By Dr. Ida Hellander

This is a two-stage bill which attempts to use the establishment of the required health benefit exchange under PPACA as a bridge to a “public-private single payer health care system” (Green Mountain Care) upon receipt of the required federal waivers. Here are some representative quotes:

“This bill proposes to set forth a strategic plan for creating a single payer and unified health system. It would establish a board …. ; establish a health benefit exchange for Vermont as required under federal health care reform laws; create a public-private single payer health care system to provide coverage for all Vermonters after receipt of federal waivers” (p. 1).

“The intent of the general assembly is to establish the Vermont health benefit exchange in a manner such that it may become the foundation for a single payer system” (p. 5).

“Green Mountain Care shall be implemented upon receipt of a waiver … of the Affordable Care Act. As soon as available under federal law, the secretary of administration shall seek a waiver to allow the state to suspend operation of the Vermont health benefit exchange and to enable Vermont to receive the appropriate federal fund contribution ….” (p. 44).

Comments and concerns

1. The reforms enacted prior to the implementation of single payer are inadequate and delay fundamental reform for 3-6 years. Several states have enacted reforms in the past only to repeal them before full implementation.

2. Provisions necessary for cost-control, such as an annual budget, and separate operating and capital budgets for hospitals, do not appear in the legislation, but do (confusingly) appear in the summary and testimony on the bill by Anya Rader Wallack (summary, p. 3 and testimony, p. 8).

3. The section on pilot projects for payment reform/ACOs appears to allow insurance companies to run ACOs: (p. 15) “the scope of services in any capitated payment should be broad and comprehensive, including prescription drugs, diagnostic services, services received in a hospital, mental health and substance abuse services, and services from a licensed health care practitioner … and may consider “whether to include home health services and long-term care services as part of capitated payments.” Only insurers can bear this much risk, and indeed the three private insurers in Vermont are already involved in developing ACOs.

4. The section on administration allows an insurance company to bid for “administration of certain elements of Green Mountain Care.” This adds unnecessary expense to the program.

5. What will the cost sharing be? (p. 39) “Green Mountain Care shall include cost-sharing and out of pocket limitations as determined by the Vermont health reform board … there shall be a waiver of the cost-sharing requirement for chronic care for individuals participating in chronic care management and for primary and preventive care.” Cost-sharing limits access to care and is ineffective at controlling costs; it should be eliminated.

6. There is no ban on investor-owned health facilities.

7. On the bright side, the single-payer plan includes Medicare and Medicaid (p. 40, 41-42), workers’ compensation and retirees (p.38); covers all “residents” (not just citizens, p. 37); there is at least a nod to the need to have comprehensive benefits including long-term care (if the budget allows); there is language on retraining displaced administrative workers (p. 56); bulk purchasing of drugs and supplies; use of “smart card” technology as in Taiwan (p. 37); and insurance coverage that duplicates the single payer is proscribed (p.41). (This last feature is contradicted, however, by a provision that allows employers to retain their existing coverage.)

8. Some additional features: There is an emphasis on mental health parity and an adequate supply of mental health professionals; emphasis on primary care and use of “medical homes” (this could be good or bad, depending on if they are part of an insurance company-run delivery system).

9. Finally, the bill does not specify financing, except to say that two options will be presented for consideration and all options for raising revenues will be considered (not just a payroll tax, as Dr. William Hsiao had recommended).


Single-payer advocates will have to fight to strengthen the single payer section of this bill, keep single payer in the bill at all (there will likely be attempts to strike it), get the necessary federal waivers and make single payer (aka “Green Mountain Care”) a reality.

Dr. Ida Hellander is executive director of Physicians for a National Health Program.