What SCOTUS ruling might mean to Vermont's single-payer plan

By Mike Miliard, Contributing Editor
Government Health IT, June 18, 2012

"The Affordable Care Act doesn't do a whole heck of a lot for Vermont," says Deb Richter, MD, president of Vermont Healthcare For All. "Most of the provisions in it, we've already done. It's kind of a shame, in a way. We would have momentum, and probably could've gotten further with single-payer, if the ACA had not happened."

Vermont comes by its reputation for progressive politics honestly. And one of its signal achievements on that front is a piece of legislation known as Act 48, signed into law by Democratic Governor Peter Shumlin in June 2011, which lays the initial groundwork for the Green Mountain State to make the pioneering move to a single-payer system.

"Because of the growth of our healthcare expenditures every year, we had to do something," says Peg Franzen, president of the Vermont Workers' Center, which labored for years to build momentum behind the bill. "Insurance companies are doing what they're supposed to do; they're making profits for their shareholders. But that's not the way we should have a health system set up. Healthcare shouldn't be a commodity."

But there's a long road ahead before so-called Green Mountain Care – tagged by opponents with the predictable epithet of "ShumlinCare" – becomes a reality in Vermont. Political pitfalls on the state and national level mean a single-payer future is far from certain. But since Act 48's passage a year ago, work on the policy front has been ongoing, aimed at improving the state's healthcare system, regardless of the outcome.

Seeking to offer near-universal coverage for Vermont's 626,000 citizens, the state-funded insurance pool is still years away from coming to fruition, and has many questions still to be answered.

One not-inconsequential detail: how it will be funded. A variety of new taxes are under consideration, but won't be voted on in the near future.

Act 48 also contained provisions to launch a health insurance exchange as required by the ACA, set up pilots to explore medical home and bundled-payment reforms and established the Green Mountain Care Board – a panel of policy experts to set rates, design benefits packages and suggest funding strategies.

Those are just first steps. As noted above, one stumbling block along the way could be the federal Affordable Care Act – which itself is up in the air, of course – with the Supreme Court ruling due by June’s end.

Vermont hopes to use money disbursed by the ACA to help build those insurance exchanges. The federal law says every state must have one by 2014, but it also allows states to petition for a waiver from the national rules if they can prove they're providing equal or better coverage of their own.

"One major advantage it could (provide) is help bring in federal dollars when people buy health insurance on the exchange," Richter says. "And then that sum of money is what we would expect to get as a subsidy when we finally do single payer."

But waivers won't be available until 2017. In today's political climate, five years is an eternity. Whether that necessary bit of dispensation ever comes depends "on the administration in Washington," Richter adds.

If it could happen today, there would be "a good chance" of success, she adds. "Obama has said if he could do it over, then single payer would be the way he would go. He's also said he believes in states' rights to innovate and do some models on their own." If it's the Romney administration? "I don't think so."

The next few years will be pivotal – on policy, politics and public opinion fronts.

"There's a lot of misinformation out there," Franzen says. "There's been a real attempt to spread a lot of fear. Which we knew would happen. When we got into this, we all knew it was going to be a five year or more battle."

In the meantime, work toward a better healthcare system has been moving forward in earnest. In the year since Act 48 was passed, the Green Mountain Care board has been hard at work on projects around cost containment, says its chair, Anya Rader Wallack.

"Right now we're very focused on trying to implement payment reform models in the state, moving away from fee-for-service," she says. "And we're working with providers around the state to develop some models for doing that."

Other responsibilities include "a whole realm of benefit design, for both our health benefit exchange and the single-payer financing plan that the governor's office will be bringing back to the legislature next year," Wallack says. "For both of those purposes we have to sign off on a benefit package that would form the floor, essentially, for everyone in Vermont. We are waiting for recommendations on those and will have to delve into whether to approve them."

In terms of the single-payer law, "there's still a lot of work to be done," she says. But, "as for our work, we're sort of off and running. We have those responsibilities, regardless of what happens in the future with the single-payer plan."

Nationally, whether the ACA stands or falls "doesn't really affect our work at all," she adds, referring to the Green Mountain Care board. "It affects the single-payer plan, and it affects our implementation of the health benefit exchange, because if the [individual] mandate is removed, it means the state will have to determine whether to pass a mandate at the state level to assure everybody's covered."

Single-payer may have far to go before it's a reality. But even if it ends up a vanishing pipe dream, Vermont is in much better shape, when it comes to keeping its citizens covered, than most other states.

By the same token, even if the Affordable Care Act is upheld and goes into full effect, "at best, it will bring the rest of the country to where Vermont already is," Richter says. "Act 48 was intended to go beyond that."

"Regardless of what happens with [single-payer], or with ObamaCare," Wallack adds, "if we do our job right, we'll have a more sustainable, higher-quality healthcare system, I think, than anywhere else in the country.",1