Strategies to get single payer health care implemented in Vermont

Remarks Presented to the Progressive Party Annual Convention, Barre, November 14, 2009 by Con Hogan

Thank you for the opportunity

I work and have worked in places that have universal coverage and versions of single payer: Netherlands, Norway, Israel, N. Ireland, Republic of Ireland, Chile, and Australia. Based on what I’ve seen it would seem to be a no brainer. But it is not.

And it could work here…

Vermont is not like a lot of the country. Here are some positive things about Vermont that are particularly in our favor.

  • Our primary care docs are in it for the right reasons, and it’s not money. They are some of the lower paid primary care docs in the country, and yet the medical ethic and enlightenment is high.
  • The quality of our health care in Vermont is high to begin with (but is in increasing danger)
  • Our political leaders are accessible (although some of them, those who you might least expect, have been resistant to real reform).
  • Our efforts at access are among the best in the nation…but we’re continuing to lose ground on that front, particularly in these hard economic times.
  • Most people in Vermont seem to want a single payer program.


And there are some negative trends in Vermont that are actually pushing us hard in a single payer direction.

  • The overall cost of health care in Vermont is rising more quickly than in most of the country. There is a growing and more intense reaction setting in across Vermont to these costs.
  • Our Vermont government constantly under predicts the rise in health care costs. People are finally catching on to that.
  • The backbones of our formal public policy on health care reform are Catamount and Chronic Disease Management. They have been adopted against all evidence.


Catamount, a subsidy program, has been tried in about 10 other states over the last ten to 15 years. In every case, like Vermont, the number of uninsured initially declined, but in every case, when it became clear that the states could not keep up with rising cost, the number of uninsured today, is greater than when the program started. Maine, Minnesota, Tennessee, Oregon are good examples. We can’t buy our way out of this.

If the stakes weren’t so high, it would be amusing to see the Health Care Reform Commission, which is a major supporter of Catamount, being puzzled by the current reduction in enrollment. Four years ago, in a series of newspaper op eds, Dr Deb Richter and I predicted this, based on the evidence.

Chronic Disease Management is good health care policy. But the experts from away, on whom Vermont has mightily depended, and our Vermont policy leaders keep crowing about the potential of chronic disease management to control cost over time. This is overt fallacy and prevarication. The relevant literature tells us, that with the exception of certain controlled populations, that these techniques will not control costs, even though they are good health care. Further, even if they somehow did control costs (which they won’t) it will take at least a decade to see any real results. Over that time, overall health care costs will have again doubled and then some. Can you imagine…

We can’t wait…

The irrelevance of these efforts are coming home to roost. The people of Vermont are now seeing that these efforts will not and cannot work to control the overall cost of health care here. And in fact they are adding to cost and complexity and are costing us valuable time and energy.

  • We have the opportunity to make a fundamental political shift of philosophy with a new Governor. We have the opportunity to elect someone who understands the problem and how to deal with it. Some of the candidates look like they might fit that bill.
  • Also, we’re starting to see some shortages in certain provider sectors such as primary care docs. People won’t stand for that. It’s already getting tough to find a primary care doc. And we’re about to see a large proportion of them leave the service over the next ten years.
  • And the new federal bills, if they continue to follow the paths that they are on, will be a great disappointment to many, and anger many others and even worse, increase our costs. More about that later…

All of these trends and dynamics are getting people more agitated on behalf of needed change.

So what can we do to improve the odds of getting publically financed and universal health care in Vermont? First, the role of effective politics.

  • We have to push our gubernatorial candidates to the wall on this one. They need to publically declare that they are for a publically financed health care system, and that they are ready and willing to get it done. This is one of the most important elections we have faced in a long long time. A Governor who believes could put wind in the sails of real reform. But a non believing Governor won’t give it a chance. It takes both the legislature and the executive to make it happen. And even a unified government doesn’t guarantee reform, to wit, the experience we are now seeing at the federal level, even with the Democratic control of Congress and the Presidency.
  • Candidates need to be advanced in every part of the State, particularly where there has been resistance from legislators to pursue a larger reform.
  • In the Legislature, could there be constructed a ‘Medicare for all’ health care caucus’ similar to the special interest caucuses in Congress, such as the black caucus, the blue dog caucus, and others. Those caucuses should be a force to reckon with in the Legislature. They could hold their own hearings to keep the pressure on. Their visibility would be in stark contrast to the fiddling and diddling of the Health Reform Committee and the House Health Care Committee.

Another thought…Over the years I’ve been visited at my home by people espousing one cause or another, energy, Vermont Yankee, voting process, etc., but I’ve never been visited by someone who is part of an organized effort to change health care. A statewide canvassing of all citizens over the next couple of years could go a long way into convincing recalcitrant legislators that it is in their best interest to promote change. Or even targeted canvassing in places that elect our legislative leaders could go a long way.

What else do we need to think about doing?

One of the problems with this subject is the enormity and complexity of it all. People want change but they don’t know how to grab hold of it, or where to begin. I have thought that the McFaun ‘Hospital Security Bill’ would have been an excellent place to begin. Here’s why…

  • It’ doable. Global budgets for hospitals. If I were a hospital administrator I’d welcome this development, why
  • It’s a more predictable way to know what my revenue for a fiscal period will be.
  • It allows me to plan ahead for an entire year
  • It allows me to spend my expensive time and energy on providing great health care, rather than managing money machines
  • It means I don’t have to waste time and money on advertising and competing with other hospitals for revenue.
  • I don’t have to waste time and money on utilization review, or determining eligibility for services.
  • I now can ask health care questions of patients first, rather than ‘what insurance do you have?’

And for the people of Vermont,

  • They would not have to worry about a medical event forcing them into bankruptcy. Nationally, that number has now reached an astounding 62%.
  • It would mean the end of 5 – 10 thousand dollar deductibles
  •  It would reduce their premiums in the order of 40%
  • And it would give Vermonters one of the most important things in life…peace of mind.

For our business community

  • It would also reduce premiums greatly
  • It would give Vermont business a major competitive edge by taking a major burden off the backs of business
  • And it would lower my workman’s compensation costs by about 13%

For the citizens in our towns and villages

  • It would greatly reduce their health care premiums
  •  It would help moderate their property taxes as the health care premiums for teachers and municipal workers would decline.

But here is the most important short term thing we could do. Vermont needs to get on with a broad economic study of the costs and benefits of universal health care, and hospital care as a subset. The Legislature put this requirement in law several years ago, for the Legislature itself to undertake such a study. It was made part of the ‘big bill’ the appropriations act. And they ignored their own lawful instruction. I was Secretary of Human Services for almost a decade under both governors Snelling and Dean, and if I had ignored such a lawful requirement, I would have been fired. But yet the Legislature ignored its own law. ..and got away with it.

Such a study would document the overall economic impact of universal coverage and public financing. We would learn, for example, how many businesses would set up shop in Vermont if health care was universal at reasonable price, and what the economic edge we would have in the marketplace, and what that edge could do to our overall economic vibrancy and revenue enhancement ability that could offset much of the cost. It would be a measure of our economic vibrancy.

We could also bring to life the immoral waste of resources of this ‘non-system’. People need to graphically see and understand the character of the waste. Organized visits to doctors offices for example by groups of citizens to see firsthand the 40% of overhead that physician offices have to bear in order to keep track of the complex individual payments, collections, and money seeking that these offices must endure in order to keep the doors open.

We need to drive home the impact of our shrinking cadre of primary care docs, the backbone of any good health care. People need to know that within ten years we will be losing many many doctors through retirement and dissatisfaction. We could publish the size of waiting lists for practices, for example, which even now are growing. The fact that the largest number of our primary care docs are over 50 years old, and will be leaving us soon, many because of their unhappiness with their current paperwork heavy circumstances, should be used to awaken our citizenry.

We need to pass a bill that takes the construction of a health care system out of the hands of legislative committees, whose members, by and large, do not have the experience, scope, or time and energy to fully understand this mega and complex issue of health care. The Legislature needs to empower a panel of both experts and informed citizens to undertake the planning of a bill that results in an ‘up or down’ vote on an entire comprehensive bill. And if the vote is ‘nay’ then it’s back to the drawing board until a comprehensive bill can gain approval. That approach will at least put the debate on a comprehensive plane, not to be picked apart by the special interests and individual committees. Compromise could be overridden by principle and sound evidence based practice by using this approach.

Finally, we need to think about all of us again, not just ourselves as individuals. We need our Legislature to think and behave the way they did when they voted to consolidate the Legislature through re-apportionment as they did in the 60’s. Many Legislators actually voted to put themselves out of business. It was hard…very hard…but was action on behalf of the greater good.

Now for a few comments about what is happening in Washington.

The bill, as passed by the House, is bringing hope to the millions and millions of people without insurance, and which has some positive and important things in it, such as expansion of community health programs, greater regulation of the insurance companies, extensions of benefits to domestic partners, and improvement of portability. From the point of view that we have never really had a serious political discussion about a national health care program for this nation, the bill is a good thing.

But the bill itself will bring a world of hurt to our health care. Why, let me count the ways.

The bill does nothing to turn the health care scramble into a system. It keeps all of the dysfunctional parts of health care. It tries to fix the unfixable pieces parts.

The budget balancing in the bill is a fiction.

You can’t cut Medicare by half a trillion dollars and have our hospitals survive. Half of them lost money last year.

You can’t even begin to control costs unless there is a publically financed way of paying for health care. You must have a system and control the money to control costs.

The bill is based on the Massachusetts approach, which mandates that businesses and individuals have ‘adequate’ health care, or they will be fined in an escalating manner. Massachusetts now has the highest percentage of people covered in the nation, and deserved ‘kudos’ for that. But its per capita price tag is now the most expensive health care system, in the world.

Their annual costs have risen, since 2002, by 6 ½ times wage growth. Vermont’s is bad enough at 3 ½ times wage growth.

Large company premiums rose 23% last year alone in Massachusetts.

And to start fining people and companies for not having or providing health care? How low can we go?

Its economic foolhardiness, yet our Congress, just like our Vermont Legislature, chose to ignore the evidence.

The overall financial impact of the DC bill is almost frightening to consider. There is the potential of increasing the overall cost of health care at rates even higher than today, resulting in even more uninsured, loss of providers, and serious decline in the quality of our care.

And little of substance doesn’t happen until 2013, four years from now. The price tag for health care will have increased 50% more by then.

Solving the health care problem is the economic and social issue of our times. The unrelenting rising costs are threatening all aspects of our lives. We are in danger of seeing our high quality care begin to erode. We will watch hospitals in Vermont go out of business, and we will see an explosion of the numbers of uninsured and underinsured if we don’t act soon.

All in all, this is an issue that cries out for constant and intense public education and political will. Anything we can do to raise the heat and elucidate the stakes with Vermonters hastens the day when our political leaders cannot ignore common sense any longer.

What is wrong with giving every Vermonter or American a Medicare For All card and publically financing our care? What is wrong with that? Why do we have to make this so expensive and complicated?

Either we succeed on this front, or we face continuing economic and social travails as our health care capacity systematically erodes our personal and public assets and more quickly erodes its ability to serve us all.

The future is in our collective hands.

Thank you.