Single Payer System for Vermont

Vermont is the second smallest state in the U.S. (2009 population - 621,000), but from the perspective of health reform, it's the most interesting!

This year the state passed Act 128 - "An act relating to health care financing and universal access to health care in Vermont." The act is remarkably readable. It's especially worth looking at the sections on "Findings" (1-4), "Principles" (4-6), and "Goals of Health Care Reform" (6-9).

Vermont is a no-BS state. The bill doesn't pussyfoot around the problem: "The escalating costs of health care in the United States and in Vermont are not sustainable...Only continued structural reform will provide all Vermonters with access to affordable, high quality health care."

When Vermont talks about "structural reform" it means something, as in 2000, when it was the first state to legalize same sex civil unions. The Assembly specified nine principles that health reform must satisfy:

1. "All Vermonters must have access to comprehensive, quality health care."
   
2. "The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms in the health care system."
   
3. "Primary care must be preserved and enhanced."
   
4. "Every Vermonter should be able to choose his or her primary care provider, as well as choosing providers of institutional and specialty care."
5. "The health care system will recognize the primacy of the patient-provider relationship, respecting the professional judgment of providers and the informed decisions of patients."
   
6. "Vermont’s health delivery system must model continuous improvement of health care quality and safety and, therefore, the system must be evaluated for improvement in access, quality, and reliability and for a reduction in cost."
   
7. "A system for containing all system costs and eliminating unnecessary expenditures, including by reducing administrative costs; reducing costs that do not contribute to efficient, quality health services; and reducing care that does not improve health outcomes, must be implemented for the health of the Vermont economy."
   
8. "The financing of health care in Vermont must be sufficient, fair, sustainable, and shared equitably."
   
9. "State government must ensure that the health care system satisfies [these] principles."

Act 128 creates a Commission charged with proposing three models to the Assembly by the end of the year. One is a government run, publicly financed, single payer system. Another involves a state run public option that would compete with private insurance. A third will presumably be some form of "market" system, most likely modelled on Massachusetts.

The Commission has hired Professor William Hsiao, a brilliant economist based at the Harvard School of Public Health to lead the design process. Bill Hsiao has worldwide experience working with governments to reform health systems, most recently in Taiwan. Here's an excerpt from a recent interview:

Q: What’s the most important lesson that Americans can learn from the Taiwanese example?
A: You can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.

Jonathan Gruber, Professor of Economics at MIT, will work with Dr. Hsiao. Gruber is central to the Massachusetts model of reform, which will most likely be the third design model.

My wife and I have spent most of every summer in Vermont since 1992, when she began teaching at the Breadloaf School of English. We've come to love the state. As a small state with a small population, Vermont has sustained a relatively thoughtful and civilized political climate. It will be able to consider alternative models without fear that the two magical words Republicans brandish on the national scene ("socialized medicine") will induce terror and bring rational inquiry to a dead stop. (Bernie Sanders, formerly Representative and now Senator from Vermont, identifies himself as a socialist!)

Our head-in-the-sand national political process made the single payer concept a non-starter in the recent health reform process. Vermont is perhaps the likeliest segment of the U.S. to give the single payer model serious consideration. And Bill Hsiao has the knowledge and experience to make the concept feasible.

Act 128 envisions legislative debate and decision in 2011 and implementation to start by July 2012.

Stay tuned!