Single Payer in Vermont?

Here is a video (~1 hour) from a Politico health reform policy panel I was on at the DNC last Thursday. Two things from this panel stood out for me, both related to the comments of Gov. Peter Shumlin from Vermont, who wants to create a universal, “single payer” health system in his state.

  • All Governors say they want flexibility, and in the South they mostly talk about being pushed too far, too fast by the ACA in terms of coverage expansions. Gov. Shumlin also wants flexibility, but in order to go further, faster. He wants flexibility to move to a single payer approach before 2017 (the ACA does not allow this prior to then according to the Governor, and he says that insurance companies didn’t want this option to be available). He doesn’t want the ACA to hold Vermont back and wants both a Medicaid and some sort of ACA waiver to move toward a single source/payer approach that will cover all Vermonters as soon as possible.
  • The Governor played down the role of ideology* in making his single payer approach possible, and said that the size of the state will be the biggest predictor of big innovations in health reform going forward. He thinks that small states that have fewer/smaller/less powerful corporate interests involved in the delivery of health care will be the ones that be most innovative in insurance innovations. Sarah Kliff has also talked about Montana’s efforts in this “single payer” direction….a small (in population) state.

In any event, it is a very different context in Vermont than it is in the South, where some states are talking (I suspect mostly talk) of not even taking the Medicaid expansion in the ACA that is now optional.

*I don’t really think single payer is technically the correct term for what they are talking about because the most likely option would leave Medicare, Medicaid and private insurance, but would create a predictable way that everyone in the state would be covered. However, that is mostly just nit picky professor talk….but hey, I am a professor.

a similar post was cross posted at freeforall

Author: Don Taylor

Don Taylor is an Associate Professor of Public Policy at Duke University, where his teaching and research focuses on health policy, with a focus on Medicare generally, and on hospice and palliative care, specifically. He increasingly works at the intersection of health policy and the federal budget. Past research topics have included health workforce and the economics of smoking. He began blogging in June 2009 and wrote columns on health reform for the Raleigh, (N.C.) News and Observer. He blogged at The Incidental Economist from March 2011 to March 2012. He is the author of a book, Balancing the Budget is a Progressive Priority that will be published by Springer in May 2012.

7 thoughts on “Single Payer in Vermont?”

  1. Is this related to what Rep. McDermott is working on?

    I think it’s a great idea and I hope California gets to try it. It could hardly be worse than what we have now. And I think it’s good that it doesn’t force people to give up what they have now, if they like it. It’s a myth that only sick people lack insurance. It could be viable and it’s worth a try.

    1. Rep. McDermott has long been for “true” single payer of Medicare for all I believe….though even in Medicare for seniors many have private gap coverage. He may be interested in something like this for Wash state, I am not sure.

  2. Part of it may be Vermont’s small size, but I think a lot of it’s ideology, at least in the packaging. Vermont is the sort of place where it’s advantageous to call what you’re doing single-payer, even if it isn’t; I noticed that in the piece about Montana Gov. Schweitzer emphasizes the block grant aspects of his proposal.

    1. I agree. The messaging of single payer and solidarity may be potent in a popular way in Vermont, but it would not be the way you would message it for the South. Something like this could be sold as universal and more efficient given people tend to get something eventually, just too late often, in the most expensive settings, and in ways that destroy family credit/finances, etc. I give the Gov credit, he is quite passionate on the topic.

    2. As a vermont resident, I’m not sure that’s the case. “Single-payer” has united some people for the proposal, but also united a lot of people against it. The current republican candidate for governor is basing his campaign on opposition to single-payer coverage.

      I think that a lot of the size-related effects are second-order ones, though. Vermonters don’t have a lot of private-insurance choices because of the small population and low density, so the myth that the market can solve everything is mostly absent (except in the mind of the above-mentioned gubernatorial candidate). The low density also means that the typical local medical facility is not very big, and the overhead of multiple payers is clearer. But most important, I think, is the widespread relative poverty among all social classes. Pretty much anyone can look around at their social circle and tick off the uninsured people, or the people whose health needs are cutting into the rest of their budget, and see how expanded coverage at lower cost would improve living conditions and improve the economy.

      It’s not clear that’s a good recipe for the rest of the country, but the fact that the people who will prospectively be covered aren’t the “other” makes a big difference.

  4. As a policy advocate in Vermont, I am proud of Governor Peter Shumlin for his commitment and leadership on health care reform. The passage of the ACA in 2010 was a big victory and it is already making a difference in the lives of millions of Americans. But in Vermont, we are also keenly aware of the failures of the private insurance system and the ways in which it continues to fail thousands of Vermonters, even while the price tag rises. The most important thing to remember about our reform model is that we are not re-creating the wheel. We want to build a publicly financed health coverage model based on the successful systems in place. both in the United States (Medicare, VA), and in other parts of the world. It’s true that we may never achieve a pure ‘single-payer’ system, but we are committed to getting as close as possible. This includes efforts to bring Medicare, Medicaid, and the self-insured into a single, streamlined ‘funnel’. If we are successful, I believe it will have ripple effects across the country. As we move forward with this policy project, we must ensure that the flexibility we seek does not open the door for the states want to use ‘flexibility’ as a vehicle for rolling back critical safety net programs for their people.

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