Justice sculpture, Shelburne Museum

The committee recognized that a third of Vermonters could not afford regular health care. It expressed its belief that “it is an important part of our program to educate the people to accept the principle that society should assume a part of the financial responsibility for the physical and mental well-being of its citizenry, and to cooperate with a health program, and further consider the public nature of the program, not on a basis of charity (either by those who receive the benefits and/or those who contribute), but to accept these as we do our educational system, namely, any money used on health is not an expense, but a good investment.”

— Vermont Rural Policy Committee, 1944

There is often a wide gulf between believing in equity and acting to make the belief real. A belief is an aspiration and does not, of and by itself, force change. Perhaps the scale of change needed to create an equitable health care system has made too many people too uncomfortable — especially those for whom the current system works well. Gov. Ernest Gibson Jr. said seventy years ago that “education and health are the very foundation stones of democracy.” As occurred with the problems he identified that were holding back school reform, we’re still struggling with the problems preventing the building of a better health care system.

How far back do Vermont health care reform efforts go? What’s the problem in creating a better system?

Vermont’s attempts at health care reform go back a century, to the 1920s. Over the years, the state has looked at many changes to improve medical services for Vermonters at a price they can afford. No one has been satisfied with the overall results, although many incremental improvements have been made. The route to a major overhaul – equivalent to the changes in school funding that resulted from the Brigham decision and in marriage rights that resulted from the Baker decision – hasn’t been found.

Is it true that the U.S. spends more than other countries on health care – yet the care we receive isn’t as good as that in most other countries?

Yes. Two studies are cited in the book that detail how much the U.S. spends on health care and what we get in return. Evidence such as this is what reformers point to when they say the private insurance-based system we have in Vermont and that exists in other states isn’t efficient and isn’t particularly effective.

What’s the best route to health care reform?

The routes to health care reform that have been tried in the past have relied on legislative leadership action. There is an ironic adage among many legislative observers (as well as some legislators themselves), though, that legislators don’t lead – they follow.  The same is said of governors. In the cases of education funding reform and equal marriage rights, lawmakers and the governor followed court orders to fix the systems. A similar court mandate on health care reform would likely lead to the broad, sweeping changes that no politician has yet championed to a successful end. The other option would be acceptance by Vermonters that a broad reform of health care is essential to the state’s overall health and prosperity – so essential, that the next legislative session could not be allowed to end until a new system was put in place. This second option is how Medicare came into being, during the presidency of Lyndon Johnson in 1965. Indeed, Medicare is essentially the “holy grail” of health care reform that is being sought. The current push by public advocates for “Medicare for all,” bolstered in part by the, literally, deathly challenges of the Covid-19 pandemic, could force the change that Vermont alone hasn’t been able to achieve.

What about ACOs (Accountable Care Organizations)?

ACOs are private ventures, approved by the state, to work towards incremental change through the use of incentives. They are not a fundamental restructuring of health care financing or a broadening of coverage, such as a single-payer universal-access model seeks. Private insurance companies are not eliminated, and only a portion of patients have so far been included in pilot projects. The Vermont Office of Health Care Advocate has warned that health providers may benefit from the ACO approach while insurance costs to patients continue to rise at unsustainable rates. The question of whether all Vermonters should be able to get the health care they need at a price they can afford isn’t being answered. Improving health care services and saving money for providers are laudable goals — but should a state whose constitutional core rests on equity for its citizens be satisfied with these goals alone?

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