The state of Vermont is on the verge of establishing our country’s first universal, publicly financed health care system. While people across the country continue to suffer exclusions from access to care, despite the Affordable Care Act, Vermont is showing the way forward. What advocates have demanded for decades will soon become reality in Vermont: a health care system that guarantees every person access to the care they need, financed as a public good through the tax system. Every resident will receive comprehensive health services, without paying insurance premiums or depending on their employer. Once such a universal system is established in one state, it can gain momentum to spread to others, just as in Canada, with health care dominos falling state by state until the vision of a universal, publicly financed health care system in the United States is realized.   

What will it take to cross the finish line in Vermont?

The breakthrough in Vermont, in form of Act 48, the 2011 universal health care law, was driven by the Healthcare Is a Human Right Campaign, a grassroots movement spearheaded by the Vermont Worker’s Center (VWC), which built sufficient people power to change what was considered politically possible in the state. What shifted the terrain after decades of policy advocacy was a systematic, rights-based organizing strategy that engaged many thousands in a direct and permanent way, grounded in personal experiences and shared values. To ensure that Vermont crosses the finish line and launches Green Mountain Care by January 2017, as the law envisions, the Healthcare Is a Human Right Campaign is aiming to grow even stronger in order to hold policymakers accountable and overcome the many obstacles entailed in the multi-year transition process.

Problems with the ACA-mandated establishment of a state exchange – carried out by the same private contractor responsible for the federal debacle – recently caught the state administration on its back foot. This has opened the door for opponents to denounce the transition plan. From businesses and the health care industry to right-wing activists, the opposition has questioned whether Green Mountain Care should go forward at all and begun to create doubt. At least two challenges lie ahead: first, to ensure the new universal system goes forward; and second, to ensure that how it goes forward – its design and implementation – leads to universal and equitable care for all residents.

The length of the transition process dictated by federal requirements (from 2011 to 2017, when an ACA exchange waiver can be obtained) increases the number of stumbling blocks. Practically, the ACA may end up reducing some people’s access to care. Thousands of residents previously on public programs (supported by the state’s Medicaid waiver) face higher costs, especially deductibles and co-pays, as these programs were terminated and people were moved into the exchange. On the upside, Vermont’s exchange implementation law was able to eliminate the state’s individual market, thus moving toward unifying and better regulating insurance companies’ operations, which could facilitate the transition to a public, unified system in 2017.

Crucial transition decisions: equitable financing and the move from coverage to care

The complete transformation of a fragmented, market-based health care system into a unified and universal system that provides health care as a public good is an unprecedented and complex endeavor in the United States. While the work of the independent Green Mountain Care board on provider payment and delivery reform has been moving along, the challenges remain significant. Vermont has until 2017 to complete the transition, but key decisions must be taken well before then. Most importantly, what revenue streams will the state use to finance the new system equitably? While substantial funds are expected from the federal government through ACA and Medicaid waivers, the replacement of employer-sponsored and individual market insurance premiums with some form of taxation amounts to a significant public policy intervention.

The state administration was required to release a financing plan in 2013, yet as that deadline approached, Governor Shumlin postponed this step until 2015. In the meantime, some business and industry lobby groups, led by the Chamber of Commerce, have stepped up their public discussion of health care financing and released their own cost estimate. Their interventions, designed to stall and ultimately derail the universal system, are amplified by voices from a vocal right-wing advocacy group, which closely monitors and comments on every step in the transition process. This January, the Governor announced that an outline of financing options would be forthcoming this spring, only to pull back from that promise in early March. The administration’s broader strategy, thrown off course by repeated delays, is now focusing on showing that the current system is not working for people and that the state’s vision for a universal system in which everyone gets the care they need, when they need it, will be the best for Vermont. The administration seeks to dominate the public debate with this vision, and is calling on advocates to support them.

As the vision of universal health care faces up to the tricky details of implementation, the Healthcare Is a Human Right Campaign has consistently offered proposals for moving the process along, guided by the human rights principles in Act 48. The Campaign developed standards for equitable financing along with a proposal for a financing plan, drafted its own implementation bill, presented testimony, met with political leaders and the GMC board, and has intervened in the public debate with statements, press interviews, and, most importantly, numerous local events and forums, including community health screenings with allied nurses and doctors.

In this legislative session, running until May, detailed transition proposals have been making their way through the Statehouse, with some legislators intent on solidifying decisions on financing and health benefits now, preempting the administration’s and the GMC board’s proposals. A bill has just been passed by the Senate defining Green Mountain Care as a benefits plan equivalent to the standard plan in the exchange. This decision would not just usurp the role of the GMC board, which is supposed to take decisions on the scope of health benefits – i.e., the range of services provided by the new system, such as dental or vision – but also put an end to the prospect of moving from an insurance system that provides coverage to a public health system that provides care. Yet the bill also includes positive elements; it explicitly declares health care a right for all state residents, and it affirms some of the financing standards put forward by the Healthcare Is a Human Right Campaign’s own bill, specifically on equitable taxation and on raising sufficient resources to meet health needs. A Campaign member testified before the committee, and the Campaign will push for amendments to the Senate bill in the House, including by promoting its own bill, which puts forward rights-based parameters for guiding the financing plan.

The first domino must fall: securing the win in Vermont

Vermont’s 2015 legislative session could become the make-or-break moment for universal health care. The November 2014 elections will influence the legislature’s make-up; and while Governor Shumlin’s reelection is likely, the Democrat/Progressive super-majority may be at stake.

The Healthcare Is a Human Right Campaign is working for a massive groundswell in the fall of 2014, calling for equitable financing to give policymakers a mandate before they return to the Statehouse for the 2015 legislative session. The goal is to scale up campaign activities over the next couple of years and demonstrate the people power and resolve that led to the 2011 victory in order to ensure the full implementation of universal, publicly financed health care by 2017.

Vermont’s Healthcare Is a Human Right Campaign has offered a model for achieving transformational policy changes. Grassroots groups in Maine, Maryland, and Pennsylvania have taken the baton from the Vermont Workers’ Center and started Healthcare Is a Human Right campaigns in their own states. As the next dominos are being positioned, it is crucial that the first one falls and paves the way for universal, publicly financed health care in the United States.