When the Affordable Care Act was passed in 2010, Vermont single-payer supporters knew that they would have their work cut out for them. It was not the kind of reform they had hoped for because it relied on the current market-based system of health insurance.
Vermont, in particular, was hurt more than helped by the new law. It was the price this forward acting state had to pay for being on the cutting edge of health care reform. Vermont health care reform was better than what the federal law had to offer. But Vermonters would have to bite the bullet and accept the new reality.
Governor Peter Shumlin and his single-payer allies tried to turn the basket of lemons into lemonade. The framework for a Vermont single payer system was created with legislation passed in 2011 creating Green Mountain Healthcare. The promise for that new law was that it would build upon the mandated piece of federal legislation, the health care exchange, and have it become a stepping stone to a single payer system in Vermont.
It meant that, in or around the year 2017, Vermont would be able to take advantage of provisions in federal law that would allow the state to use federal insurance payments to Vermont to be put into a common insurance pool. This would allow the state to create a single insurer, most likely a state entity, to offer insurance.
On a practical level this means that although the state would take the risk for insurance, it would most likely hire an insurance company to manage the program. Most people believe that Vermont Blue Cross Blue Shield would be that administrator because they already insure the lion's share of people in the private insurance market.
Once this plan is in place it would eliminate any private insurers from the health insurance marketplace. It would be the beginning of a modified single payer system. Modified, because any single payer system in Vermont might not be able to capture roughly 40 percent of the insurance market, those people who have insurance through a self-insured employer.
Any self-insured business, which is generally a business of 400 or more employees, does not have to abide by state insurance rules because of a 1974 law called ERISA. If the Vermont single-payer plan turns out to be better financially than a self-insured plan, employers would have the option, but not the obligation, of buying into the single payer system.
Not having a big enough pool of Vermonters enrolled in a single-payer plan could be a problem that might not make it financially viable. One could make a case that 300,000 to 400,000 people would be enough to make a single payer plan work. For that to happen it would mean that enrollees would have to represent a wide cross-section of the population. It would require recruiting a lot of young and healthy people so the risk of insuring everyone would be spread widely.
There is also a political hurdle that single-payer supporters will have to jump over. They knew that if the rollout and implementation of the exchanges did not go well it would be a hard sell to move forward to an even bolder plan. That is why many single payer supporters held their noses and worked hard to make the exchanges work well.
Unfortunately, their worst nightmare played out and the rollout was a nearly a complete disaster, at least according to the media. They did the best they could to support efforts they had control over but they could not control the IT piece of things and that is where everything hit the fan, both in Vermont and nationally.
So now we have a state getting back on its feet after a man-made disaster. The memory of this rollout will not go away anytime soon and when the legislature convenes again in a few days we will be constantly reminded of the failures of the health care exchange rollout. We will also, most likely, hear that legislators of all parties are not willing to move too quickly to the next level of reform.
The Governor says he is committed to moving ahead with single payer implementation. If he pulls it off, I would be the first to nominate him for a new category of Nobel Prize, in the field of Political Magic.
Richard Davis is a registered nurse and long-time health care advocate. He writes from Guilford and welcomes comments at firstname.lastname@example.org.