After Major Setback, Single-Payer Movement Shifts Focus To Universal Primary Care

May 04, 2018

Vermont Public Radio

By Peter Hirschfeld

It’s been more than three years since then-Gov. Peter Shumlin abandoned his pledge to create a universal health care system in Vermont, but advocates are working this session to reignite the embers of the single-payer flame.

On a Tuesday evening in late January, around 50 Vermonters showed up for a public hearing on the floor of the Vermont House of Representatives.

The topic was Senate Bill 53 — an act relating to universal coverage for primary care services.

Each person was allotted three minutes to say their piece; it was not the first time Millard Cox had done this.

“So here we are again,” Cox told the House and Senate health care committees. “I don’t know how many times I’ve been here. But we come back every year, asking for a different, more humane, more rational health care system.”

Like most of the people in the room that night, Cox supports a universal, publicly funded health care system for Vermont — something akin to the single-payer framework used in most other developed countries.

Even proponents of single-payer say that likely isn’t happening anytime soon in Vermont, but a number of key lawmakers have thrown their weight behind what could be called "single-payer light."

S.53 is a bill that would commit the state down a path toward universal primary care. Cox told lawmakers in January to seize the opportunity to pass it.

“And take us to a system in which health care is considered a universal human right and a public good,” Cox said.

According to a 2015 study by the state, universal primary care would cost about $200 million a year, assuming providers are paid at the rates they get now.

S.53 directs the state to develop a program framework, come up with a tax to fund it and to institute universal primary care beginning in 2019.

Dr. Deb Richter, a practicing physician and leader of the single-payer movement, says the bill would allow every person in Vermont to see a primary care doctor of their choosing, free of charge. She says it’s a good place to start.

“Because primary care is really where you go to find out whether something is serious or not. ... And certainly, I have had patients who have actually died as a result of avoiding care,” Richter says.

Richter says even insured Vermonters avoid care because they can’t afford their co-pays and deductibles. That’s the case for Patricia Reid, who urged lawmakers to pass universal primary care at the public hearing back in January.

“Although I currently carry private health insurance, I do not access care when I need it due to financial barriers,” Reid said. “It does not have to be this way. With universal publicly financed primary care, we would reduce the need for expensive hospitalizations and emergency room visits by preventing disease and treating conditions earlier.”

For Richter and others though, universal primary care is a means to a much greater end.

Addison County Sen. Claire Ayer, who chairs the Senate Health and Welfare Committee, says the more she learns about the health care system, the more she believes it faces an existential crisis.

“The only way we’re gonna be able to survive this — these changes in health care — is for everybody to pay for it and everybody to get it,” Ayer says.

Ayer says the decision to shelve single-payer in 2014 was a serious blow to the cause; she says it does not have to be fatal.

“OK, maybe we can’t do single-payer right now, I get that,” Ayer says. “But let’s see if we can take this chunk that benefits everybody and move it out the door.”

But even proponents of publicly funded health care in concept aren’t ready to make the universal primary care commitment.

Senate President Pro Tem Tim Ashe says there’s no disagreement that Vermont needs to improve access to health services, especially primary care. Before the state can commit to a publicly funded system, however, Ashe says lawmakers need far more information than they have now.

“When you’re talking about hundreds of millions of dollars of public expenditure, the general rule of thumb ought to be that prior to concluding what the right solution is, we have done the homework first,” Ashe says.

Ashe says the state also faces unknown, and potentially unknowable, risks at the federal level. President Donald Trump last year called for a Medicaid overhaul that could have cost the state hundreds of millions of dollars annually in lost federal revenue.

Any public financing framework that relies on cost-sharing with the federal government, Ashe says, is vulnerable to acts in Washington, D.C., over which the state has no control.

“I wish we could be in a reality that Donald Trump’s not the president and we don’t have the most right-wing, anti-government Congress possibly in U.S. history. But we do live in those times right now,” Ashe says. “I worry about the rug being pulled out if we were to start moving forward with the actual implementation without doing the homework first.”

Ayer and Richter say Vermont has already conducted a number of rigorous universal primary care studies. Asked to explain the urgency of committing now, rather than conducting more due diligence, Ayer offered an analogy:

“Remember when you were a teenager and you asked your dad if you could use the car on Saturday night? If he said, ‘Yes,’ that was a commitment,” Ayer says. “If he said, ‘We’ll see,’ it left the door open. But you knew pretty much it wasn’t gonna happen.”

The primary care bill has faced a bumpy road this year. Back in March, the Senate Appropriations Committee stripped the legislation of any language committing to, or even endorsing, universal primary care.

But, last month, the House Health Care Committee reintroduced the original provisions. Committee chairman Rep. Bill Lippert cast the decisive vote in favor of the language, and then explained why.

“Because I think it also is a statement toward what I believe we should have, which is publicly financed health care,” Lippert said.

Asked recently whether he’d support universal primary care, Scott answered with a decisive "no."

“You know, I’ve seen that movie before, and I know how it ends, and it’s called single payer," Scott said. "And I don’t believe the end of this movie would be any different."

Scott said the state is moving forward with an alternative health reform initiative, led by a coalition of providers known as an "accountable care organization."

Richter, however, says the thousands of Vermonters who mobilize in support of single payer have not disappeared.

“And as things get worse and worse, which they are,” Richter says, “they will be a force to reckon with.”