Single Payer Isn't Dead: How States Are Keeping the Movement Alive
By Michael Corcoran
truthout | Op-Ed
Monday 02 August 2010
The grassroots single-payer movement in Vermont reflects the growing belief that the fight to make health care a human right must come from the states. But will the passage of federal reform get in the way?
When Barack Obama signed the Patient Protection and Affordable Care Act in March, many thought the long and tedious stretch of legislative wrangling and endless debates about health care reform had come to an end and the prospects for further meaningful reform would be shelved for years or decades.
But while the country was consumed with the incredibly narrow debate in DC, dictated largely by drug and insurance lobbyists, anti-abortion politicians and a collection of conservative Democratic senators with close ties to the insurance and drug industries, another significant health care battle was taking place hundreds of miles to the north, in the tiny little state of Vermont, population, 600,000. By the time Obama signed a federal health care bill into law, the Vermont Workers' Center was almost two years into its "Healthcare is a Human Rights campaign," which had the unambiguous goal of abolishing for-profit health care in the state and passing a statewide, single-payer health care system that guarantees health care as a right to all Vermonters. In May, the Vermont Legislature, under constant pressure from this growing people's movement, passed a bill that could possibly lead to Vermont being the first state to pass a single-payer health care system, setting up what could be a crucial phase of the fight for health care justice.
If Vermont is able to break this ground, the implications could reverberate well past the borders of the Green Mountain State. The fight for statewide single-payer here reflects a growing belief among health care activists that the path to a universal public system, will not take place in Washington, DC, where moneyed interests have a death grip on the legislative process, but through state houses across the country. Further, the effort in Vermont may prove to be the first test case of the "state innovation" language in the federal reform bill and could indicate if Obamacare will ultimately serve to enable statewide single-payer systems or if it will kill them. Finally, the movement in Vermont also highlights a fascinating debate over the rhetoric of health care reform. Should advocates point to the significant savings associated with single-payer health care and the unsustainability of the current system? Or should the primary emphasis view the fight for public health care as a matter of basic human rights?
Federal Reform: A "Distraction" to the Fight for Health Care Justice
For the last year, James Haslam, long-time director of the Vermont Workers' Center, paid only scant attention to the massive fight in Washington over health care reform. "In many ways the argument in Washington was something of a distraction for us," he said in an interview with Truthout, from his home in Burlington Vermont. "The debate gave some people the impression that healthcare would be fixed. But to us it was clear that what they did in Washington does not address the crisis, because they preserved the current profit system. We thought it was important to define healthcare as a human right."
Indeed, the reform that eventually passed in DC is memorable not only for its scale - some $900 billion in federal spending over ten years - but also the fact that it failed to fundamentally change the private, for-profit basis of the United Sates woeful health care system, which leaves more than 46 million without insurance and is the most expensive in the world. Not only did Congress fail to even consider some kind of public, guaranteed, universal system, the likes of which exists in every developed nation on the planet, but progressives could not even muster through Congress a minuscule "public option," that had been understood as the major consolation prize that would ensure liberal/left support for Obama's health care reform.
So the Workers' Center, unlike many progressive organizations, chose not to rally on behalf of federal reform and instead dutifully set out to "get people to think about healthcare as a human right," as Haslam describes it. The first year of the campaign began ever so cautiously. Rather than narrowly focus on a specific piece of legislation, or even the details of single-payer health care, organizers simply made their way across the state, passing out surveys and listening to stories from those who had been left behind by the health care system. Many of them were from the tens of thousands of uninsured Vermont men, women and children.
The group held hearings in every corner of the state - from St. Albans to Brattleboro - and heard gut-wrenching story after gut-wrenching story: women who stayed in abusive relationships so their children would not lose health insurance; a hobbled logger who continued to work one of the world's most dangerous jobs on a bad knee with no insurance ("life is scarier when you step out of the woods," he said); families with insurance still facing bankruptcy, because the coverage did not protect them from financial ruin.
"From talking to people, we came to learn that people in Vermont really did believe that healthcare was something that everyone should have and that it should not be treated as a commodity," Haslam said, noting that 95 percent of those polled by the Workers' Center, believed health care to be a human right.
A Different Approach
At the core of every action and statement made by the Workers' Center, was its emphasis on human rights. It is noteworthy just how much this approach differed from reform efforts in Washington. While Democrats in DC were obsessing over "bending the cost curve," cutting the deficit, and other technical (though vitally important) elements of health care reform, in Vermont, the bulk of the rhetoric used avoided that approach. The Workers' Center often cited the Universal Declaration on Human Rights and held events to correspond with its anniversary.
Anja Rudiger, the Right to Health Program coordinator for the National Economic & Social Rights Initiative, has assisted with health care campaigns in Vermont and elsewhere. She says the language of human rights is being adopted by an increasing number of organizations and individuals as they attempt to build movements.
"A human rights focus puts humans at the center. It is about people's experiences and about people's needs and it is a very powerful approach to get people in all kinds of communities involved," she said in an interview with Truthout.
This approach may seem simple, but it does take discipline. After all, the finances of statewide single payer remain persuasive. According to a study commissioned by the Vermont Legislature in 2006, Vermont would save $51 million a year if it switched to single payer. Still, Haslam insists, the focus should not be on cold economics. "It's important that the debate over healthcare reform not only be about how to finance a system," he said.
The difference in rhetoric - and policy goals - is not the only reason why reform in Vermont is so different than in DC. While reform in Washington was largely hammered out in closed-door meetings between politicians and industry officials, in Vermont, the drive for change has come from the bottom up - at rallies, committee hearings and parades. "In Vermont, a few hundred votes can make the difference for a politician," Haslam said. "The people have a much larger voice on what goes on than in Washington ... we had people from our campaign at almost every single related committee meeting, telling their stories."
Building the System
Even in Vermont - home to a self-identified socialist senator and Ben and Jerry's ice cream - passing single payer will be no easy task. A bill that could have been a stepping stone to single payer was passed in 2005, only to be vetoed by Gov. Jim Douglas. This led to a private-public compromise, Catamount Health, that has been hampered by state budget issues, ever-rising premiums and low enrollment.
With Governor Douglas not seeking re-election, single-payer activists are no doubt keeping a close eye on the 2010 Vermont gubernatorial race, which is expected to be a battle between Vermont's conservative Lt. Gov. Brian Dubie and the winner of a hotly contested democratic primary. Organizers express optimism that any of the Democratic front-runners will be favorable to their position. Senate President pro-tempore. Peter Shumlin, who in July received a key endorsement from former president of Physicians for a National Health Program Deb Richter, may be the most friendly to the cause. In a letter to the Barre Montpelier Times Argus, Richter and other health professionals called Shumlin, "the only candidate who has shown unwavering support for a publicly financed universal health care system in Vermont." (A similar dynamic exists in California, where the Legislature has passed single-payer bills twice in recent years to have them met with vetoes from Gov. Arnold Schwarzenegger, who is termed out in 2010).
"Whoever is the governor, we think we can work with them to pass a bill," Haslam says, confidently. Nonetheless, others have lingering fears that the Legislature will punt by passing another half-measure, or using federal reform as an excuse to hold off on anything dramatic. Others fear Dubie, who polls ahead of all the Democrats, may win the election and simply veto any meaningful reform.
But despite the many political obstacles, the Workers' Center continued to fight, and at the end of the 2009 legislative session, got behind S.88, which calls for three health care systems - all to be based on human rights principles - to be designed. Among the three systems to be designed will be a single-payer system and organizers' hope is that S.88 will lead to a new health care system in the near future.
While the grassroots movement may be focused on human rights, designing a system will require a hard look at the economics of dramatic reform. And to handle this task, the Vermont Joint Fiscal Committee (which handles legislative business when the session is out), has assigned Dr. William Hsiao, the creator of the much-praised Taiwanese health care system, which has dramatically lowered costs and increased coverage since it was implemented in 1996.
Single-payer activists have celebrated this selection as a sign that the Legislature is serious about reform. "We are at the door step of history," noted Walter Carpenter, a volunteer for the Workers' Center.
For Carpenter, a Montpelier resident who nearly died at the hands of the system when he suffered liver disease, the issue is personal. "In the last of my four operations for liver disease, I had lost my job, was turning yellow again and had to negotiate the price of my own life," he told Truthout.
Will Obamacare Derail Statewide Single-Payer Efforts?
Perhaps, the worst possible conclusion would be if a movement in Vermont managed to secure a historic health care victory, only to be killed by the very federal health care reform that some overzealous commentators praised as "the greatest social achievement of our time."
But this is entirely plausible. One major element of planning a new system is dealing with the federal government. The final version of federal reform includes "state innovation" language that address the ability of states to create their own health care systems. These systems, according to a memo by the Center for Policy Analysis, "could delay implementation of state single-payer plans." Igor Volsky, writing for Think Progress, says the federal reform might be "a major set back for single-payer advocates":
"States that still chose to pursue their own plan, will have to reconcile their programs with the federal requirements for Medicare, Medicaid, FEHBP, Indian Health Service and, most importantly ERISA - a 1974 law that, among other things, preempts states from enacting legislation that is "related to" employee benefit plans ... States will have to go to Congress if their reform affects the health insurance offered by large employers."
Rep. Dennis Kucinich (D-Ohio) had pushed hard to include an ERISA waiver, but it was dropped from the final bill - yet another painful example of progressive impotence in this legislative process. More trouble for statewide single-payer advocates occurred when the date for when states could opt out and make their own systems was pushed back from 2014 to 2017 - three years after statewide exchanges will go into effect.
This, according to Michael Briggs, communications director for Sen. Bernie Sanders, (I-Vermont), was an unfortunate and inexplicable tweak to the final bill. "Bernie (Sanders) has encouraged statewide single-payer for years. He was the one who pushed for and implemented provisions that would allow states to experiment. But, for complicated reasons I don't fully understand, the date that these states could start experimenting was pushed back until 2017," he said in an interview with Truthout.
This could mean that even if Vermont is able to pass through a single-payer bill in one of the next legislative sessions, it may require an act of Congress - a place notorious for not even giving single payer a passing glance - to allow such a transformation to take place. It is hard to grasp what a cruel irony it would be if Obama's health care legislation became the death nail for statewide single-payer movements across the country.
But not all are so pessimistic. Dr. Hsiao, in an interview with Truthout, said he felt the new federal legislation, "left quite a bit of room for state innovations," and was confident the state could secure the needed waivers should Vermont push legislation through.
Senator Sanders, too, has encouraged Vermonters to push through a bill. "As a long-time advocate of single-payer I'm glad the state is going to have a study," Senator Sanders told The Nation. "I think the result of it will show that the most cost-effective way to provide universal, comprehensive health care to every Vermonter is through a single-payer approach. What the Vermont legislature has done is very important, very positive and I strongly support their efforts."
Sanders added that he "will be going right into the President's office and making the fight on the floor of the Senate that Vermont should be able to become a laboratory and go forward with a single-payer program. And I think if it works in Vermont many other states will want to do the same thing."
Could Vermont Lead the Way?
Sanders has a point. Washington has proven to be entirely unwilling, or incapable, of truly standing up to entrenched special interests. Indeed, the Canadian single-payer health care system was created in much the same way as Sanders envisions for the United States, with one province taking the lead and others following in turn as the positive impacts became obvious. "Vermont, being a smaller state could be a demonstration site. And it can show states across the country how we can bend the cost curve," said Hsaio.
"The battle for healthcare as a human right in Vermont is also really a battle for healthcare for people all over the country," Haslam said.
This is precisely why the battle for single-payer health care in Vermont ought to be seen as a national struggle. The reform talks in Vermont may not involve close to a trillion dollars, but the type of change that could come out could represent a fundamental change in the way a state delivers and finances health care. And if it works, it could spread.
In fact, formidable statewide single-payer movements are forming all over the country and making the case that health care should be a human right - in Montana, Pennsylvania, New Mexico, Minnesota, Maryland, California, and elsewhere. It is clear that private, for-profit health care is unsustainable and that Washington, DC, is not capable of addressing the issue. So, the responsibility to end this crisis now falls on grassroots movements across the states. Will Vermont be the first domino to fall?
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