Vermont Universal “Fewer Payer” Healthcare Bill Passes

From the Vermont Digger

You can call it Frank. You can call it Fred. But don’t call it a single-payer health care system. That was the message Rep. Mark Larson, D-Burlington, delivered to lawmakers in the House Appropriations Committee last week and during the House floor debate on Vermont’s latest effort to reform its health care system. The euphemism single-payer was struck from the bill in an amendment to make the legislation more palatable to Republicans, sources say. The bill passed 89-47 after eight hours of debate, speeches, amendments and roll call votes. The legislation now goes to the state Senate.

The actual, rather unsexy moniker? “A Road Map to a Universal and Unified Health System,” or Green Mountain Care, for short.

Larson said “fewer-payer” would be more accurate. That’s because the state’s single payment system (in theory administered by a sole entity) will always have at least a few “payers.” In addition to Green Mountain Care, other payers would include Medicare and Medicaid, large self-insured companies like IBM and supplemental insurance (likely for teachers and state and municipal employees who have “Cadillac” plans).

Whatever you call it, passage of H.202 pushes the state toward a single-payer health care reform construct, and the goals set out in the “road map” are audacious: All Vermont residents would be eligible to receive an “essential” health benefit package; health insurance companies would be effectively cut out of the game and relegated to a peripheral role in the new system; and cost containment measures would be designed to push the system toward fiscal sustainability. All this would be accomplished under an ambitious, three-year timeline.

Though government-controlled health care payment systems are commonplace in most countries in the developed world, no other local or state government entity in the United States has come as close to implementing a universal health care system for all of its residents. Vermont would be the first state to achieve what has been impossible elsewhere – including President Barack Obama’s much-compromised attempt to reform the national system — if the state can negotiate the push and pull of special interests, namely single-payer activists and a host of medical professionals and facilities that stand to win or lose — whatever is proposed.

The Legislature has outlined a new “road map,” but it isn’t the first time lawmakers have gone down a garden path toward the dream of creating a fully fledged universal coverage plan. Two previous health care reform efforts that achieved partial gains nudged Vermont closer to the goal. In 1992, Gov. Howard Dean and the Legislature launched the successful Dr. Dynasaur program, a Medicaid-subsidized health care plan for children under the age of 18 whose families financially qualify. Just five years ago, the Legislature and Gov. Jim Douglas enacted Catamount Health, a Medicaid-subsidized program for uninsured Vermonters. Despite this last effort to extend coverage to uninsured Vermonters, 47,000 residents are currently without health insurance, and 160,000 are underinsured and find it difficult to pay for health care costs as out-of-pocket expenses and deductibles rise.

With H.202 and the Hsiao report in hand, the third time might be the charm. This go-round Gov. Peter Shumlin, a Democrat, has made health care reform his signature initiative and his Democratic compatriots in the Statehouse are determined to make it so. The effort builds on the work of economist William Hsiao’s initial research for the design of a “single-payer” health care system.

Republicans opposed the bill because they say they can’t support sweeping reform without knowing how much the system will cost or who will pay for it.

Hsiao proposed a 14.5 percent payroll tax, and also suggested that an income tax could also be an option. The House Health Care Committee decided the “details” are beyond the Legislature’s purview for the time being. The board and a team of eight researchers from the Department of Banking, Insurance, Securities and Health Care Administration will devise the system; lawmakers will be responsible for approving a financing plan (2013), a budget (2014) and plans for implementation of the system (2012).

If the legislation is enacted as is, (the Senate is taking testimony on the bill Thursday night), it will set a few parameters in place for the formation of the Green Mountain Care board and implementation of the health care exchanges under the federal Affordable Care Act. In addition, the bill sets the stage for Green Mountain Care, the single payment system. H.202 hands over the biggest decisions – the benefit packages for consumers, reimbursement rates for doctors and hospitals and how the cost containment and payment reform systems will work – over to the five-member professional board.

SUBHEAD Debate on the floor

Rep. Mark Larson, chair of the House Health Care Committee, introduced the bill and was subsequently queried by lawmakers for about 5 hours. Larson, D-Burlington, was unflappable. He didn’t lose his cool, even after about three hours of steady grilling from Rep. Tom Koch, D-Barre Town, who used an amendment proposed by Rep. Cynthia Brown, a Democrat, as an opportunity to flay open the underlying bill.

Larson began with a preamble that explained the rationale for reform. “Our current system is broken; it’s too costly; and there is no mechanism for cost control,” Larson said. The state is spending $4 billion a year on health care now; he said that total will likely grow by a third, or by $2 billion over the next two years. “We have a system that has demonstrated that despite all of our efforts cannot control the cost of health care,” Larson said.

The system, he said, is also unfair and inequitable. Constituents say the premiums they pay for health insurance are comparable to a tax, except that some people pay and others don’t, and yet everyone benefits.

“At a time where Vermonters are increasingly seeing the cost of copays going up and the amount of coverage going down, we can’t afford to spend money on things that don’t add value to our health care system,” Larson said.

The second amendment, proposed by Rep. Linda Waite-Simpson, D-Essex Town, passed on a voice vote. The amendment will require the state to hold a public hearing and an economic study regarding how Green Mountain Care would affect for self-insured employers, including IBM which is in Waite-Simpson’s hometown.

Browning’s amendment would have confined H.202 to the formation of the board and the exchanges and would have stopped short of allowing the state to move forward with the laying the foundation for the single payment, universal Green Mountain Care plan.

“We need more detail,” Browning said. “I don’t think we’re ready for this commitment. The other problem I have with it is the level of uncertainty it creates, which is the worst thing for economic activity and the worst thing for business.”

Rep. Tom Koch used the amendment as an opportunity to conduct a courtroom-like cross-examination of Larson. With a laser-like focus, Koch methodically deconstructed the 92-page bill section by section, raising questions about how the plan would affect self-insured employers; how the bill would contain costs under a per capita reimbursement system; whether the system would limit care to patients in order to contain costs; how the plan would monitor health care quality and whether the legislation would provide adequate reinsurance in the event of catastrophic medical claims.

“Is not one of problems with capitated payments is the economic incentive for providers to do less for patients?” Koch interrogated.

Larson replied: “That’s true if you don’t monitor the quality.” He said Green Mountain Care would include safeguards to prevent providers from underserving people under capitated payment system.

Koch also pointed out a sole reference to “single-payer” and then proceeded to use a Gertrude Stein style a rose is a rose is a rose line of questioning to highlight what was already spelled out in the legislation – that is, passage of H.202 means that most Vermonters, not already covered by Medicare or a large self-insured employer, would, in 2014, shift toward one health care administration system. He pointed out that the objective of the bill is to eliminate insurance competition.

Koch and other Republicans also argued that including self-insured companies in the Green Mountain Care system would be unconstitutional; Larson said the state would not seek an ERISA waiver, and said such waivers are not possible to obtain. Businesses, he said, would continue to function as they do now.

Nevertheless, an amendment from Rep. Heidi Scheuerman, R-Stowe, and Rep. Oliver Olsen, R-Jamaica, proposed that the state exclude self-insured companies from the Green Mountain Care system.

Scheuerman said under the proposal, self-insured companies would pay double – they would pay insurance premiums and potentially a payroll tax, as suggested by Hsiao’s report. Scheuerman said a number of large, self-insured companies could be affected, and she rattled off a list: GW Plastics, General Electric, General Dynamics, Pizagalli Construction, Plasan, King Arthur Flour, Cabot Creamery, CVPS, among others.

Scheuerman said while the state may not require participation in a single-payer plan, companies would likely be forced to pay into the plan. “There is a lot of uncertainty in this bill, and the angst is palpable for businesses in this state,” Scheuerman said. “This is one piece of certainty if we take this off the table to say this would be one thing we wouldn’t do. At least take this off the table and don’t force companies to pay.”


  1. Tom on March 30, 2011 at 2:07 pm

    Maybe this will be the start of a real healthcare reform movement in this country..The Republicans will again, fight tooth and nail to protect the interests of the for profit health insurance companies that line their pockets..Hopefully Vermont won’t buckle like the American Congress and Senate did in their healthcare bill.

    • Colleen Wagner on March 30, 2011 at 3:02 pm

      AMEN to what Tom said.
      It is a shame that so many people know what the problem is but we can not do anything about it.

      I do truly hope this paves the way to universal healthcare and puts the money grubbing insurance executives out of the picture for good.

    • jackie Saner on March 30, 2011 at 3:52 pm

      I agree with you. This is all about the big corporate bucks, and more and more they seem to have a strong hold on our politicans. Amen to Vermont for doing what needed to be done. Stay strong Vermont because this plan will be attacked non stop by the bought off politcans! Don’t you wonder who this ‘majority public’ is that the GOP’rs keep refering to as being against universal healthcare? I haven’t run into anyone against it, except of course the Right wing. Interestingly my 88 year old dad is against it but is 100% for his Medicare. Go figure how they think, I sure can’t.

      • Shelly Ottenheimer on March 30, 2011 at 10:23 pm

        Cheers Jackie! I have been wondering where the 80% of all people in this country, according to the Republicans, are who are not for universal health care. That is just wrong. Most everyone understands that we could do it for better and less and that everyone could be covered if we just cut the greedy corporations out of the equation, well everyone that is except for Fox News fans who are in deep trances and doing the biding of the greedy billionaires’ corporations, which is basically cutting their own throats while endeavoring also to cut ours. Sadly, there are many Medicare recipients, my father included, who don’t have a clue that they are receiving entitlement through Medicare. They just know that they like it and that it works very well for them and to extend this socialized, yes socialized form of health care for everyone else is to them communism.

  2. Ben on March 30, 2011 at 2:34 pm

    I was there at the AMSA/PNHP rally last weekend. We marched around Montpellier, waving signs, then we listened to some great student speakers from around the country. The governor spoke, as did Senator Sanders, who told us that a federal bill which is likely to pass would allow this Vermont bill to take root.

  3. Michelle on March 30, 2011 at 2:40 pm

    Go Vermont! If Vermont can construct a good working model for a move toward a single payer (or even ‘fewer payer”) and show that savings, efficiency and better health can be achieved with it, then perhaps more states will adopt similar programs.

  4. Arthur W on March 30, 2011 at 2:54 pm

    I applaud Vermont for pushing this wonderful plan along. Hopefully
    it becomes law and will show the value of single payer.. Opps, I
    meant “Fewer Payer”. Green Mountain Care has a very nice
    ring to it, eh?

  5. Tony on March 30, 2011 at 3:33 pm

    I really hope vermont can get this done and show the rest of us how stupid we have been for fighting this. The greed in the U.S. makes me sick. This country would be so much better off if we worked toward making things better for everyone, not just the rich and greedy.

  6. Brandy on March 30, 2011 at 3:44 pm

    Wow! Maybe I should move to Vermont? I’ve been told it was rejected in Missouri but since we voted on that a lot of people told me they didn’t understand the wording. I think if it was explained and put to a vote again by the people I doubt they would vote against it. I mean I don’t see what all the whining is about opposing it except that it would help poor people (like me) have basic care. In the long run us having basic care would or could keep us from getting terminal illness, going in debt and leaving a huge defict for the state. I mean you don’t have to be a rocket scientist to do that math.
    Wonderful, Go Vermont! Would you mind another resident?
    I wasn’t sure if my state rejected it how I could go about being a part of the Healthcare system through the federal.

    Ben that is wonderful! I wish my state would take hold and understand what a good thing it is instead of believing whatever someone tells them. I mean they really should read the healthcare law themselves it is much better then the current system run by the healthcare businesses and puts more control in the hands of the person needing health insurance.
    I looked what it would cost for me before the hc law went through and it was $400 a month with preexisting. Now it’s $200 a month. Still too much for me to afford but it’s getting closer to being an ‘afforable healthcare act’.

  7. Ellen B Levin on March 30, 2011 at 3:48 pm

    We are finally making progress in this country for the right of all people to have access to healthcare. I applaud Vermont and hope the rest of the nation follows.

  8. Kate on March 30, 2011 at 3:59 pm

    Leave it to Vermont to do the right and prudent thing, that should have been done long ago. May all the other states follow in your footsteps! I think I need to move to Vermont…..

  9. Mal on March 30, 2011 at 4:32 pm

    As a resident of Maine, we are watching this with great interest & support. Our Dirigo Plan has stumbled along for a few years now & nobody’s happy with it so far. Our current clown–er–governor, is set to dismantle anything resembling “what they have in North Korea.” So–hang in there & win this fight!

  10. Mitzi Potz on March 30, 2011 at 6:12 pm

    This is so very exciting – I think it would be fantastic if all the States would follow suit and then the Federal Government would change to the same plan. I am from Canada and one thing I never had to worry about was “What would I do if I got sick”. This is just a start though.

  11. Shelly Ottenheimer on March 30, 2011 at 10:09 pm

    Go Vermont!!! This is really good news, and the people of Vermont should feel proud for being wise and able to see through the tangled for-profit mess that has been called health care in this country when it has been anything but and is really profit-driven sickness insurance with greedy insurance corporations and pharmaceutical companies making billions of tax-free profits while Americans are delivered an inferior return, if we even get a return. We can hope that this will help to lead the way for the rest of the states to follow suit. We really can do much better for much less money by removing insurance from the equation. It would be a shame to see the CEO’s of say Blue Cross to no longer make over $13 million per year on the backs, illnesses, and graves of the rest of us. Congratulations Vermont!

  12. FrankyLamouche on March 30, 2011 at 10:53 pm

    Mattachusetts is next.

  13. Judy Lujan on March 31, 2011 at 1:00 am

    Now if we could only get the rest of the country to follow suit…

  14. Maryanne & Christopher Mckinnon on March 31, 2011 at 10:26 am

    Congratulations Vermont! And way to go! This is an important step in the right direction toward health care for all. One fine day, we will purge the insurance gangsters and profiteers from what should be a basic human right, Universal Health Care. As a resident of Maine, a state badly in need of this kind of change, your example gives one hope and inspiration.

  15. ANNETTE TERZIOTTI on March 31, 2011 at 4:17 pm

    Natural health care is the way to go. Everything we need to be healthy is in nature. Pharmaceuticals pollute the planet, make people sick, cause brain damage and kill people. Real doctors need to teach their patients how to eat to stay is an x-drug sales person and her explains all about the corrupt FDA and how the medical industry creates illness by using pharmaceuticals to create a revolving door of medical care increasing their profits. the emphasis needs to be one educating people about food & wellness not a pill for everything.Pills are for profit and sickness.

  16. Mark Nevin on April 2, 2011 at 8:29 am

    Go Vermont!! You have the solidarity of those of us fighting the good fight all over this country! Never give up and never give in…once again much love and encouragement!
    Healthcare is Right, Not a Privlage,

  17. Katherine on April 3, 2011 at 12:33 am

    What fabulous news! (for a change)