Diagnosing Vermont’s Single Payer Crash

I have a commentary in this week’s New England Journal of Medicine on “the demise of Vermont’s single payer plan.” Beyond what’s in the article, here are some points of note.

First, as some of ardent single payer proponents note, the plan was never “pure” single payer because VT Gov. Peter Shumlin never envisioned including Medicare in the system.  So it would have been single payer — except for Medicare and other federal programs that would have been challenging to include.  Though including Medicare in the original plan would, quite likely, have been politically suicidal, the point is well taken.


Second, Vermont’s move in this direction in 2011 was the most exciting and important pro-single payer development in a generation at least.  A state chief executive with a strongly Democratic legislature in a small, progressive and compact state — one could hardly imagine a more auspicious opportunity.  Add to that the disappointment among so many Democrats in 2010 that the Affordable Care Act did not go further.  I admit to being caught up in the exuberant enthusiasm.

Third, Gov. Shumlin’s abandonment of the initiative this past December closes the door not just to Vermont’s ambition, but also, I conclude, for single payer initiatives in states generally.  Three serious and credible sets of financing estimates (2011, 2013, 2014), with declining projections of feasibility, are now indispensable cautionary documents that will make any political leader think twice before emulating Shumlin’s 2011 impulse.

The loss of single payer is not the end of the road for health reform in Vermont.  While the single payer process was underway, another process — financed by the federal government as part of the State Innovation Model (SIM) program through the Center for Medicare & Medicaid Innovation, to undertake reform of the state’s medical care delivery system.  Indeed, some health system reformers in Vermont bemoaned the attention that the single payer took away from SIM action.

Finally, I hope, the loss of Vermont’s single payer quest is not the end of single payer in the U.S.  As I suggest in the commentary, perhaps in the not-too-distant future, our nation will wake up to the inanity of running so many enormous, wasteful, and separate federal health programs — Medicare, Medicaid, the ACA expansions, the Veterans Health Administration, Tri-Care, and more — all to provide health benefits and security.  There’s a better and more sensible way, and I hope we can get there.  I’m just not holding my breath.

Author: John McDonough

I offer insights and opinions on how to improve health care systems for everyone

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