A Doctor’s Push for Single-Payer Health Care for All Finds Traction in Vermont

By Amy Goodnough for the New York Times –

Many people move to Vermont in search of a slower pace; Dr. Deb Richter came in 1999 to work obsessively toward a far-fetched goal.

She wanted Vermont to become the first state to adopt a single-payer health care system, run and paid for by the government, with every resident eligible for a uniform benefit package. So Dr. Richter, a buoyant primary care doctor from Buffalo who had given up on New York’s embracing such a system, started lining up speaking engagements and meeting with lawmakers, whom she found more accessible than their New York counterparts.

“I wrote a letter to the editor, and the speaker of the House called me up to talk about it,” Dr. Richter, 56, recalled recently. “It was astounding. In New York, I couldn’t even get an appointment with my legislator.”

Twelve years later, Dr. Richter will watch Gov. Peter Shumlin, a Democrat, sign a bill on Thursday that sets Vermont on a path toward a single-payer system — the nation’s first such experiment — thanks in no small part to her persistence. Though scores of people pushed for the bill, she was the most actively involved doctor — “the backbone,” Mr. Shumlin has said, of a grass-roots effort that helped sway the Democratic Legislature to pass it this spring even as other states were suing to block the less ambitious federal health care law.

“We wouldn’t be where we are without Deb,” Mr. Shumlin said in an interview. “She’s made this her passion. And like anyone that’s making significant social change, she has qualities of persuasiveness and leadership and good judgment that are hard to find.”

As in all states, the cost of health care has increased sharply in Vermont in recent years. It has doubled here over the last decade to roughly $5 billion a year, taking a particular toll on small businesses and the middle class. All 620,000 of the state’s residents would be eligible for coverage under the new system, which proponents say would be cheaper over all than the current patchwork of insurers. A five-member board appointed by the governor is to determine payment rates for doctors, what benefits to cover and other details.

But much remains to be worked out — so much that even under the most optimistic projections the plan might not take effect until 2017. Most significantly, Mr. Shumlin still has to figure out how much it will cost and how to pay for it, possibly through a new payroll tax. Whether he will still be in charge by 2017 is among the complicating factors.

“If we had the exact same Legislature and the same governor we could get it done,” Dr. Richter said. “It’s a big if, because the opposition has a ton more money to convince people that the governor is evil and this is socialized medicine and all kinds of other scary stuff.”

The opposition will probably include insurance companies, drug makers and some employers who say there are too many unknowns. Many doctors, too, are wary of the change and what it might mean for their income. Dr. Richter said she believed a “slim majority” of the state’s 1,700 licensed physicians were supportive.

“One of the bigger worries I have is we’ve had all this hoopla and nothing’s going to happen,” she said at a coffee shop here recently on a rare quiet afternoon. “But it might also be helpful to us, because it’s going to be hard for any opposition to be steadily pushing for seven years.”

The federal health care law has complicated Vermont’s plans, requiring the state to first create a health insurance exchange to help residents shop for coverage by 2014. The state would then need a federal waiver to trade its exchange for a government-run system.

Dr. Richter said she embraced the idea of a single-payer system as a young doctor in Buffalo, where many of her patients put off crucial treatments because they were uninsured. As a medical student, she saw a patient with a life-threatening heart infection caused by an infected tooth that had gone untreated because he lacked dental insurance.

“He was in the hospital for six weeks, and I was like, ‘This makes no sense,’ ” she said.

She went to a meeting of Physicians for a National Health Program, a group that advocates for a national single-payer system, and started researching the concept. Before long she became a vocal advocate, even becoming president of the physicians’ group, and moved to Vermont.

John McClaughry, a former Republican state senator who is against the new law, said Dr. Richter meant well but did not understand the “long-term damage” it would wreak. In particular, he said the law would drive away businesses that did not want to help pay for it.

“She’ll tell you that putting in single-payer will attract businesses from all over the place,” said Mr. McClaughry, vice president of the Ethan Allen Institute, a conservative research group. “I don’t think she has any appreciation of business decisions at all.”

Since moving with her husband and two sons to a rambling old house within view of the State House, Dr. Richter has given about 400 talks on the single-payer concept, tutored lawmakers in the State House cafeteria and testified before the Legislature more times than she can remember. Once, she presented a printout of all the insurance companies her small practice in Cambridge had billed over five years.

“It was like 190 pages long,” she said. “Here we were, this tiny rural clinic having to bill all these different addresses. And all of them have different rules and reimbursements; I mean, it’s ridiculous.”

Some supporters of single-payer health care say Vermont’s law does not go far enough, mostly because it would allow at least a handful of private insurers to stay in the market indefinitely. Self-insured businesses like IBM, the state’s largest employer, could continue providing health coverage to workers under the law, though they would have to help finance the new system, possibly through a payroll tax.

Physicians for a National Health Program is among the critics, saying the law “falls well short of the single-payer reform needed.” Allowing private insurers to remain in the state will prevent meaningful savings, the group says.

Dr. Richter acknowledges that the law will not allow for “strict single-payer,” but said it still promised “health care for everybody, for less cost.”

“This is not the top of the mountain, but it’s the first time anyone has headed up the mountain,” she said. “No other place in the country has gotten this far.”