Not everyone buying into Vermont's single-payer plan

By Nancy Remsen
Burlington Free Press, May 16, 2011

MONTPELIER, Vt. — The headline “Green Mountain Dreams” over a David Weigel piece in the online news magazine Slate last week captured how many people view the health reform legislation that Gov. Peter Shumlin will sign into law May 26.

For advocates of a single-payer health care system, the bill the Legislature passed during the final days of the 2011 session is a dream come true. For the first time, policy-makers have put the state on a road leading toward a government-financed insurance program that would cover all Vermonters.

Supporters acknowledge much remains to be done before the dream can become reality. The bill poses dozens of questions that must be answered, lists a host of conditions that must be met and sets the likely start date far in the future — 2017, or 2014 if the federal government cooperates.

Still one local supporter, Walter Carpenter of Montpelier, said the legislation means the state now stands “on the doorstep of history.”

Outside Vermont, single-payer advocates have a more tempered reaction.

“They have announced an intention more progressive than other states have done,” said Dr. David Himmelstein, a founder of Physicians for a National Health Program. “It could be important if they go ahead and do it, but they haven’t done anything that I can tell.”

Opponents see the legislation’s stated intention — to establish Green Mountain Care to provide health insurance to Vermonters — as either a pipe dream or a nightmare.

Rep. Patti Lewis, R-Berlin, explained some of her concerns after voting against the bill.

“I cannot support a bill of this magnitude, when there is no true answer to how much this plan will cost. Our state is simply too small to finance this plan,” she said. She added, “This is like taking a prototype plane for its first flight.”

Darcie Johnston, executive director of a newly organized group, Vermonters for Health Care Freedom, fears the worst.

“As much as the governor would like to portray this bill as harmless, it is anything but,” Johnston said. “This bill will put into motion a process that will kill job growth and drive some of our doctors out of state or out of business. It will also require the Legislature to come back next year and pass the largest tax increase in Vermont history to begin paying for it.”

Outside Vermont, Robert Zirkelbach, press secretary for America’s Health Insurance Plans, warned that Vermont’s legislation would take away the health insurance coverage that people like and rely upon, and “put Vermont taxpayers on the hook for the soaring cost of medical care.”

More than single-payer

Anya Rader Wallack, Gov. Shumlin’s special assistant for health reform, says the legislation is much more than a promise to explore consolidation of the state’s health insurance system.

For example, the bill responds to the federal mandate that states establish health benefit exchanges, or health insurance markets, by planning one for Vermont that would also simplify insurance purchases and claims processing.

“What makes Vermont stand out is it is taking the federal law and going a step further with it,” said Alan Weil, executive director of the National Academy of State Health Policy. “It is intriguing and exciting in the sense of seeing a state want to pursue its own approach within the national context.”

The legislation also tries to tackle the biggest problem in health care — its skyrocketing cost, Wallack said.

“In most states, the focus is on how to contain costs in the current budget year,” Wallack said. “We were able to pull together all the legislative leaders and the governor to look way out in the future.”

The bill creates a board charged with overseeing initiatives to control cost growth. Topping the list of initiatives the board must pursue: revamping the way doctors and hospitals are paid to move away from a system that encourages quantities of tests and procedures over efficiency and best practices.

Enrique Martinez-Vidal, vice president of AcademyHealth and director of its State Coverage Initiative, said many states are talking about provider payment reform, but few have laid the groundwork that Vermont has with its Blueprint for Health. Nor, he added, has any other state tried to “tackle that issue statewide.”

A lot of states will be watching Vermont’s payment reform efforts, Martinez-Vidal said.

“Vermont could be totally unsuccessful doing single-payer health care and be successful in payment reform, and that could be huge,” Martinez-Vidal said.

The third component of the legislation is the planning process it spells out to determine if and how the state could move to a more consolidated health coverage system.

“The fact that people were able to broadly agree that we need to go somewhere like single-payer is something to be proud of,” Wallack said. “There is a lot of work to do here. We know that.”

Himmelstein at Physicians for a National Health Program said he would have preferred legislation with more commitment to a single-payer system. Still, he added, “I’m not condemning what they did.”

“There are a lot of studies and reports, but that will provide a lot of information states will be interested in,” Martinez-Vidal said. “We applaud Vermont for taking the lead in that.”

In Vermont, supporters, critics and skeptics also wait anxiously for the reports that more than 50 people across state government have been charged with producing over the next one to two years.

Wendy Wilton, Rutland treasurer and former state senator, is among those eager for more details. Over several months, she gathered data to produce what she called her “back-of-the-envelope” analysis of the finances for Green Mountain Care.

She ended up with more questions than answers about the feasibility of a more consolidated insurance system, she said.

“Having done this process, I concluded the proposed system has the same damn problem as the current system — health care costs will increase faster than the economy grows.” she said.

“I know we need reform,” Wilton said, noting that health insurance represents one quarter of the payroll expense in Rutland where she is treasurer.

“This thing is monumental. It affects everyone. That is why it is so important to get this right,” Wilton said. “We have to have our eyes wide open going forward.”