Why single payer died in Vermont

[George II]

(note: this is a few years old, but it points out the pitfalls of "single payer" )

Why single payer died in Vermont

Vermont was supposed to be the beacon for a single-payer health care system in America. But now its plans are in ruins, and its onetime champion Gov. Peter Shumlin may have set back the cause.

Advocates of a “Medicare for all” approach were largely sidelined during the national Obamacare debate. The health law left a private insurance system in place and didn’t even include a weaker “public option” government plan to run alongside more traditional commercial ones.

So single-payer advocates looked instead to make a breakthrough in the states. Bills have been introduced from Hawaii to New York; former Medicare chief Don Berwick made it a key plank of his unsuccessful primary race for Massachusetts governor.

Vermont under Shumlin became the most visible trailblazer. Until Wednesday, when the governor admitted what critics had said all along: He couldn’t pay for it.

more at:

https://www.politico.com/story/2014/12/single-payer-vermont-113711

Also:

https://www.politico.com/story/2014/12/vermont-peter-shumlin-single-payer-health-care-113653

[drray23]

1. Was doomed to fail.

Vermont is too small to affect the cost of healthcare and "bend the curve". One of the premise of universal healthcare is that if it's done at a big enough scale, drug makers and the like wont be able to raise prices freely.

If it was done at a federal level or even by a big state like California, the health industry would be forced to negotiate and deal with it. This is what happened with fuel emission standards for cars and catalytic converters. California drove the whole thing and it ended up being nationwide because it was not cost effective for companies go keep making two versions of the same cars.

[qazplm135]

3. correct

one can debate whether it works or not, but trying it out in such a small state was NEVER going to work. It doesn't even really count one way or the other to be honest.

[DrToast]

4. But California IS trying and they're running into many problems too

California hasn’t given up yet, but it’s proving difficult even for a state like California.

[emmaverybo]

28. Vermont already had high taxes, on income, retirement, sales...one factor was that Vermont

experienced disastrous, widespread flooding and has done a great deal for flood prevention. Also, it is a beautiful state offering good education, pristine cities. So I can see that a big upswing in taxes
for healthcare there would have been a difficult pill.

[still_one]

2. That is why it is so important to know exactly how much it will cost, and where the money will

come from

Just saying the 1 or 2% of the wealthiest, or cutting military spending isn’t good enough

We need numbers

[CTyankee]

5. Even the smaller countries in Europe can do this in one form or another of universal coverage.

Let's look to those countries, both large and small, to see how they did it. It works for them, they won't give it up for our form of health care and they are healthier and happier as a result. Their health outcomes, the measures of a healthy society, are positive there.

[MichMan]

29. Nearly all of them have VAT of 15-20%

I haven't seen anyone advocating for that.

[CTyankee]

32. I am not an economist. However, it seems to me that you would have to look at the bigger

picture: what are they getting for their taxes and are those services relatively equally distributed across all incomes? Going on that premise, my guess is that those taxed do feel it is equitable, or else they would get rid of it. Right?

[Blue_true]

38. Even though all of those countries have liberal histories,

the majority of them have elected rightish PMs recently. The exceptions are Iceland (a true leftist) and to an extent, Denmark.

[CTyankee]

39. Haven't read up on their relative right wing policies but I haven't hear anything about their

wanting to switch their countries over to an American style health care system. Did I miss something?

[MichMan]

45. It's not a question if they want to change their system to ours...

… Are we willing to impose the VAT taxes that they use to pay for it?

[CTyankee]

48. Before we get to that, let's not skip over another option: Warren's tax reform plan whereby

The inordinately wealthy pays more in taxes to support health care for everybody. This renders the question of a VAT irrelevant. The money is already there; it's just not being taxed as it should.

I cannot go into her spiel on this because she boils it down better than I can. But she says it every time she talks about her ambitious plans. She knows where the taxable money is and that it is being shielded from taxation by the power of the very rich in charge of Washington through President Trump.

Listen to her next speech. I guarantee she will explain it all again (and you can probably find it broken down on her website). Then we can debate further.

Is it a deal?

[Hortensis]

57. Yes. Almost all the transfer of wealth has been from the higher-taxed

working classes to the lower taxed and even often tax-free. For a variety of reasons, dollars in our pockets are of far more benefit to the nation than in those of the 0.5%.

As for analyzing the various ways other nations do it, we're of course not exactly leading on this. Very intelligent people have been doing that for decades and taking notes. That's a huge reason the ACA turned out as excellent as it did, even though the Repubs removed some very important, even critically, parts and allowed literally no tweaks to the "prototype."

I've read more than once that the nations considered to have the best overall systems offer more than one means of healthcare access.

[Blue_true]

58. I like Senator Warren's plan.

But there is not many inordinately rich people in this country. They are called the 1% for a reason. I don't believe that taxing 2% of their assets will produce nearly enough, in fact taxing away 15-25% of their assets won't be enough.

I wish the super-rich were uniformly better at understanding that they get to keep what they have only because their is a public funded infrastructure around them (public schools, police, firefighters, water plants, sewers, roads, ect). They can send their kids to private schools and hire bodyguards, but those things will fail them in a New York minute if society crumbles around them. So, longterm it is in the rich's best interest to help fund society in proportion to their wealth and earnings.

But the fact is, other people will have to pay more in taxes. How well that works depends upon the tradeoff they get, if in net they spend less each year on all things like taxes, healthcare, schools, they will likely grow to love the new system. But if the tradeoffs are not made crystal-clear, don't expect people to take a chance, unfortunately many would prefer to stay with an ignorant and totally incurious demagogue.

[5starlib]

40. Europeans like government, Americans don't...that's the big difference

My European friends actually trust the government to do the right thing so they have no problem forking over 50% of their check to them. In America, there is a big distrust of government that the media happily partakes in. This is why MFA and single payer are so difficult. It's too easy to make a caricature of "big government." We will never be Denmark.

[CTyankee]

42. Was it Denmark that got the highest grade on the "happiness" metric for their country?

They seem to like their way of life. They sure don't have our measure on the mental health scale. Nor the violence and murder scale. They are happy and part of that is feeling secure with their form of government, their level of satisfaction with their lives. They don't have our violence, our poverty, our child health outcomes, etc.

Exactly why then is "trusting their government" such a bad thing?

[5starlib]

43. It's the culture here that is different.

There is no such thing as "big government" there. They are very happy with their government. Americans mostly have a distrust of politicians that run the government. There's none of that in Sweden and Denmark. Obama caught hell cause the healthcare.gov website wasn't working on day 1. Remember that? It was a minor deal, but the media and Republicans had a field day.

[CTyankee]

46. I mentioned earlier about this "not trusting the government" thing with what I like to say:

we were able to win WW2 and put a man on the moon and we can't deliver decent health care to people?"

I wasn't referencing the minor flub on launching the ACA with that remark but it certainly fits in.

The fact is that winning WW2 and enabling our space program were all "big government" undertakings. Your tax dollars at work. And it wasn't without certain sacrifices either. I tell my grandkids about how this country did not build new automobiles and houses in the WW2 years because the factories were busy making war machinery: tanks and planes, etc. I was born during WW2 but I remember my parents talking about rations on food and gas. Unheard of today!

[Cuthbert Allgood]

41. Would I not have to pay for my insurance premiums and deductibles?

Would my employer be able to pass along what they pay for my insurance to me as salary?

Then the tax needed to pay for this is likely going to be a net increase in money I have in my pocket. If only Sanders didn't say this....oh...wait.

[CTyankee]

49. It seems to me that the answer to your first question is yes. Why?

Because employers look for the best employees, who of course they need to pay. With health coverage out of the picture they can offer more in salary than they would have had to pay in health care costs.

[Me.]

6. AHA!

[brooklynite]

7. The problem with a State-based system, is that you can always cross the border

[Docreed2003]

8. I agree with others that seeing the numbers is vitally important

However, the elephant in the room that no one is addressing is what exactly will the Medicare for All system look like compared to what we have now. How will this system affect hospitals, particularly smaller community based hospitals? What kind of impact can we expect on providers? Will physician salaries be slashed? Will this system limit access to innovations in healthcare such as minimally invasive techniques which tend to be more expensive that traditional open surgeries?

We all want universal quality healthcare, but, as someone who works in the field, the lack of details on what we can except as providers from Medicare for All is a big issue.

[peggysue2]

13. Yes, the devil is in the details

And the details are MIA. I don't think that's a bug in the presentation. Either the nitty-gritty details are not there (let's hope for the best) or the details are less than an easy sell to the public.

I'd wager on the latter scenario.

That being said, skirting the difficulties and/or being less than open with the public will ultimately doom the entire enterprise. The American public will not buy into a 'trust me or we know what's best' presentation. All those details and the pros and cons need to be out there and open for discussion.

Without that? DOA.

[CTyankee]

50. I remember hearing some of your hypotheticals during the Obamacare debate.

I also remember that my health care did not change. My doctor was still my doctor. My hospitals were still my hospitals. Etc.

This basic idea works in every other country in the world. What do they know that we don't?

[Docreed2003]

53. I think the difference in Obamacare is that it didn't fundamentally change the system

Obamacare didn't change the current system as much as it was an obvious improvement in that system. In order for MfA to work on any kind of reasonable budget, financial cuts to the system are a must and the data shows that, despite their massive CEO pay, health insurance corporations are not the primary reason for healthcare costs.

In order to have a system that covers everyone and doesn't bankrupt the country, cuts are going to be required. That's what no candidate has addressed. So where will the cuts come from? Hospital reimbursements? Then you can guarantee many smaller hospitals will close. Physician salaries? We already have a shortage of many specialties and I'm not sure that it's an easy sell to convince young people to spend 4 yrs in college, 4 yrs in Med School and 3-5 yrs of graduate medical education to take a position that will require 60-80 hrs a week, because that's what I typically work now, to make less money.

I staunchly support universal healthcare and I'm not opposed to MfA. What I'm opposed to is any plan that doesn't directly spell out exactly what impacts we will see. It's not enough to say well we're going to raise this tax and the cost is this amount.

[CTyankee]

54. Shouldn't the FIRST question be: why are we out of step with every other country in the world

on this?

IOW, what do they know or do what we don't do or know? And did they not think those questions you cite through as they were planning their system?

Every country has universal health care and have tailored it to their situation and preferances. Doing nothing is not an option. Whoever said it would work?

[BootinUp]

9. Buzz phrases don't necessarily make good policy. Nt

[peggysue2]

10. Green Mountain Care didn't fail for the lack of trying

It failed because despite their best efforts, Shumlin and his team could not get the numbers to work. The tax liability was simply too onerous for business and residents alike without reducing the level of care below what Vermont citizens already enjoyed.

This is something none of the Medicare for All supporters want to talk about, specifically Shumlin's conclusions: the exploding costs of healthcare services and pharmaceuticals must be contained and reduced BEFORE a universal approach is viable, be it statewide or nationally. Not going to happen with a magic wand or hoping for the best. It will take a Herculean effort and OMG . . . time to accomplish.

This is also the reason no one wants to discuss the level of taxation to get the M4A program off the ground. Yes, in the long-term the single-payer, universal healthcare construct will save money and improve health and care. In the short-term? It's going to be very painful. And in the short-term people need healthcare and help now, in the moment. For the healthy this might not be a huge consideration. But for those who have daily health needs now, chronic conditions or deadly disease/injury this jumping into the abyss without a parachute is life or death. And remember, even for the healthy, we're all one accident or infection away from needing a viable healthcare system in place.

The public option can serve as a transition until we have the necessary pieces in place. Which will probably take a decade or more to accomplish.

I wish our candidates running on the M4A were honest about the pitfalls of transforming the entire health care system. They seem to forget how difficult it was for Obama and Pelosi to push through the ACA. We have a structure in place from which to build and expand. The public option provides a safety net for those who need it, the greatest good for the greatest number.

We can get to a truly universal healthcare program. But please, let's not pretend it will be easy. Or quick.

[George II]

14. You point out a very important aspect of this issue. People sometimes mix "health care coverage"...

...with "heath care expense", two completely different things.

The level of insurance coverage won't necessarily affect the overall cost of medical treatment and procedures. All it will affect is how much the individual will pay.

Let's say the cost of a procedure is $1,000 and under one's current insurance plan $800 is covered. That means the "out of pocket" cost of the individual is $200.

Now, under some form of "universal coverage" the procedure will still cost $1,000. It will be paid by the "universal" plan - but where does that extra $200 come from? TAXES. "Medicare for All" only affects the cost of healthcare insurance coverage, not the actual cost of healthcare.

As much as some would like to think, the Federal government can't legislate how much a doctor or hospital charges for their services.

[wellst0nev0ter]

19. I guess people LOVE paying $400 for insulin

that only cost $2 to make.

[peggysue2]

30. My husband's diabetic

He's absolutely aware of how ridiculous the cost for insulin is, how the American public is being gouged. Which is why we need to get a handle on those costs now. Medicare for All is not an instant cure-all for exorbitant pharmaceutical costs and/or healthcare services. This is going to be a huge, huge battle and it's not going to happen overnight.

Meanwhile, we can implement the public option--another fight but more winnable and less expensive--and be a step closer to the ultimate goal of universal healthcare. A transitional period--otherwise known as the greatest good for the greatest number--would, I think, offer the best chance of success. Once passed, that PO transition would give us a go at expanding Medicare and the inherent costs involved, as well as get a handle on healthcare service costs and bring the pharmaceutical companies into line.

Because until we have those knowable costs under control, M4A simply won't fly. It's also not going to fly without specific details provided to the public. This 'trust us, it will be fine' model doesn't work. Nor does a Revolution-in-the-streets answer provide an adequate substitute for the nitty-gritty facts.

The good news is that all our candidates support the goal of universal healthcare. The bad news is it won't be easy or quick.

[wellst0nev0ter]

36. Funny, public option alone won't bring down drug prices either

What it WILL do is leave 10 million Americans uninsured, that is what Biden's own campaign website says.

What I AM objecting to is people saying Medicare For All will cost too much, ignoring the fact that healthcare costs are grossly and artificially inflated. And if we get ticky-tacky with the nitty-gritty of whatever health program we roll out, we wouldn't even have Obamacare today.

[emmaverybo]

31. Excellent points. A great deal of political capital was spent on getting Obamacare done. I am in

utter wonder that Sanders and Warren appear to think they will have not only endless political
capital, but financial as well for all their ambitious ideas.

Why not for now as a universal healthcare program is worked on get Obamacare up and running with lowered premiums, expand Medicaid as was intended, offer a buy in through public option or Medicare, lower eligible age to get Medicare? I find inflexibility where I want to see more openness and transparency for progressive plans.

[peggysue2]

33. It seems to me, emmaverybo that . . .

Elizabeth Warren did support lowering the Medicare age to 50 or 55 as a transitional way of offering access to more citizens. Frankly, I thought that was a really good idea at the time. Why the sudden jump to Bernie's nebulous, undefined M4A program is somewhat mystifying, particularly with the public's opposition to dumping private/work insurance programs. And being unwilling to even talk about the details is not a good look.

There is a lack of transparency in the actual math. I give Bernie Sanders props for admitting those tax increases will, in fact, be across the board. Yes, even on the middle class. Everyone else has been highly evasive. Unlike Frank Bruni, I do not think evasiveness, slipperiness and cunning are attractive and/or effective. Certainly not with healthcare. It's too personal and for those with chronic conditions or deadly injury and illness, it becomes a matter of life or death.

[Hoyt]

11. It also failed in California and Colorado, primarily because legislators didn't have the guts

to tell votes how much their taxes would have to increase to pay for it.

I know that people would supposedly save money by paying more in taxes, BUT not having to pay premiums and even as much in cost-sharing such as deductibles and co-insurance. But, the legislators found the amount of needed tax increase just couldn't be explained to voters.

That's our loss, but a lesson in what is facing mandatory Medicare-for-All vs. a choice of a Public Optioin.

[peggysue2]

15. That's the nuts and bolts, Hoyt

But, the legislators found the amount of needed tax increase just couldn't be explained to voters.

That's what Shumlin and his team found out. They were dedicated to finding a way around the problem. But in the end, they simply could not get the math to work.

I think it's more than a little disingenuous to leave this part of the story out. Americans hate taxes. Always have. If you're going to raise them, you better have all your ducks in a row and clear explanation (all details included) before the public will sign on. Without that, M4A will go nowhere. Which is why the public option is the best alternative/transition.

[CTyankee]

20. I also suspect that voters think they're bullet proof and won't incur those health care items that

will be taken care of. But they are not tax-proof, i.e. they'll be saddled with the taxes and won't need the services the taxes pay for. That, and their taxes will pay for "those people" to get health care.

[Hoyt]

24. Agree completely. Always hate posting that opinion, knowing the "big idea" folks will bash me. :)

[turbinetree]

12. Quote from Mozloom.................National Federation of Independent Businesses

“There will never be a good time for a massive tax increase on employers and consumers in Vermont, so they should abandon that silly idea now and get serious,” Mozloom added.

https://www.opensecrets.org/orgs/summary.php?id=d000000160

Looks like the NFIB wants people to die....................because most of the republicans on the list voted fifty times to take health care away.......................and now they have a psychopath DOJ Federalist Society Attorney General and traitor in the white house which have the same mantra.........................


Warren is right, Molzoom we need a trust buster in the white house to get rid the corruption .....................

[lunamagica]

16. K&R for visibility

[Gothmog]

17. Adopting single payer in the US will be a major effort

The fact that this program could not be adopted in Vermont is telling

[Thekaspervote]

18. There's another elephant in the room that no one wants to talk about. A good percentage of

Americans take poor to lousy care of themselves. Yes, preventative care pushed by a single payer option would be great, but where’s the personal responsibility for your own body?

Daily care, the right foods, appropriate supplements, exercise, enough sleep, stop smoking would do more to cut the costs of health care across the board than any other single thing

Health is so important, yet many are unwilling to budget for things that have a proven track record of keeping you healthier.

Yes, many individuals don’t have enough to budget for the bare essentials so they need more coverage

[VarryOn]

21. It may come to prohibiting certain unhealthy things or...

At leasting charging people more who engage in certain things. Or maybe better, charging people less who have healthy habits.

With my current plan, I get a premium discount because I dont smoke. I get $500 each year for 100 visits to the gym

I got a better life insurance premium after I sold my motorcycle.

Overweight people should get a bonus for dropping weight. Maybe reward people with good bloodwork numbers or no ERvisits for the year.

I just know that incentives work. Incenting people for healthy habits could save a lot of money.

[Thekaspervote]

35. Yes, those things all work!!

[5starlib]

44. So what about the food deserts in urban areas?

There are many areas where you can't get decent food in this country...nothing but fast food and junk food. Also cheap food is largely bad for you. So you can't go about making people pay more for being fat. It's not that simple. And giving people rewards for being skinny is not good either as it may not be a fair system.

[Thekaspervote]

55. All I'm saying is you have to start somewhere and do what you can!

[NYMinute]

22. There just isn't enough money

to go from zero to single payer.

If the average tax rate now is 20% and we support a $2 trillion budget, to pay for a $18 trillion plan would require a 180% tax.

Math is everyone's friend.

[subterranean]

37. Where do you get your numbers?

The current U.S. budget is around $4.5 trillion, and total healthcare spending is a little over $3.5 trillion per year. I can't imagine why that would skyrocket to $18 trillion under a single payer plan. If anything, it should come down.

Also, we wouldn't be starting from zero. The government already pays about half of our total healthcare expenditures. New taxes would be needed to make up the other half. Those taxes would certainly be nowhere near 180%.

[Progressive dog]

23. Most people like their insurance coverage

according to the polls.

Warren and Sanders say Americans don't like their health insurance. Polls don't back that up. A new Kaiser Family Foundation poll finds that when it comes to expanding coverage and lowering health care costs 55% of Democrats and Democratic leaning independents prefer to vote for a candidate who does so by building on the Affordable Care Act.

https://www.cnn.com/2019/09/14/politics/poll-warren-sanders-health-insurance/index.html
Many of those on Medicare choose to belong to a Medicare Advantage plan run by an insurance company.

[BlueMississippi]

25. K&R nt

[greatauntoftriplets]

26. Yup.

I was writing a healthcare policy blog at the time, and it was going to be way too expensive.

[JI7]

27. Sanders did nothing to help with this either

[zipplewrath]

34. They couldn't get access to the existing federal monies.

One big problem was that they couldn't get the access they needed to the money already going to the feds through military, Medicare, federal employees, etc. If you can't get to that, you start with a serious deficit.

[myohmy2]

47. I don't care...

Bernie,

" Today, more than 30 million Americans still don’t have health insurance and even more are underinsured. Even for those with insurance, costs are so high that medical bills are the number one cause of bankruptcy in the United States. Incredibly, we spend significantly more of our national GDP on this inadequate health care system—far more per person than any other major country. And despite doing so, Americans have worse health outcomes and a higher infant mortality rate than countries that spend much less on health care. Our people deserve better.

We should be spending money on doctors, nurses, mental health specialists, dentists, and other professionals who provide services to people and improve their lives. We must invest in the development of new drugs and technologies that cure disease and alleviate pain—not wasting hundreds of billions of dollars a year on profiteering, huge executive compensation packages, and outrageous administrative costs. "

https://berniesanders.com/issues/medicare-for-all/


...we can make it work...we can start with a wall street transaction tax...

...do it...

[Kurt V.]

51. apples and oranges.

[empedocles]

52. Single payer is a looming Dem disaster for 2020!

[LincolnRossiter]

56. Careful. Some here will accuse you of spouting rightwing talking points for daring

to suggest that Sanders and Warren haven’t fully gamed and priced out a workable MFA plan.

[Gothmog]

59. Speaker Pelosi-There's no need to reinvent health care -- just improve Obamacare

I agree with Speaker Pelosi https://www.cnbc.com/2019/09/17/nancy-pelosi-no-need-to-reinvent-health-care-improve-obamacare.html?__source=sharebar|twitter&par=sharebar

Democrats should focus on making improvements to Obamacare instead of trying to reinvent the wheel with “Medicare for All,” House Speaker Nancy Pelosi said Tuesday.

“God bless” 2020 Democratic presidential candidates putting forth Medicare for All proposals, Pelosi said in an interview with “Mad Money” host Jim Cramer. “But know what that entails.”

Pelosi’s thoughts on how to improve the nation’s health-care laws appear to align with those of former Vice President Joe Biden, who in his 2020 presidential bid is calling for building on provisions of Obamacare, formally known as the Affordable Care Act.

“I believe the path to ‘health care for all’ is a path following the lead of the Affordable Care Act,” Pelosi told Cramer. “Let’s use our energy to have health care for all Americans, and that involves over 150 million families that have it through the private sector.”

[Gothmog]

60. Societal Savings are not tax revenues and cannot be use to pay for this plan

Such a plan in theory may generate societal savings but such savings would not pay for a program. Governments can only spend tax revenues and/or borrowings. This study does not say how one would pay for such a program in the real world. I note that Prof. Krugman like the concepts of such a plan in theory but notes that taxes will have to be raised a great deal to pay for such a plan
Back in 2016, here is his position Prof. Krugman compares Sanders hoped for health care savings to the GOP tax cuts. http://krugman.blogs.nytimes.com/2016/01/19/weakened-at-bernies/?_r=0

On health care: leave on one side the virtual impossibility of achieving single-payer. Beyond the politics, the Sanders “plan” isn’t just lacking in detail; as Ezra Klein notes, it both promises more comprehensive coverage than Medicare or for that matter single-payer systems in other countries, and assumes huge cost savings that are at best unlikely given that kind of generosity. This lets Sanders claim that he could make it work with much lower middle-class taxes than would probably be needed in practice.

To be harsh but accurate: the Sanders health plan looks a little bit like a standard Republican tax-cut plan, which relies on fantasies about huge supply-side effects to make the numbers supposedly add up. Only a little bit: after all, this is a plan seeking to provide health care, not lavish windfalls on the rich — and single-payer really does save money, whereas there’s no evidence that tax cuts deliver growth. Still, it’s not the kind of brave truth-telling the Sanders campaign pitch might have led you to expect.

Today, Prof. Krugman says that such a plan is feasible if you are willing to pay a great deal more in taxes
https://www.alternet.org/news-amp-politics/paul-krugman-explains-why-single-payer-health-care-entirely-achievable-us-and-how

If we went to government provision of all insurance, we’d pay more in taxes but less in premiums, and the overall burden of health spending would probably fall, because single-payer systems tend to be cheaper than market-based."

The amount of higher taxes are not quantified in this article by Krugman. To pay for any such plan will require massive tax hikes

Again sanders has utterly failed in his attempts to get Vermont to adopt his magical single payer plan because the state of Vermont cannot use hypothetical societal saving to pay for this plan. Even Krugman admits that much higher taxes are needed