The Demise of Vermont’s Single-Payer Plan

By John E. McDonough, Dr.P.H., M.P.A.
The New England Journal of Medicine, April 23, 2015

On December 17, 2014, Vermont Governor Peter Shumlin publicly ended his administration’s 4-year initiative to develop, enact, and implement a single-payer health care system in his state.

In reality, the Vermont plan was abandoned because of legitimate political considerations.

In many states, legislators continue filing bills to establish state single-payer systems. Because of Vermont’s failure, their path is both clearer and more difficult. Any other state considering this path will find obstacles similar to Vermont’s.

In the early 1990s, I served as a Massachusetts legislator who took a turn as the state’s leading single-payer advocate. After years of failure, I reluctantly concluded that single payer is too heavy a political lift for a state. Though the economic case is compelling, our body politic cares about more than just economics. In 2011, many observers thought that Vermont, a small and progressive state, was the ideal locale in which to try single payer. No more.

At some point, perhaps 5 to 15 years from now, as the size and scope of Medicare, Medicaid, and the ACA subsidy structure balloon far beyond today’s larger-than-life levels, our political leaders may discover the inanity of running multiple complex systems to insure different classes of Americans. If advanced by the right leaders at the right time, the logic of consolidation may become glaringly evident and launch us on a new path. If such consolidation is to occur, like it or not, I believe it will happen federally and not in the states — and no time soon.


From the audio:

“People who like the state approach refer to how the Canadian health care system started with the adoption of universal coverage for hospital services in the province of Saskatchewan back in the 1940s, and that is the idealized model. I just am unclear, unsure, doubtful how relevant that model is in an advanced developed system like those in the United States and the fifty states at this point.”

John McDonough is a professor of public health practice and director of the Center for Executive and Continuing Professional Education at the Harvard T.H. Chan School of Public Health.

NEJM article and audio:

Professor John McDonough, as an academic and as a legislator, has long been in the trenches with single payer. He knows what he is talking about.

The problem with using Saskatchewan as a model for reform in the United States is that Canada began with a clean slate whereas we have complex federal and state financing systems that will need to be replaced. States alone cannot do it without federal action.

Though we need federal reform, it will not happen in the immediate future since the politics are not in alignment. We need to intensify our efforts with the basics: education, coalitions, and grassroots organizing.

Until we get the politics aligned, activists should continue advocating for whatever state reforms are possible that would move us closer to health care justice. But do not let up in the least on the drumbeat for a single payer national health program – an improved Medicare that would cover everyone.