Vermont's single payer proposal – listen to William Hsiao

By William C. Hsiao, Ph.D.
The New England Journal Of Medicine
March 16, 2011

The United States faces two major problems in the health care arena: the swelling ranks of the uninsured and soaring costs. The Patient Protection and Affordable Care Act (ACA) makes great strides in addressing the former problem but offers only modest pilot efforts to address the latter. Experience in countries such as Taiwan and Canada shows that single-payer health care systems can achieve universal coverage and control inflation of health care costs. Because of strong political opposition, however, the U.S. Congress never seriously considered a single-payer approach during the recent reform debate. Now Vermont, wishing to solve the intertwined problems of costs and access through systemic reform, is turning in that direction.

Perhaps we are at the dawn of systemic reform in U.S. health care. The Vermont single-payer plan will never be as efficient as Taiwan’s or Canada’s because it must work within the bounds of federal laws and programs and the realities of porous state borders. Nevertheless, it can produce substantial savings to fully fund universal coverage, reduce health care costs for most businesses and households over time, and reform a fragmented delivery system. Of course, someone will bear the burden — mostly the private insurance industry and high-wage businesses that don’t currently offer insurance. But if Vermont can navigate its political waters and successfully implement this plan, it will provide a model for other states and the country as a whole.

http://healthpolicyandreform.nejm.org/?p=13939&query=home

Also posted at:
https://pnhp.org/news/2011/march/state-based-single-payer-health-care-a-solution-for-the-united-states

Comment: 

By Don McCanne, MD

Many in the single payer community are looking at this as a great opportunity to do what Saskatchewan did – establish the first state (provincial) single payer system to serve as a model for the rest of the nation. This perception is right on – almost, but…

Saskatchewan began with a tabula rasa. They were not hindered by a quagmire of federal programs, laws and regulations. Vermont and all of the other states attempting to establish a single payer system must obtain waivers allowing them to be exempt from these federal constraints. The problem with that is that waivers do not exist for most programs and regulations, except for the subsidies in the insurance exchanges, and for Medicaid, but even these “1115” Medicaid waivers have very significant limitations on the modifications that can be made.

We still require comprehensive federal legislation if we are to achieve a true single payer system on the state level. The legislation to introduce a complex set of policies into the existing meshwork likely would be more complex than legislation to replace our current financing with a national single payer system. The political barriers would certainly be as great, if not greater.

The point is that we must not let up in the least in our efforts to educate the public on the financial and moral imperative of a national single payer program. Comprehensive national legislation is absolutely essential, even for state-based single payer systems.

In the meantime, state programs that adopt many of the features of a single payer system can serve to relieve to some degree financial hardship and physical suffering, as a temporary measure, until we can enact a national program. Efforts, such as that in Vermont, certainly deserve our support, but also would benefit from our efforts to have them include as many single payer policies as are possible under the current federal restraints. Partial successes on the state level can show the nation that we can do far, far better than we have done with the Affordable Care Act.

So let’s continue to support these state efforts. But rather than relaxing our stand on behalf of a national single payer system, we need to intensify our efforts since William Hsiao has shown us that “the Vermont single-payer plan will never be as efficient as Taiwan’s or Canada’s because it must work within the bounds of federal laws and programs and the realities.”