The Vermont State House wrapped up work on a bill that would bring universal health care to the state, approving the final version and sending it to Governor Peter Shumlin for his signature. Shumlin plans to sign the bill within the next two weeks. The vote today was 94-49.

The legislation works within existing structures but does guarantee publicly financed health care to every resident of Vermont.

The legislation establishes a state health insurance exchange — mandated by the new healthcare reform law called the Affordable Care Act (ACA) — through which individuals and small businesses can purchase coverage. The bill envisions this exchange becoming a publicly financed health plan called Green Mountain Care that is available to all Vermont residents. Proponents of Green Mountain Care have touted it as a single-payer system, but the bill allows individuals covered under the state plan to buy supplemental policies from private insurers. In addition, individuals can keep the insurance coverage they already have.

For these and other reasons, a group called Physicians for a National Health Program contends that the Vermont bill falls short of a true single-payer model. Although Governor Shumlin disagrees with that assessment, lawmakers removed the expression “single-payer system” from the bill and replaced it with “universal and unified health system.”

Even in France and other European countries with single payer, individuals can buy supplemental policies; I don’t have a problem with that at all. The “keep what you have” provision sounds like a bad idea, a compromise to get it passed, but over time the old plans will gradually get phased out as younger Vermontians opt for the publicly-financed option.

This ends the main legislative actions in Vermont needed to set up the system. But two major hurdles remain for this to get implemented. First of all, Vermont must dedicate a funding source for the program, which has yet to happen. They may be able to draw funds from the federal government that go toward health care, but they will need to find additional funding sources. The expectation is that broad-based taxes would finance the universal health care system. But the specifics have yet to be worked out.

The other major issue is getting the proper waivers to implement the system. Under the Affordable Care Act, states would have to wait until 2017 to opt out of the federal system and enact their own reform plan. The Department of Health and Human Services has to certify that the state will be able to supply an equivalent amount of coverage to its citizens without a higher cost. That state would then receive all the funding they would have gotten from the federal law for their unique system. A bill introduced by Vermont’s Peter Welch in the House and Ron Wyden in the Senate would move that opt-out date back to 2014. This makes a lot more sense, since that’s the year the exchanges go live. Otherwise, Vermont would have to set up exchanges and implement the ACA for three years, only to opt out later.

There will probably be some other legal hurdles to jump through as well, from either insurance companies or providers. The federal ERISA law will be the subject of a significant challenge.

Vermont lawmakers and the Governor hope to have single payer in place in Vermont within 3-5 years if all goes well.

David Dayen

David Dayen