Vermont: Finally real hope for health care reform

By Ethan Parke, May 9, 2011

One icy and treacherous day in February 1988, I slithered my way to Montpelier from my farm in the Northeast Kingdom to testify at a hearing about universal health care. The previous year the Legislature had set up a health care board that was charged with coming up with a plan to provide health care to all 62,000 uninsured Vermonters.

Twenty-three years later, I am still trundling up to the Statehouse to watch, and in my own way, to participate in discussions about reforming health care in Vermont. For the most part, it has been an exercise in futility. But May 2011 feels different. I don’t want to celebrate quite yet for fear of jinxing the progress that has been made with the passage of H.202, but I do believe Vermont has now laid the groundwork for a more equitable and sustainable health care system.

Gov. Peter Shumlin deserves enormous credit for changing the direction of our health care reform efforts. When the Democratic leadership in Washington was saying single payer was “off the table,” Shumlin courageously campaigned for governor on a single payer platform. When Republicans chanted “government run” and “socialized medicine,” Shumlin stood by the principle of health care as a public good.

H.202 reached final passage with a 94-49 vote in the House, after weeks of hard work by legislators poring over every sentence of the 142-page bill. But it was Shumlin, as Senate leader in the previous session, who conceived the idea of bringing Harvard health economist William Hsiao to Vermont to design a universal health care system. And it was the Shumlin health care team, led by Anya Rader Wallack, who wrote the initial draft of the legislation and shepherded it through the legislative process.

What makes H.202 different from all previous attempts at health care reform in Vermont? For one thing it contains a rather explicit commitment to public financing of health care. Quoting from the bill: “The purpose of Green Mountain Care is to provide, as a public good, comprehensive, affordable, high quality, publicly financed health care coverage for all Vermont residents in a seamless and equitable manner regardless of income, assets, health status, or availability of other health coverage.”

This, if it comes true, is nothing short of revolutionary. Gone will be the health insurance–employment linkage, gone will be the individual bankruptcies caused by health care debt, and gone will be the cost shifts inherent in providing uncompensated care. Most importantly, gone will be the immoral nature of our current system, which treats health care as a commodity to be bought and sold, rather than as a service that is necessary to our collective well-being.

Predictably, Vermont’s new health care legislation has been attacked from both the right and the left. Republicans want to know the price tag, which is unknown at this time because there is not yet a financing plan or a benefits package. However, it is unlikely that the ideologues in the Republican Party would support this law even if these components were known.

Make no mistake, Green Mountain Care will be paid for with taxes, but new taxes for health care will amount to no more than is currently paid in Vermont to private insurance companies, and possibly less. Green Mountain Care will also take advantage of every federal penny that is available for health care, either by maintaining existing federal programs, such as Medicare, or by rolling them into Green Mountain Care through a federal waiver. Either way, seniors and those on other federal programs would get better coverage than they now have.

On the left are critics such as the Physicians for a National Health Program, which issued a press release claiming that “the bill passed by the Vermont House falls well short of the single-payer reform needed to resolve the health care crisis in that state.” Specific criticisms were that the bill would still allow a role for private insurance, that hospital expansion would not be controlled, that co-pays and deductibles would still burden citizens, and that for-profit providers would be allowed to deliver inferior care at inflated prices.

Granted, there is much yet to be worked out before Green Mountain Care is implemented. Even the start-up date is in doubt due to the federal health care law that currently prohibits state innovation prior to 2017. And there are many vested interests that will fight to preserve the status quo every step of the way, as they always have. But what other state has taken so bold a step as Vermont?

Later this year we will have a five-member board that will have authority over the Green Mountain Care benefit package, and will decide whether or not to impose cost-sharing requirements on individuals. The board will set provider reimbursement levels and hospital budgets, and will make final decisions on health facility investments. The board will also recommend an annual health care budget to the Legislature.

No later than Jan. 15, 2013, the secretary of administration will recommend financing plans that could be used to implement Green Mountain Care. The financing would be very broad-based. Everyone—employers and individuals—would contribute. Although private health insurance could still be offered in the state, the broad-based financing would induce most employers to drop their private plans in favor of Green Mountain Care.

The consolidated financing is what would create the savings potential. Not only would administrative waste be reduced and lucrative profits for insurance companies eliminated, but the state would have the opportunity to direct health care spending in ways to boost efficiency and improve quality. This has been loosely termed “payment reform,” an idea that can be effective only when financing has been consolidated so that spending decisions can be made in a rational and publicly accountable fashion.

One of the difficulties of enacting universal health care at the state level is that it must be done in partnership with the federal government. Also, because Vermont is a state, not a country, there are many cross border issues that must be resolved. Such issues include how to pay for Vermont residents who work for out-of-state employers and how to cover health care services Vermonters receive out of state. These complexities will be a challenge going forward, but if the performance of this year’s legislature is any indication, no problem will be too daunting.

Senate President pro tem John Campbell and House Speaker Shap Smith made sure that H.202 did not stall in committee, as so many bills in previous sessions had done. Senate Health and Welfare Committee Chair Claire Ayer kept the discussion amiable, while Mark Larson, Chair of the House Health Care Committee, with soft-spoken nerves of steel, made sure that the bill adhered to the principle of health care as a universal public good.

Special recognition should go to Senator Kevin Mullin, the lone Republican from either chamber to vote for the bill. Senator Mullin, with his emphasis on fiscal responsibility, added much to the debate, and a stronger bill was passed as a result of his efforts.

Vermont’s new health care legislation is only a first step. But it is a historic first step because for the first time, a pragmatic, achievable road map has been set out as a matter of state policy, leading to a publicly funded health care system that retains high quality health care within a system of cost controls.

Twenty-three years have passed since I first walked into the Statehouse on a health care mission. At that time I was thinking of my family, and of Vermont farmers, and of low income people who had no health insurance. Even then, however, I wanted more than charity. I wanted recognition that we are all in this together, that a functional society could devise a way to provide health care to all, the same as we decide to have public schools, or fire and police protection. I watched and mourned the failed attempts at health care reform in 1989, 1994, 2005, and 2007. Now, finally I have hope.

Ethan Parke is a resident of Montpelier, Vt.