On the Republican side, yes, as Markos writes, their intransigence means that the Heritage-devised plan they should have embraced and worked with Democrats to home and perfect is less than perfect, still leaving out too many people. That's particularly true of all the people in the Medicaid gap. Those millions, as many as 6 million, are in health insurance purgatory—too poor to qualify for subsidies to buy private insurance, making too much to qualify for traditional Medicaid.
But, now that Obamacare's success seems to be firmly assured, we can press its shortcomings and highlight it as the first step toward the universal health care. Vermont is a great place to start and plays a key role here, but it can't do it alone. Below the fold, we'll talk about why that's the case.
Vermont is working toward obtaining a waiver from the federal government to create what would be the first single-payer system in the country. The state can't actually put it in place until 2017, because the law requires all states to follow the new law until then. But they have a small window to do it, too, because there's no guarantee a 2017 White House will be cooperative.
Vermont wasn’t satisfied with the health reform law that Washington passed in 2010, the Affordable Care Act. That law expands health coverage by growing the existing health-care system. Americans who already had health insurance have seen barely any change. Uninsured people have gotten covered through two existing programs: the individual insurance market (where millions of Americans now receive subsidies to help buy coverage) and Medicaid, a public program for low-income people.There's the rub for a small state like Vermont, operating as it does within the national health care system—an extremely expensive system. A team of economists the state contracted with to determine how much it might cost estimates that the state will have to come up with an additional $1.6 billion in tax revenue in 2017 to pay for a single-payer system. Shumlin and his advisors think that they'll be able to save $36 million in statewide health spending in its first year, $86 million in the second year, and $158 million in the third, mostly from administrative expenses. But a second estimate by research company Avalere Health, obtained by the state's medical community, puts the price tag on the first year of the system at $2.2 billion.
[Gov. Peter] Shumlin had a different idea. He didn’t want to build on what existed. He wanted to blow up what exists and replace it with one state-owned and operated plan that would cover all of Vermont’s residents—an example he hopes other states could follow. […]
On May 26, 2011, Vermont passed Act 48, the first law in the nation that provides health coverage to all residents of a state. Act 48 established Green Mountain Care, a health insurance plan that all Vermont residents would gain access to, by virtue of being Vermonters.
Green Mountain Care cannot start until 2017 because the Affordable Care Act requires states to hew to the federal health reform model for the next three years. […]
Between now and then there are two big questions that Vermont has to answer: how much will single-payer cost, and can the state find a way to pay for it?
The state's providers question that they'll see as much as Shumlin is predicting in the way of administrative cost cuts. The genius behind a single-payer system is that there's only one entity that a provider has to bill, significantly reducing administrative costs. The problem with trying to superimpose that idea into our existing national system is that there will be other insurers that Vermont's providers have to deal with, because they see a lot of patients from surrounding states, and they have to deal with all of the insurers that cover those folks.
"In Vermont we’ll go from four to five commercial payers to one," Fletcher Allen chief executive John Brumsted says, "But we still have a dozen or so more than we’re negotiating with and interacting with in Northern New York and New Hampshire. We still have to have the infrastructure in place to support multiple payers."It's not just negotiating with multiple payers, but trying to set up a cost-controlled system within the context of a national system that has exorbitant, irrational costs in its DNA. One small state going up against that Vermont might have greater success if it could convince New York, New Hampshire, Maine or Massachusetts to join in. A regional single-payer system would have the advantage of a larger market capacity for negotiation.
Vermont, whether it succeeds or not, will provide critical experience for all the states—or potentially regions—to experiment with health care. But what it's demonstrating now is that Obamacare alone is not enough to reach the goal of universal health care. It should provide key lessons for how to get there, however.
In the meantime, President Obama and Democrats in Congress have to focus like a laser on both the achievements of Obamacare—8 million enrollments in the exchange market, millions more in Medicaid, at least 1 million adult children on their parents' plans, and as many as 8 million in new employer-sponsored plans off the exchanges. That's huge. It's working and Democrats need to yell that from the rooftops, particularly as Republicans have nuthin' but repeal.
But there are still millions of people left out, and that's the message Democrats need to run on as well. They need to run on it and win, and then fix it. Vermont will have a much easier time in making a transition to single-payer if the federal government works to incorporate a public option component into Obamacare. Say, for example, using the Medicaid funding forfeited by red states to create a Medicare buy-in on the exchange in those states.
The whole 2014 and 2016 table has turned with the remarkable success of the Affordable Care Act. The law finally has the momentum denied by Republicans and the courts after its passage. So now's the time for Democrats to build on it, energize the base and start talking more reform.