qotd: John McDonough on Vermont’s single payer lesson

The New England Journal of Medicine
April 23, 2015
The Demise of Vermont's Single-Payer Plan
John E. McDonough, Dr.P.H., M.P.A.

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:
http://www.nejm.org/doi/full/10.1056/NEJMp1501050

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Comment by Don McCanne

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.