One of the central promises of Bernie Sanders' presidential campaign is the creation of a single-payer health-care system.
His rival for the Democratic nomination, Hillary Clinton, calls it unrealistic. His "Medicare for all" bill in the U.S. Senate, she points out, failed to attract a single cosponsor. What's more, everyone knows the idea of creating an entirely government-run health-care system won't go anywhere in Washington. It has even been rejected in Sanders' own state of Vermont, despite years of trying.
“We’ve been at the threshold of implementing some sort of single-payer system for just about every decade since the ‘70s,” said Con Hogan, a former aging services secretary in Vermont and now a board member of Green Mountain Care Board, a state-created group overseeing health-care innovation.
After several false starts, a bill was passed in 2005 that would have led to a single-payer system. Instead, it was vetoed by Jim Douglas, the Republican governor. In 2011, a single-payer bill again passed. This time, it was signed by Democratic Gov. Peter Shumlin. Suddenly, Vermont was on its way to becoming the first state to create a single-payer system in U.S. history.
The intent was to have a plan up and running by 2017. "Vermont already has 91, 92 percent of its residents insured," said Hogan. "This piece of legislation was meant to get us over that hump for the remaining uninsured."
The law created the Green Mountain Care Board to oversee the implementation of the new system. Separately, Shumlin hired outside experts to crunch numbers and put an economic price tag on the plan. That group included Jonathan Gruber, a controversial architect of the Massachusetts health-care expansion and the federal Affordable Care Act; William Hsaio, who oversaw Taiwan’s transition to a single-payer system; and health policy expert Steven Kappel of the University of Vermont.
After the three presented their options in a 203-page report, state legislators seemed to lose their enthusiasm. Specifically, they weren’t happy with the proposed tax increases. Vermont businesses would have been subject to an 11.5 percent payroll tax, while residents would have paid additional income taxes on a sliding scale, capped at 9.5 percent. Legislators didn't even bother debating this financial plan.
"It died," said Hogan. "It was disappointing because I was looking forward to having that debate, but the bill just died."
Instead, Shumlin decided at the end of 2014 to kill the single-payer plan altogether. Shumlin conceded that instead of costing $2 billion annually, as his administration had originally estimated, the price tag would start at $2.59 billion in 2017 and go up to $3.17 billion by 2021.
Despite the setback, single-payer advocates don’t think Shumlin's retreat means this is Vermont’s last attempt.
"It really depends on who our next governor is, since Shumlin isn’t running for re-election this year," said Deb Richter, the head of Vermont Healthcare for All, a single-payer advocacy group. "I think it’s something we’re going to have to build back up and implement incrementally, starting with primary care.”
Meanwhile, the Green Mountain Care Board remains hard at work. Hogan said the board is developing a statewide accountable care organization (ACO) that would work like a single-payer system, at least on the financing side. The ACO would aim to move the state from a fee-for-service system, while keeping overall costs down. The board is aiming to have a plan ready to present to the federal government by next year.
Long-shot efforts to enact single-payer continue in other states. Colorado voters will soon have their say on the issue, with an initiative on the ballot this fall.