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Duck and Cover: Update and Analysis on Vermont’s Single Payer Plan

By Dr. Brandon Green
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Allow me to propose a little game of word association:  What do you think of when I say the word Vermont? If you run out of connections after “Ben,” “Jerry,” and perhaps “maple syrup,” then you have about as much familiarity with Vermont as I did, prior to this year.  Back in March, I joined bus-loads of medical students, nurses, and fellow doctors from Physicians for a National Health Program to rally for the single payer legislation at that time being considered in Montpelier (Vermont’s capital if you’ll recall elementary school geography).  It’s really hard to exaggerate just how small a place Vermont is.  As a recent transplant from Oklahoma to Boston, I get teased frequently for what my new-found East Coast friends perceive as my country-bumpkin roots, but I can’t help but get a little smug when I compare the size of just my birth city, Tulsa, to the whole of the Green Mountain State. What’s Tulsa’s metropolitan population? Just shy of 1 million.  Vermont’s state population:  about 600,000. No state in the union is less populated, except Wyoming, and I figure they must be counting grizzly bears and moose in their census of roughly 500,000. Though judging by all the cautionary signs on the highway, moose also figure heavily in Vermont’s head count.  So I’ll admit that I’m no expert on Vermont, but I did expect, generally speaking, that a small state with broad consensus must have a relatively easy time enacting the political will of the vast majority of its population.  Not so.

Back in January before my little sojourn north, I wrote here, perhaps too optimistically, about the brave plan being considered in Vermont’s legislature to enact a single payer health insurance plan. Well Vermont’s legislative session is finished for the year, and with regards to the single payer question, the legislators resolved resoundingly to…keep thinking about it.  Well, not that they would keep thinking about it per se. Rather the House and Senate provided for a 5 member Green Mountain Care Board  – made up of people nominated by the state government, doctors’ and nurses’ associations, and the hospital industry – to oversee the implementation of the ACA mandated insurance exchanges, and to prepare a proposal in 2013 about how a universal coverage system and its payment mechanism might be implemented.  The actual language defining single payer as the guiding principle of the board’s deliberations was thoroughly scaled back, though not totally eliminated as some of my colleagues have fretted.  So, this essentially leaves the issue in limbo for another few years, and while this board kicks the can down the road, Congress still has to decide whether to allow states to experiment with their own health insurance plans starting in 2014, as opposed to 2017 like the ACA currently stipulates.   

What we have here is neither a loss nor a victory for us health care system reformers.  In short, the Vermont legislature punted to what we think will be a sympathetic, non-elected committee, rather than take the hard decisions about committing to finish the drive to a single payer system and all the political sacrifices such a move would entail.  This does leave us with a potentially advantageous place to start the next play when the board first convenes in July.  But, the tactic also begs the question: what does this mean for our democracy as an instrument of reform, or even just as the means by which we affect the will of the people?  I understand this outcome as a product of the increasing influence of corporations on our democracy.

While our PNHP activists were in Montpelier, some of the locals in the capitol were commenting about the massive influx of new insurance and drug company lobbyists seen around the golden dome.   One insider remarked that in a small town like Montpelier you generally know everyone, and these people in nice new suits definitely stood out.  For sure, these outsiders had their work cut out for them;  Vermont’s electorate is decidedly liberal.  Vermonters have seen fit to send the only self described socialist to Congress (and in interest of full disclosure, I       Bernie Sanders), to elect a governor who campaigned on a single payer platform, AND to empower him with Democratic super-majorities in both houses!  And yet, legislators didn’t feel they had the political cover to take on the insurance industry or the throngs of conservative political action committees who would be targeting their districts in the wake of any really progressive reform. 


Gov. Peter Shumlin addresses crowd at PNHP rally for single payer in the Vermont state house, 3/26.

The math makes sense.  When the Supreme Court, through the Citizens United decision, deemed that corporations were “people” with unlimited protection to free speech through monetary donations, they forever tipped the scale insurmountably in favor of corporate profits over public good.  No ordinary middle and lower class private citizens can muster the financial heft of your average corporate player or super PAC, to say nothing of the juggernaut that is the insurance industry.  And after their lobbyists worked their way through what should be considered the liberal safe haven of Montpelier, the bluest of legislatures with an unprecedented mandate for this specific reform couldn’t pluck up the courage to seize the moment and give the people what they’re asking for: Vermont’s declaration of independence from the for-profit insurance model in favor of one that firmly defends the patient.  Instead they opted for the innocuous political middle ground – let’s form a committee and talk about this a while longer.  

Surely the more liberal members of the state government are praying that the board delivers a neatly wrapped single payer solution in a couple years that they can get behind, to minimize their exposure time to the sausage making process and the renewed pressure from the insurance industry.  Some of their bolder stipulations in the bill seem to bear this desire out.   Members of the Green Mountain Care Board are forbidden to have any employment or financial relationship with entities being regulated under the board’s purview, and this includes the kind of smaller gifts the device and drug manufacturers have already previously been banned from doling out to the state’s health care professionals.   In addition, the insurance industry gets no explicit nominating authority to the board.  So, while I think it’s clear that the legislature has its heart in the right place and are stacking the cards in favor of meaningful reform, they are simultaneously hiding behind this unelected board, hoping these five people with no political careers at stake will be able to make the hard decisions, and that they, the elected representatives, can be spared no matter how the game ultimately plays out.           

Even while I remain hopeful that this strategy will be a means to our desired end, I admit that it raises concern (no matter where one sits on the political spectrum) about accountability in our politics.  I certainly do not want to see the day when the only way we can work through our big contentious issues is from behind closed doors and through unelected intermediaries.  And yet, on its own, Citizens United underhandedly degrades the very fabric of our Republic, substituting the needs of the people for the whims of faceless corporate actors who have no particular allegiance to one country over another apart from whichever one has the most favorable tax policy.  If we were ever a nation for and by the people, we are more than ever at risk of becoming the USA LLC.  In the face of that threat even in the tightly knit communities of Vermont, does the little guy have to play dirty too?  The political realist in me thinks perhaps so, but the truth is that there is no such thing as political cover and we take risks either way.       

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  1. Brandon Green

    Authors note: the parenthetical idea about Bernie Sanders was meant to include a heart symbol, indicating my affection for the brave Senator, but the formatting change from my word processor to the html apparently didn't allow for it. Hopefully the sentiment is inferred.

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