An often-forgotten backdrop to the current focus on Gov. Peter Shumlin’s single-payer health care reform plan is that we have been through this exercise once already.
The first legislative effort to install a single-payer system came in January of 1991 when Sen. Cheryl Rivers, a Democrat from Stockbridge, introduced S-127, a Canadian-style single-payer plan for Vermont. Canadian style means that it would cover everybody in the state, it would be financed entirely by taxes and it would leave the delivery system – the doctors and hospitals – in the private sector.
Rivers was serving on the Health and Welfare Committee of the Senate and her bill went there first. The chairperson of the committee was Sen. Sally Conrad, a Democrat from Chittenden Country. For the entire two-year tenure of that Legislature, Conrad and Rivers formed one of the most aggressive and dedicated teams to pursue a policy initiative in the history of Vermont.
The first legislative effort to install a single-payer system came in January of 1991 when Sen. Cheryl Rivers, a Democrat from Stockbridge, introduced S-127, a Canadian-style single-payer plan for Vermont.
They not only held hearing after hearing in their own committee, they spent the summer of 1991 holding hearings around the state and working hard to garner public support. In 1993, Howard M. Leichter, a political science professor from Oregon, published a long article in Health Affairs detailing this effort. He came to this conclusion:
“Two things were clear on the eve of the 1992 Vermont legislative session: There was broad and deep support for health care reform, and the option with the most visibility, although not necessarily political support, was S-127 [the Rivers single payer bill].”
Conrad, Rivers, Wright
Meanwhile, the Democratic House Speaker Ralph Wright put forward his own bill in 1992. This was a universal access, but multi-payer plan. It also established the Vermont Health Care Authority, a new piece of state machinery to manage the system, with a mandate to control costs, design benefit packages, regulate the administration of health care insurance and so on.
In the early weeks of the 1992 session, it became clear that single payer lacked significant support inside the Legislature, despite Leichter’s estimate of its public appeal.
In fact, Rivers and Conrad couldn’t get S-127 out of their own committee; they had a 3-2 Democratic majority, but couldn’t get a third vote from the other Democrat or either of the two Republicans on the committee.
In the early weeks of the 1992 session, it became clear that single payer lacked significant support inside the Legislature, despite estimates of its public appeal.
The House had just a scattering of support for single payer, and none in the key committees, Health and Welfare and Commerce. Still, in a striking bit of political legerdemain, Conrad and Rivers struck a deal with Ralph Wright, the speaker, to modify the House’s health care reform bill to include a study of a single payer plan. H-733 then went on to final passage.
That was the way the situation stood at the conclusion of the 1992 session. The new Vermont Health Care Authority would commission a study of two reform plans: a multi-payer system envisioned by the House and a Canadian-style single-payer plan, with both to be presented to lawmakers in 1994.
Floundering Support
The history of the process that followed the submission of the two reform plans in the mid-1990s is unrelievedly bleak. The single-payer idea had no support and vanished from the scene. But the multi-payer plan, despite apparently very broad support, ran into increasing difficulty, particularly in how to finance it, and the whole idea finally collapsed in a welter of technical confusion.
The loss was a particularly bitter one for Ralph Wright, one of the most influential House speakers ever to serve. Wright later wrote a book, All Politics is Personal, and described how disappointed he had been by then Gov. Howard Dean’s refusal to fight harder for reform.
"Governor, what are we going to do with the Health Care plan in the Senate?" I was prepared for a lengthy dialogue on a strategy carefully outlining an advance to final victory. I didn’t have any such plan, but this was the governor’s baby, and I had the hope of a child that father would now outline how to get the job done right. "He barely looked up from his reading and he nonchalantly answered, “Nothing, it’s dead.” "That’s it? It’s dead? Two years of grinding and fighting and it’s dead? Everything went out of my mind, as the only visual I had was the Governor in a hospital room, pulling another sheet up over a patient’s face and turning to look at the charts on the patient in the next bed. We had little to talk about for the rest of the flight.
The failure of health care reform in Vermont was striking to many observers. In the early 1990s, Vermont was considered a leader in the country, along with Minnesota, Oregon, Hawaii and a few others; they were the states who wouldn’t wait. Health reform failed in every one of them.
Equally striking was the fact that a huge effort by then First Lady Hillary Clinton to design a federal reform program fell completely apart.
These failures meant that a political generation would pass before health care reform would be taken seriously again. Yet, there are echoes of those days in the current initiative for reform.
Shumlin's Early Days
Peter Shumlin was a young legislator in the early 1990s, a member of the House Health and Welfare Committee that wrote H-733. I was on the same committee, and served as one of three House members of the conference committee with the Senate. I had been charged by Ralph Wright to work on the bill with Paul Harrington, then the chairman of the House Commerce Committee. Harrington is now executive director of the Vermont State Medical Society and a key player in the new reform arena.
Anya Rader (now Wallack) was Howard Dean’s 25-year-old planning director and she ran the health reform effort for the new governor. Two decades later, she is serving as the chief designer of Shumlin’s single payer reform plan.
In the light of this history, it is worth asking how the experience of the first reform campaign has colored the current effort.
Shumlin's single-payer design is dramatically different from the Rivers-Conrad effort of 25 years ago. The key difference lies in the area of cost containment.
One very important way is that Shumlin’s single-payer design is dramatically different from the Rivers-Conrad effort of 25 years ago. The key difference lies in the area of cost containment.
The Canadian style single-payer scheme is, at best, very light on cost containment. Act 48, the Vermont law that incorporates the Shumlin program, is packed with it. The entire effort of the Green Mountain Care Board is aimed at cost containment – by regulation, payment reform and recasting the operations of the health care delivery system.
The conditions that must be met on cost containment, sustainability and economic impact – the so-called triggers in Act 48 put forward by Rutland Sen. Kevin Mullin – put cost containment in the Canadian system in the shade.
Still, despite the protections built into Act 48, getting to a genuine single payer in Vermont remains a high-wire act. Vermonters will elect a new Legislature in November. Passing the financing plan for single payer will be the biggest challenge that any legislature ever has faced.
