Once again, the states are leading the way on health care reform. This past week, the Vermont House and Senate passed two versions of a bill that would essentially get a consultant to design three systems for health care in Vermont: something similar to Canadian single payer, something similar to a private system with a public option, and something similar to the recently passed federal health insurance bill.
The bill, S.88, has been passed by both houses of the legislature, but a different version was passed in each house. It was first passed in the Senate, then amended in the House. According to a press release, this means that the Senate will now vote on the House version. Sometimes bills like this go to kind of conference committee like a blog post at the Vermont Progressive Party's website suggests, but in an email Progressive State Representative David Zuckerman said that, although a committte is "the usual event," he "would presume they [whoever issued the press release] know more than we do."
What's definite is that the bill does not go straight to the governor's desk from here.
What the bill would actually do depends on which version you're reading. According to that same press release, which was clearly issued by supporters:
The bill charges the Health Care Reform Commission with hiring a consultant to create least three designs and implementation plans for a new health care financing system in Vermont. The designs must include a "single-payer" system, a "public option," and one based on state and federal reform initiatives. The final report will be issued February 1, 2011...
S. 88 takes steps to lower health care costs. It calls for statewide expansion of the Blueprint for Health, an innovative program for strengthening primary and preventative care, which was a model for the recent federal reform. A community health systems pilot program is also established to coordinate how different institutions care for their patients and get paid for their work.
The Associated Press reported it as,
The House version calls for that as well as a parallel design of a system with a public option for health insurance, meaning a system in which a health insurance program offered by the government would compete against those offered by private companies. The House's version also would expand previously enacted reform efforts...
The Senate focuses on single-payer as the goal, but also calls for two alternative designs. Differences will have to be worked out in a conference committee of three members from each chamber, and it's not clear what Gov. Jim Douglas, a Republican, will do with the bill...
...provisions to expand existing efforts to control costs and slow hospital budget increases, Tringe said. He [Gov. Douglas] does not like a provision requiring drug companies to disclose to the attorney general when they provide free samples to doctors' for distribution to patients, she said.
The bill may or may not have the support of Republican Governor Jim Douglas at this point, although he is not in favor of single payer or, as the AP story notes, every provision of the bill. While it was not a partisan vote - partially because of the six Progressives and two independents in the Vermont legislature, but also because of supportive Republicans - there were Republicans that were strongly opposed to the bill.
Another supportive perspective comes from the Brattleboro Reformer's opinion page, where Democratic State Representative Carolyn Partridge wrote (although this part of the piece is not necessarily dependent on whether or not she supports the bill),
The bill creates a framework for reform by laying out principles and goals.
The first principle includes the following: "It is the policy of the state of Vermont to ensure universal access to and coverage for essential health services for all Vermonters. All Vermonters must have access to comprehensive, quality health care. Systemic barriers must not prevent people from accessing necessary health care. All Vermonters must receive affordable and appropriate health care at the appropriate time in the appropriate setting, and health care costs must be contained over time."
The bill creates the Joint Legislative Commission on Health Care Reform, the members of which will be appointed by the Speaker of the House and the Senate President Pro Tempore, with two non-voting members appointed by the governor.
But many people who strongly support single payer either reluctantly supported the bill or opposed it based on the differences between the House and Senate versions of S.88 mentioned in the AP piece. The aforementioned post at the Progressive Party's blog states:
This week S.88 debuted in the House Health Committee and they took the 21-page straightforward bill and turned it into a 104-page disaster...
It is too complex...
They have combined a plan for studies (as laid out in S.88) with a plans for implementation. This will effectively render all studies useless...
...focused on quality of care and delivery instead of costs and accessibility...We need to find an affordable way to pay for this.
Embedded in the Blueprint for Health are too many regulations that are worrisome and that doctors do not support including serious issues of patient confidentiality.
In an email exchange with Progressive State Representative David Zuckerman, who was absent for the final vote because he knew "our caucus would be voting yes" and he "had to get out to the farm" because his wife is currently somewhat incapacitated, he said that it's a complex issue. On the one hand, S.88 was a wonderful bill when it was in the Senate and is not without its merits even as the House passed it (otherwise, the Progressives wouldn't have voted for it unanimously). And before that final unanimous vote, the Progressives worked against making it more convoluted and supposedly less effective. On the other hand, in Zuckerman's words,
My thoughts during the debate (and I spoke them on the floor) is that we have discussed universal healthcare since I have been in the legislature (14 years) and probably longer than that... Unfortunately in implementation, the single payer bits somehow keep getting forgotten. Whether they are removed from debate (Gov. Dean) or removed from implementation (Gov. Douglas) the end result is the same. Tweaks to the system, but relatively mild progress in the big picture...
As one legislator said to me, "if this bill helps just one person then I can not see how anyone can vote against it.", my reply was "that there are 40,000 people without insurance (and many more without actual adequate care...but that is another topic). If we help get one more covered each year then it will be 40,000 years until eveyone is covered..."
So as Progressives we generally voted against the House version to add a lot of complication to the bill. However, once we lost that, we voted for the bill to keep moving forward. Because while we would rather the focus be put on the larger overhaul, we are not obstructionist and we do want to see whatever progress can be made.
A former Progressive State Representative, Terry Bouricius, told me that he feels the House version of this bill isn't even going to lead to single payer, and that was even dubious in the Senate version. He emailed to me an exact copy of what he sent to his current representative, and the general idea of the message was that piecemeal reforms like this don't lead to single payer. In fact, he says, they just prevent it ever being implemented:
When I was in the House in the 1990s and pushing for single-payer, the cautious (though well-intentioned) said, no, let's focus on "managed care" as the way to contain costs and improve care. We had to wait years for everyone to see that HMO's weren't going to solve the problem...
I recall when I was on the Commerce Committee (charged with reforming health insurance), a lobbyist from the Golden Rule Insurance Company was giving testimony. When asked, why the state couldn't simply put everybody into one big insurance pool, she responded..."That isn't insurance. Insurance exists to protect the assets of individuals who have assets to protect in case of tragedy. What you are talking about is providing health care to everybody. That isn't insurance. If you wanted to do that, you'd just raise a tax and pay for everybody's health care."
By PRETENDING to deal with the health care crisis through all these other little "fixes"' in the House Committee version, I can practically guarantee that no real effort toward single payer will take place for years to come. Vermont needs to MOVE on single payer while Obama is still in office (we can't assume he will get two terms), as we will need various waivers that only a Democrat will allow.
Another person who completely opposed the House bill was Deb Richter, a doctor in Montpelier and former president of Physicians for a National Health Insurance Program. "The over-loaded House version is about changing the delivery of our health care by adding layers of costly bureaucracy," said Richter. "The House Health Committee's claims that this will save money are disingenuous. No evidence of cost-saving exists." The story continues in the Barre Montpelier Times Argus:
Richter supports the Senate version of S.88, the bill that began in the committee of Sen. Doug Racine, D-Chittenden, a gubernatorial candidate, and would hire a consultant to design at least three new health care models – including a single-payer system – for Vermont.
So opinion is divided on the bill, although it did end up passing with a fairly large majority. What effects the bill has in the long run - or, in the short run, what it will look like if and when the governor signs it - remain to be seen. Either way, it's just more evidence that the health care fight is not over in any way, and that strong movements for single payer at the state level are leading the way.