we say, or leaner policies, and because that's all people can really afford. So this is what comes from us. So did you release this press release now because it's election season or there's this particular timing around this agreement? Yes, we felt that this needs to be something where people say to their legislators or the candidates, are you are you going to do something about this? Are you going to at least stop the piece that you can? And lobby essentially the Green Mountain Care Board to say enough is enough. This is a failed experiment. This is not working. And we need to we need to stop it. Yes. So you've worked a really long time in this field, in this work, I mean, not only as a doctor, but as an activist and an advocate for all pair systems. How do you keep up your hope that there will ultimately be a change? I keep up my hope when I take care of people that are suffering needlessly, because they don't have access. I keep up my hope because, unfortunately, you need a critical mass of middle class voters that say enough is enough. And we need to do what every other industrialized country has done and have a publicly funded program for everyone. I look at all major change in society, civil rights, women's right to vote. All of those things took decades. And I see this isn't really about me. This is really about what I can do to make a change and and educate people, educate voters, educate legislators. I am hopeful that it will work because it's the only thing that will work. We need to we need to listen to the evidence and look around the world. Every other country has figured this out. What we do is we tend to when, you know, back in the 90s, when when this was debated in Vermont, what did what did Governor Dean do at that point? Said, let's put all our hopes into HMOs. Beaver service is the problem. Health maintenance organizations is the solution. We don't need to do single payer. We don't need to do a publicly funded universal health care system. It's a bait and switch, quite honestly. And this is another bait and switch. That's what this is. And we, you know, people, it's so complicated that most people are just swamped by it, overwhelmed, including legislators, that they tend to say, it's too much for me. I trust you. It also removes them from having to make the decision. If the ACO says, don't worry, we'll lower costs, we'll take care of this for you. Just send us the money. We'll be fine. Everything will be fine. We'll take care of it for you. And that's again what happened back when when we would discuss this in the past. So when when ends up to be enough public pressure, and when people understand that, you know, we've exhausted every other possible bait and switch, we will get changed. There really will be no other way to do it. Because it is something that everybody needs at some point in their lives. We'll need health care. And you want to make sure it's there for you. Because that's the other piece. Because that one of the hospitals in Vermont that was funding one care, millions of dollars, had to drop their addiction medicine program. One of the measures that the feds are looking at is have we reduced overdose deaths and have we reduced suicide? Now why would you drop a program that was treating hundreds of patients for lack of $500,000? You're paying millions into this one care. And you drop essential programs Springfield drop their OB program. There are so their programs that are basically going away that are serving Vermonters because they're paying into this administrative structure one care. So what action can people take to support this action that you're asking for? What kind of where do you see the public participating? You said voting, but who do you vote for? And what other kind of political action are you looking to mobilize? Well, one thing we know is legislators will tell you that they are more inclined to vote for against something if they get 10 phone calls, 10 phone calls. And that is something that Vermonters can do. We have amazing access to our legislators. It's just one of the wonderful things about Vermont. And so they can they can call their legislators and say, we want you to vote against this. We want you to influence your colleagues. The other thing is educating them about what it is and what it isn't. This is not solving the problem. This is not helping Vermonters now. And we can't wait five or 10 years for, I think the current CEO said we need to wait and we're not going to see results right away. We need to wait five years. We need to wait 10 years. We can't wait. This is this is catastrophic for so many Vermonters who are doing without right now. And just in closing, we are in this special period of the pandemic. What have you been observing as a doctor? I mean, I think one of the things you did mention is people are delaying getting coverage or getting service, medical service, because of the high deductibles. But is this exacerbated by this period of time? So far, I think we're in kind of a unique spot right now. Initially, we saw a big cutback and people coming in due to COVID. In other words, everyone canceled. It was it was catastrophic for several weeks. When it became clear that that we were handling it correctly, according to the evidence, more and more people of 95% of the people we're seeing now are in person in our office, at least. So I'm seeing that because we've handled COVID in an appropriate way, we're not seeing the same circumstances that people are seeing in other places. I'm seeing more, you know, again, people avoiding care because of the cost. The whole COVID thing, it's not as much of an issue right now. I am concerned and very concerned about the flu season, however, which may start as early as December and how to handle that. I'm concerned that we're not going to have enough personal protective equipment. Health professionals won't. So those are the things that concern me in the near future. And are you advocating for people to get their flu shots? Absolutely. That's the first thing we ask them when they come in. And we have in our clinic, in our health center, we have flu clinics where that's all we do, you know, for the whole day for patients is have them come in and we see other patients as well. But we have this clinic where people can just walk in and get their flu shot. So we've been pushing that in a big way for anyone over the age of six months. And is it safe to get flu shots in the drug store, sort of these random places like the supermarket? Does it matter? Yeah, it's absolutely appropriate and fine for people to do it that way. Wherever they can get their flu shots is, and keep in mind that the state pays for the vaccines. And so no one should have to pay for a flu shot. If they have no insurance, they should not have to worry about getting a flu shot. They can get a free flu shot, they can call the health department. And just a sort of final question. I read an article, I think maybe it was in the Atlantic talking about this epidemic, pandemic that we're in, the COVID ultimately becoming kind of like a flu that, you know, it's never going to go away, it's going to become part of the infections that we have to deal with on an annual basis. Do you see it playing out that way? You know, I must say that I don't know. I think it's one of those things that's evolving and that we're learning a lot. Whether this will be something that we will end up seeing every year, it's hard to say. I mean, you know, there are illnesses that we've managed to abolish. Once we get a vaccine, a reasonable, reliable, safe vaccine, that may actually eliminate, you know, if you look at things like polio, we rarely see polio. Where we see things like measles, we see it in people who've not been immunized. So yes, it may be that if we don't get a safe, reliable vaccine, but quite honestly, I don't know if we really know that yet. Yeah. And do you think that, how high is the bar of vaccinating as many people as possible in Vermont for COVID versus the flu shot? Is it the same kind of thing we need to do? Or is it a two-step process? Or, I mean, I know we don't know exactly, but I'm just wondering, like, how big a deal is it to vaccinate the state of Vermont at that time? I think we have the capacity to be able to vaccinate every single Vermonter who's willing to be vaccinated. That is something, you know, again, it depends on supply. It depends on safety side effects and things like that. But I do trust that we will end up with a safe vaccine and that people will be able to access that. I think that'll be something that will be covered, that people won't have to worry about the cost of that. Well, Dr. Deb Richter, thank you so much for your activism, your care as a doctor, and for spending some time with us today. We really appreciate it. I'm happy to do it, Lauren Glenn. Take care. Thank you.