The Little State That Couldn't Could? The Politics of "Single-Payer" Health Coverage in Vermont.

In May 2011, a year after the passage of the Affordable Care Act (ACA), Vermont became the first state to lay the groundwork for a single-payer health care system, known as Green Mountain Care. What can other states learn from the Vermont experience? This article summarizes the findings from interviews with nearly 120 stakeholders as part of a study to inform the design of the health reform legislation. Comparing Vermont's failed effort to adopt single-payer legislation in 1994 to present efforts, we find that Vermont faced similar challenges but greater opportunities in 2010 that enabled reform. A closely contested gubernatorial election and a progressive social movement opened a window of opportunity to advance legislation to design three comprehensive health reform options for legislative consideration. With a unified Democratic government under the leadership of a single-payer proponent, a high-profile policy proposal, and relatively weak opposition, a framework for a single-payer system was adopted by the legislature - though with many details and political battles to be fought in the future. Other states looking to reform their health systems more comprehensively than national reform can learn from Vermont's design and political strategy.

Prospective political analysis for policy design: enhancing the political viability of single-payer health reform in Vermont.

BACKGROUND: In 2011 the state of Vermont adopted legislation that aims to create the nation's first state-level single-payer health care system, a system that would go well beyond national reform efforts. OBJECTIVES: To conduct a prospective, institutional stakeholder analysis to guide development of a politically viable, universal health care reform proposal, as commissioned by Vermont's legislature in July 2010. METHODS: A total of 64 semi-structured stakeholder interviews with nearly 120 individuals, representing 60 different groups/institutions, were conducted between July and December 2010. Interviews probed stakeholders regarding five major design components: financing options, decoupling insurance from employment, organization/governance, comprehensiveness of benefits, and payment reform. RESULTS: There was a range of opposition and support across stakeholder groups and components, and more remarkably a diversity of views within groups often believed to be unwavering supporters or detractors of comprehensive health reform. Given the balance of conflicting views, relative power, and acceptable trade-offs, the research team proposed a single-payer health care system financed through payroll taxes, decoupled from employment, with a generous benefit package, governed by a public-private intermediary. CONCLUSIONS: Prospective political analysis can assist in choosing among a range of technically sound policy options to create a more politically viable health reform package.