March 20th, 2018

Universal Primary Care: Its Time Has Come

Dear Editor:

Way back in 1990 I treated a patient in the inner city of Buffalo. He was an electrician in his mid-thirties who had waited until complications from his diabetes rendered him blind and in end stage kidney failure. He waited because he had no insurance. At the point I first saw him he was unable to work and was finally eligible for Medicaid. Unfortunately the diabetes had taken its toll on his health and he was never able to return to work. He died several years later. He was one of many uninsured patients I took care of.

Fast forward to just last week when a primary care colleague of mine saw a patient in her early 40s who had an enlarging mass in her breast which had been bothering her for more than a year. She finally sought help when the mass began bleeding. It was diagnosed as cancer and had already spread to her lymph nodes. Why had she not sought help when her symptoms first appeared? She was uninsured. A working Vermonter who could not afford insurance and made too much money to be eligible for Medicaid.

These are only two examples of the many catastrophic cases I have seen over the years.. And they are just the experience of one physician. I am not alone. Every health professional I know can give dozens of examples of patients who delayed care and suffered the health consequences. Some have died as a result of delays in seeking care. Many of them were “insured” but had huge deductibles they could not afford to pay, which in effect rendered them uninsured. They too have often delayed care. In almost 30 years we have made so little progress.

What to do? In 2011, Vermont passed legislation that would have led to a comprehensive publicly funded universal health care system for all Vermonters. We should begin taking steps towards implementing that system. Governor Shumlin and the legislature were hesitant to change the whole system at once. Administration studies showed that $2 billion in private spending on insurance and out of pocket costs would be replaced by taxes in order to cover every Vermonter. A tall order yes. But starting with a sector of care and building up from there is a lot more doable. There is a bill (S53/ H248) that would establish a fund that would ensure that every Vermonter had first dollar coverage for primary care, outpatient mental health and substance abuse services. That means, no out of pocket costs for those services. The cost? $200 million in new taxes. Sounds astronomical until you consider that this is about 3% of what we will spend on health care this year . Health care costs will reach $6 billion in total which is about $17million per day. So the $200 million needed to establish a universal primary care system for everyone is a bit less than 12 days of health care spending.

Access to primary care when available to the whole population has been shown in numerous studies to reduce ER visits, to reduce rates of hospitalizations, to improve the health of the population, increases life expectancy, lowers infant mortality, lowers heart disease mortality, lowers premature mortality from asthma, emphysema and pneumonia; patients get earlier detection of breast, skin and colon cancers. (1) Need I go on? If there were a medication that could do all of that , we wouldn’t hesitate to invest in it.

S53 – a bill that moves us towards universal access to primary care is sitting in Senate Health and Welfare and the committee will be taking testimony this coming week. It’s parallel bill H248 is in House Health.

I can’t help but think how the cancer patient mentioned above might have fared had she had free access to primary care. I doubt she would have delayed seeking care. We need to move forward with universal primary care as the first step to a comprehensive health care system for all Vermonters.

Dr. Richter is a practicing family physician and lives in Montpelier.

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