Wednesday, December 24, 2014

John McDonough on what follows Vermont

December 23, 2014
Vermont ends single payer bid
Feds now left to confront the issue
By John E. McDonough

Many American dislike the Affordable Care Act not because it goes too
far but because it does not go far enough. About 24 percent of
Americans believe the ACA should be expanded, and by that, many mean a
Medicare-for-All single payer financing scheme that takes insurance
companies out of the equation.

Since the ACA is nothing like single payer, for four years now, the
candle in the window for single payer advocates has stood in the
governor's office in the Vermont State House. Gov. Peter Shumlin got
elected in 2010 promising to bring a single payer health financing
scheme to Vermont, and various people in his administration have been
hard at work figuring how to make it happen. Last Wednesday, though,
Shumlin snuffed out the candle, admitting that he couldn't make the
numbers work.

So what is single payer's future? Like all good Democrats, I harken to
the words of my late boss, Sen. Kennedy: "…the work goes on, the cause
endures, the hope still lives, and the dream shall never die."

Today, in the United States, we have three-plus mega-health insurance
programs in Medicare, Medicaid, and the new ACA subsidy/exchange
structure. Medicare is actually two programs when you count Medicare
Advantage. Medicaid is nearing 70 million covered lives. And as
employer coverage continues its 25 year plummet, the ACA subsidized
exchange world is going to grow in size and importance.

It may take 5, 10, 15 years, or even longer – but at some point, some
Republicans and Democrats will propose federal health insurance
consolidation. The illogic and wastefulness of running these enormous,
siloed health insurance behemoths will become clear – that will be the
backdoor start and momentum will grow.

The Vermont failure, I believe with regret, signals the end of serious
efforts to achieve single payer at the state level. It's too big a
lift, economically and politically. Shumlin inadvertently blew out the

At the federal level, I do expect it – but through the backdoor, not the
front, and no time soon.

(John McDonough is a professor at the Harvard School of Public Health
and the author of Inside National Health Reform.)


Comment by Don McCanne

John McDonough is one of the nation's most astute observers of health
care reform. We can take solace in his prediction that the entire nation
will eventually achieve single payer reform, while regretting that it
will be a slow process.

For those who differ, prove him wrong.

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