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Vermont Lays Out a Path to Single-Payer, But It's a Long Journey

By Jane Norman, CQ HealthBeat Associate Editor

May 26, 2011 — Last Thursday was a day of celebration for advocates of single-payer health care when Vermont Gov. Peter Shumlin signed into law a measure that's intended to pave the way for government-run health care in the Green Mountain State.

But it's a case of delayed gratification. Numerous questions and uncertainties surround implementation, the costs have not been determined, and the law is unlikely to go into effect until sometime six years or more down the road.

In remarks at the Statehouse in Montpelier, Shumlin, a Democrat, acknowledged that Vermont has a way to go before its proposed system can achieve the cost efficiencies and quality dreamed of by those who advocate a single-payer health care system.

"I realize that people have legitimate questions about how a single-payer will be financed and operated, and we will answer those questions before the legislature takes the next step," Shumlin said. "We'll be getting input from all Vermonters moving forward, which is essential to the success of this effort."

He said that 47,000 state residents are uninsured and another 150,000 have inadequate coverage. The objective is to provide them and the rest of the state's residents with better health care.
While single-payer advocates were happy with the bill signing and its significance, they said the details of implementation are problematic.

The leaders of Physicians for a National Health Program, a prominent single-payer group, praised the Vermont measure and said it's providing inspiration for the rest of the country. But Garrett Adams, president of the organization, said in a statement that "the actual provisions of the law fall considerably short of the single-payer reform needed to realize those goals."

One problem is that multiple private insurers would still be allowed to operate in Vermont, denying residents the savings they would see under a true single-payer plan, he said.

Meanwhile, the liberal Web site Firedoglake mounted a petition effort asking the federal Department of Health and Human Services to grant the waivers the state would need from Medicaid, the Children's Health Insurance Program, Medicare, worker's compensation laws and more.

The three-part Vermont measure, which its House approved earlier this month, will establish a paid Green Mountain Care Board whose five members—all state employees—will be appointed and in place by October, according to Shumlin's office. It's supposed to work with providers to reduce their reliance on fee-for-service payments. The board will also have approval over insurance rate requests and eventually will review hospital budgets.

In addition, the bill authorizes the creation of a health exchange, which is required for the state to set up under the federal health care law by 2014 or the federal government would step in. "The intent of the general assembly is to establish the Vermont health benefit exchange in a manner such that it may become the foundation for Green Mountain Care," the bill says.

Green Mountain Care is the third element: the single-payer system that would begin in 2017, the earliest date at which current federal health care law (PL 111-148, PL 111-152) allows states to ask for waivers from the overhaul measure to set up their own systems. The Vermont congressional delegation is pushing to move that date to up 2014.

Vermont's system would not go into effect until its legislature approves a budget and means of financing for it, yet to be determined though new taxes are thought to be likely. A benefits package would have to be approved by the Care Board.

Supporters of the federal health care law saw Vermont's move as proof that the law has plenty of flexibility to allow states to make their own decisions about how to run their health care systems. "We hope that other states across the country take inspiration from Vermont to implement their own unique pathways to improving health coverage, costs, and quality of care," said Ron Pollack, head of the advocacy group Families USA.

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