When he stepped into the ballroom at the Seaport Boston Hotel on Nov. 2, Gov. Peter Shumlin might have expected a reprieve from the criticism he’s faced for the glitch-filled rollout of Vermont’s health care exchange.
He was, after all, addressing an audience of physicians devoted to bringing single-payer health care to the United States.
Then again, perhaps he knew what he was getting himself into when he accepted the invitation to speak at Physicians for a National Health Program’s annual meeting. The group has had an ambivalent response to Vermont’s efforts to implement a publicly financed health care system, pointing out that it’s a misnomer to call it single payer but also calling it a “step in the right direction.”
Whatever his expectations, Shumlin found himself defending the state’s approach against criticism from the organization’s co-founder, David Himmelstein, a well-versed physician and single-payer purist who thinks a state-by-state approach could interfere with national reform.
During a question-and-answer session at the end of his speech, caught on video by a pro-single-payer blog (the event was closed to the media), Shumlin and Himmelstein engaged in a testy debate about how Vermont’s publicly financed reform plan, slated for implementation in 2017, stacks up against a hypothetical national single-payer system.
After talking over one another several times, Himmelstein told Shumlin, “In fact, you are not going to be able to enact this single-payer program …”
“Yeah, we are,” Shumlin interjected.
“Well, by definition, if you’ve got this Medicare, Tricare …”
Shumlin cut in again, “Well, you’ve written us off before we’ve even tried.”
“No, no, I’m actually just saying what’s true, and that is you can have a publicly financed program. … It will be enormous progress. But let’s not confuse it with single payer because you will give up much of the administrative advantage of the single-payer program.”
Himmelstein, who has reservations about implementing health care reform on a state-by-state basis, was pointing out that, unlike Medicaid waivers, which the president can grant to states, Medicare waivers require congressional approval. Without that waiver, Medicare participants can’t be fully integrated into Vermont’s system.
According to Himmelstein, in this context, “The best a state plan can be is a very partial single-payer plan where there has to be someone making the effort to maintain per patient billing for part of the system … and that attenuates a very substantial part of the administration savings.”
Dismissing Himmelstein’s skepticism, Shumlin responded, “But if you help me get rid of those Tea Party nuts in 2014, I’ll get it done.”
But from Himmelstein’s point of view, victory for Vermont could have the perverse effect of slowing progress toward health care reform in other states.
“If you can get a waiver for Vermont to do better, you can get a waiver for Alabama to do worse and it’s a Pandora’s box that we need to be very careful about opening for Medicare,” Himmelstein said.
Shumlin also had allies in the crowd who argued that Vermont’s health care system will eventually galvanize reform at the national level.
Deb Richter, the former president and a current board member of Physicians for a National Health Program and a prominent advocate for single payer in Vermont, defended the state’s approach and described Himmelstein’s strategy as unrealistic.
“Everyone knows the best solution is a total country solution, but we all know that isn’t going to happen soon. We can’t get anything passed in Congress,” Richter said. “So why not gives the state a chance to do it and show the rest of the country that it can be done more cheaply and we can cover more people.”
Richter also contested Himmelstein’s suggestion that a waiver for Vermont could open the door to states looking to further privatize health care.
“Look what they’ve done with Obamacare,” she said. “Those states are already doing bad things, and I don’t imagine that this is going to allow them to do anything worse.”
The difference in opinion between Richter and Himmelstein is also a source of controversy within her organization, Richter said.
