News & Opinion

Right-Wing "Think" Tanks and Health Policy

"You can always tell if you're succeeding by the viciousness of the opposition." — Dr. Quentin Young, PNHP National Coordinator


By Nicholas Skala. Updated by Chris Gray, July, 2010

As the movement for single payer expands, attacks on single payer in the media by the far right have increased. In addition to misleading articles and op-eds, several books attacking single payer by conservative pundits were published in recent years, including one endorsed by former GOP Speaker of the House Newt Gingrich.

The PNHP National Office has identified 20 right-wing think tanks that employ full-time health policy "scholars" to oppose national health insurance and advocate for health care privatization, deregulation and market-based reforms. These groups are funded with millions of dollars from wealthy far-right foundations such as the Lynde & Harry Bradley Foundation, the Charles Koch Foundation, the John Olin Foundation, the Adolph Coors family’s Castle Rock Foundation and the Scaife Family Foundations, which share an ultra-conservative social agenda.

The Right-Wing "Echo Chamber": Although they masquerade as legitimate research institutions, most of these policy think tanks are little more than PR firms for those who want to obscure the facts about health care in America. Many, such as the Fraser Institute, produce bogus research and purposely avoid peer review. Instead, they provide "experts" with fancy titles to write editorials and appear on TV news programs to spread misinformation. Each of these institutions is funded by the same small group of ideological foundations, and it is extremely common for these "experts" to cite each other's bogus research in their commentaries, giving the impression of wide scientific credibility for their views. Twenty of the top "think" tanks are detailed below. Members are encouraged to take the lead on behalf of PNHP in responding to misinformation spread by these and other groups.

Tennessee Ernie Ford and the Company Store




Circleville Herald
Thursday, September 30, 2010 9:54 AM EDT

You load sixteen tons, what do you get?
Another day older and deeper in debt.
Saint Peter, don’t you call me ’cause I can’t go
I owe my soul to the company store

Senate Republicans last week protected the Company Store again by blocking the DISCLOSE ( Democracy Is Served by Casting Light on Spending in Elections) act for the second time. The DISCLOSE act would have required corporate CEO’s to appear on the television attack ads they bought. We have no way of knowing till months after the fact, and then only if we are relentless in seeking the information, what corporation sponsored the mendacious propaganda on our screen. The Bush appointed Roberts/Alito Supreme Court damaged free and fair elections this January by ruling that corporations ( aka the Company Store) have the right to dump unlimited, unidentifiable cesspools of bucks directly into any election they choose. We perhaps should require that candidates dress like NASCAR drivers, with the corporations that bought them printed in large letters all over their jumpsuit.

Want to run for office in West Virginia on a platform requiring compliance with mine safety? You lose. CEO Don Blankenship of Massey Energy, owner of the mine that killed 29 miners this past May after hundreds of safety violations, can buy up all the air time, newsprint space with gazillions of profits made from endangering his workers. No one will hear you. Used to be government was the referee, us looking out for each other. Decades of social legislation from 1900 on had made for a large, stable middle class. Since the Reagan revolution, the Company owns the referee.  The anger of the Tea Party is understandable, but they have it wrong, it isn’t the government that is hurting us, in fact taxes are lower than they have been in 60 years. It is the unregulated corporation that crashed Wall Street, took your job and home, profits from your healthcare and owns the store.

Before the Citizens United Supreme Court ruling Cincinnati billionaire and principal shareholder of American Financial Group Carl Lindner could contribute only a maximum of $4,800 to Republican Senate candidate Rob Portman. On August 2nd American Financial Group donated 83 times that amount, $400,000 to American Crossroads. In mid-August American Crossroads spent $454,000 on a statewide television ad backing Portman. American Crossroads was founded by former Bush operative Karl Rove as one of hundreds of front groups taking in billions of corporate dollars for Company Store friendly candidates. American Crossroads’ take in August alone was $2.6 million, $7.9 million from January up to August. $2 million of the August booty for American Crossroads came from two Texas businessmen.

“This is perhaps the best example to date of a big dollar impact in Ohio stemming from the high court’s Citizens United campaign finance decision..” (quotation, figures from “Court ruling boon to Ohio campaign”, Columbus Dispatch 22 September 2010 p. B1). Democratic Party Senate candidate Lee Fisher notes “This is an election, not an auction. Our democracy is about one person one vote… and should not be subverted by corporate spending without transparency.” Ohio Democratic Senator Sherrod Brown adds “It’s especially essential that the public knows who these people are giving this money.” Brown further noted that many outside groups, including an arm of American Crossroads aren’t required to ever disclose their donors. (“Brown: TV ad donors should be revealed” Columbus Dispatch 23 September 2010 p. A8)

A new Associated Press poll found that Americans who think the Patient Protection and Affordable Care Act of 2010 (PPACA) does not do enough to make healthcare more available outnumber 2:1 those who oppose the law believing that government should not be involved in healthcare. Four out of ten Americans believe the new law does not go far enough, one in five oppose the PPACA citing opposition to government involvement. (Washington Post 26 September 2010) One would think the nation was overrun with Tea Partiers screaming and packing firearms to health reform town halls based on FOX news reports. The fact is, Americans wanting further reaching reform outnumbered those fearing government two to one.

How then did we end up the health insurance industry/pharmaceutical company friendly PPACA? Part of the answer is Rick Scott, former CEO of Columbia/Hospital Corporation of America who was forced to resign after his company was fined $1.7 billion for fraud, kickbacks and understaffing of hospitals to cut costs. Scott founded “Conservatives for Patient’s Rights” to fight healthcare reform. Scott’s group spent $20 million, just a fraction of the $1 million industry spent every day of 2009 to insure Company Store friendly reform. (Geyman, J., MD; Hijacked; The Road to Single Payer in the Aftermath of Stolen Health Care Reform, p.79) As former CEO of a criminal healthcare corporation, I question Scott’s concern for patient rights.

This November, before you vote, consider that much of what you see and hear about candidates was financed by the Company Store. Consider which candidate and which political party has consistently stood up for the middle and working class.

Dr. Cotton is a member of Physicians for a National Health Program while working full-time in the emergency department, one of the few places in America that treats everyone based solely on need.

Brown, Wyden offering health-care revision


By: Sarah Kliff
November 17, 2010 07:54 PM EST

Sens. Scott Brown (R-Mass.) and Ron Wyden (D-Ore.) will introduce legislation Thursday allowing states to opt out of the controversial individual-mandate requirement of the health care reform law far sooner than they would under the law passed by Democrats earlier this year.

"States shouldn't be forced by the federal government to adopt a one-size-fits all health care plan. Each state's health care needs are different," Brown saysin a statement accompanying the legislation. "Our bill provides flexibility, and allows states like Massachusetts to opt out of portions of the health care law."

The bill is a significant step on both sides of the aisle. It's an effort by a Senate Democrat to ease one of the law's requirements. And it's the first Republican-sponsored effort to modify - rather than repeal - a provision in the law.

The Affordable Care Act allows states to set up health care systems without a mandated purchase of health insurance, as long as they meet minimal requirements established by the Department of Health and Human Services. States can begin applying for mandate waivers in 2017, three years after the individual mandate is set to take effect.

But Wyden, who co-authored health reform's waiver provision with Sen. Bernie Sanders (I-Vt.), has previously spoken out against the 2017 start date as problematic: States would have to go through the motions of setting up a mandate-centered system only to dismantle it a few years later.

This new legislation would roll the waiver date back to 2014, when the individual mandate comes into effect.
In an interview with POLITICO, Wyden described the legislation as a natural fit for Oregon and Massachusetts, two states that have experimented significantly with their health care systems. 

"Oregon and Massachusetts are ideal bookends on this," he said. "Oregon was one of the first to start using institutional dollars on home care, essentially giving seniors more of what they wanted. Sen. Brown obviously has an interest in Massachusetts, where Mitt Romney and Ted Kennedy have come from.

"He was easy to work with in a divisive political climate. We kept the focus on state innovation and the opportunity to get away from one-size-fits-all, federal, cookie-cutter reform. "

Wyden pushed back against those who might interpret his legislation as a form of resistance to health reform.
"Clearly by HHS putting in place the coverage framework, you make it clear a state can't go off and do nothing," he said. "They have to have all kinds of services that are more in line with the spirit of coverage. The state will obviously work with the federal government, which will be looking on."

Wyden pressed CMS administrator Don Berwick on the issue at a Senate Finance Committee hearing Wednesday morning, asking him for his views on how much flexibility states will receive. He got a positive reaction.

"The cliché about states as laboratories of democracy is not just a cliché, it's true," Berwick said at the hearing. "The diversity of approaches that we're seeing emerge state by state has been there for a long time. I think we should be doing everything we can to encourage it."

Wyden has also pursued Oregon's Health Authority Office on the issue, indicating his intentions to introduce legislation rolling back the waiver date and encouraging the state to apply.

"Section 1332 is scheduled to go into effect in 2017. I intend to introduce legislation shortly to accelerate that date to 2014," Wyden wrote in a letter in September. "Moreover, if the bipartisan legislative leadership and the executive branch were in support, I would like to explore the possibility of Oregon moving forward with a federal waiver even earlier."

In Vermont, single-payer health care in a single state

Tuesday, December 14, 2010

By Josh Goodman, Stateline Staff Writer

Congress never really considered a single-payer health plan run by the government. Vermont is planning for one. This isn’t some liberal fantasy. Vermont lawmakers are serious. To understand how serious, you only have to look at the resumes of William Hsiao and Jonathan Gruber.

Hsiao, a Harvard economist, is credited with designing Taiwan’s single-payer system. Gruber, an M.I.T. economist, helped design Massachusetts’ near-universal health care system and the federal health care reform law itself. They’re on the team that the Vermont legislature contracted with this year to explain how single-payer would work there. In other words, the nation’s 49th most populous state is deploying some of the world’s leading experts to redesign its health care system. Their report is due early next year, after which Vermont will decide whether to become America’s first single-payer state.

If Vermont decides on that course of action, the experiment will serve as a test of whether more aggressive government intervention can improve health care and reduce costs. Long before the results of that experiment would be known, Vermont’s project could serve as a test of something that even the state’s conservative counterparts elsewhere are interested in finding out: just how much power states have over their own health care systems.

Containing costs

Vermont is perhaps an unlikely place to try something dramatically new in health care. That’s because by most standards, Vermont’s health care system already is one of the nation’s best. The United Health Foundation has ranked Vermont the healthiest state in the country four years in a row. Fewer than 10 percent of Vermonters lack health insurance, one of the lowest rates in the country.

If the state’s only concern were getting insurance to the comparatively few people who lack it, Vermont could sit back and wait for the new federal law, with its promise of near-universal coverage, to kick in. But expanded access is only part of what the state wants — and it isn’t the part that officials tend to mention first.

“For Vermont, it’s all about containing costs,” Peter Shumlin, the governor-elect, told Stateline. He points out that the annual cost of health care in Vermont — for individuals, businesses and government — has doubled to roughly $5 billion a year over the past 8 years. “It’s killing small businesses,” Shumlin says, “kicking the middle class in the teeth.”

Vermont’s problems paying for health care aren’t much different than the problems other states face. What makes Vermont different is that many of its top officials believe the solution is to have only one entity providing health insurance. In their boldest schemes, they’re hoping to drive private health insurance providers out of existence and to free employers from the responsibility of providing health insurance to their employees.

That includes Shumlin, who led the state Senate when it approved the legislation approving the study that Hsiao is leading. The five-way Democratic primary for governor had other single-payer supporters, but none was more forceful than Shumlin. He won the primary by 203 votes, then won the general election by 2 percent.

Providing health insurance to everyone is, of course, a very costly endeavor. But Shumlin and many of the Democrats who run the legislature think single-payer can save money in a couple of ways. For one, they note that hospitals and doctors’ offices spend a lot of money filling out paperwork and coding claims for insurers. These administrative costs aren’t especially high in Vermont compared to many other states, but supporters of the single-payer plan believe that if health care providers could deal with one insurer, they’d be able to focus more on providing care and less on processing claims.

Supporters also see single-payer as an antidote to the fragmentation of Vermont’s health care system. For example, state Representative Mark Larson, who’s expected to chair the House Health Committee next year, laments that his local hospital, Fletcher Allen Health Care in Burlington, is planning to sell off its outpatient dialysis units.

Fletcher Allen made the move because it was losing money on dialysis. The reimbursements it was receiving from all of Vermont’s various public and private health insurance providers weren’t enough to pay for the costs. In the current system, even if it were clear that the cheapest and best way to care for dialysis patients was for Fletcher Allen to own the units, the state’s power to do anything is limited. The structure of health care is subject to the vagaries of Medicare and private insurers, not coherent planning.

Under single-payer, that would change. “It’s very hard to direct a strategy for accomplishing long-term savings in health care — to manage care better, to minimize unnecessary procedures, to invest in strategies that have demonstrated savings in quality and cost — without some system of financing and payments to direct those efforts,” Larson says.

One-state experiment

There remains one huge question: Can wholesale reform work in a single small state? State Representative George Till, a member of the legislature’s Health Care Reform Commission, is skeptical of single-payer. 

Till points out all the different entities that provide health insurance to Vermont patients. There are the state’s private insurers. There’s the state itself, through Medicaid and through its coverage of state employees. There’s the federal government, separately through Medicare and the Veterans Health Administration. There are some larger companies, such as IBM, that self-insure. And there are many people whose health insurance isn’t even based in Vermont. “At the hospital that I work for, we deal with 14 different insurers from New York,” says Till, who is a doctor.

Due to those complications, what Vermont is trying to do is, at its heart, a test of the power of state government. Can a state wrest total control of health insurance from the federal government and private companies? 

The simple answer is that it can’t without federal permission. Companies that insure their own employees at their own expense are exempted from state health care regulation under the federal Employee Retirement Income Security Act, known as ERISA. Medicare and the VA, of course, fall under federal purview. The new federal health care law forbids states from receiving waivers from its provisions until 2017, although some senators are working to change that date to 2014, when the law’s most consequential provisions kick in. 

If those efforts succeed, states would gain a lot more freedom to do what they please. For now, though, the definition of single-payer is in doubt, even among the people who are designing Vermont’s programs. “The last thing we want to do is create the perfect policy that can’t be implemented,” says Steven Kappel, a Vermont-based health care researcher who is part of the Hsiao-Gruber team.

The question is whether single-payer without Medicare patients or without VA patients or any other piece of the pie would really be single-payer at all — and whether leaving a piece out would undermine the advantages of the change that Vermont expects. The researchers are charged with developing other plans beyond single-payer: One is a government plan open to all Vermonters with conventional private insurance as an alternative. Despite Shumlin’s commitment to single-payer, it’s possible another option might look more appealing in the end.

Chance to lead

For now, though, those obstacles haven’t compromised the incoming governor’s commitment to the single-payer concept. In fact, he doesn’t think he has much of a choice.

Shumlin’s view is that health care interests are powerful enough in Washington that aggressive cost containment isn’t really possible there. “I believe that the states will have to lead true, meaningful health care reform,” he says. “We have a real opportunity to lead the country in health care if we have the courage.” But Shumlin and others also argue that, despite some of the difficulties, Vermont is the perfect place to try.

The biggest advantage Vermont has is the political environment in the state. Blue Cross Blue Shield Vermont, the state’s largest private insurer, has stayed neutral on single-payer. “We don’t think it’s our role,” says Kevin Goddard, the company’s vice president of external affairs. Even the state chamber of commerce, while somewhat dubious of the concept in its purest form, isn’t actively opposed yet.

What everyone agrees upon is that some very smart people are thinking about the best way to structure Vermont’s health insurance system. The initial report is due next month. Even critic Till says, “I think people will listen very carefully to what Dr. Hsiao comes back with.” 

— Contact Josh Goodman at

SPAN's 3rd Biennial Teach In and Lobby Day

Irony on the Ides of March:
The Problem and Solution Share the 31st Floor

By Mary Nichols-Rhodes

"Lobby Day"
By 8am on Tuesday, 3/15, SPAN Activists Alice Faryna, Arlene Sheak, Bob Krazen, Connie Hammond, Dick Bozian, Don Rucknagel, John Ross, Kurt Bateman, Debbie Silverstein, and I were trickling in to the Riffe Building in Columbus to set up shop on the 31st Floor, Conference Room South A for a full day of citizen lobby visits and a program about the Health Care For All Ohioans Act prepared for legislators and their staff.

I was oriented to the 31st Floor by the Riffe Building Manager -- location of the restrooms down the hall, large kitchen around the corner -- and advised that around noon, much of the 31st floor would be restricted to public access and we could not pass barriers marked as such.  Mysterious and curious since the Governor was planning to release the Budget on 3/15 at an undisclosed location.
We set up the room in preparation for the afternoon Teach In and after a brief overview and planning for our scheduled meetings, teams of SPAN members fanned out in Riffe Center and to the Capitol Building for SPAN citizen lobby visits over several hours, at the offices of  State Senators Brown, Hughes, Kearney, Stewart, Sawyer, Schiavoni, and Wilson, and State Representatives Carney, Celeste, Clyde, Driehaus, Fende, McGregor, and  Pillich. 

Region 6 Coordinator Debbie Silverstein has compiled an amazing book of information about the Health Care For All Ohioans Act addressing it's positive impact on business and the economy, related supportive articles, a list of SPAN endorsers, and hard-data tables that specifically note what Ohio schools and counties are spending on health insurance and the millions of dollars that would be saved by each under a single payer plan.  This union printed and professionally bound book was explained and presented to each of the legislative offices visited. 
SPAN teams returned to South A to eat lunch and discuss  results/reactions to the HCFAO Act at their lobby meetings.  There was tremendous positive feedback and appreciation for the data listed in the Lobby Book, though many said that the reality is, they likely wouldn't co-sponsor the HCFAO Act but if it came up for a vote, they would vote yes.

However, in previous sessions when Democrats held the majority and were Committee Chairs, the HCFAO Act was not given sufficient hearings and proponent testimony. Therefore the likelihood of this bill being acted upon in the current political anti-people climate is nil.  As Senator Skindell told us recently, the winds of change will not come from inside the legislature, it must come from those of us on the outside, applying pressure and making the case that this is what the people demand.

"Teach In"
As 1pm approached, participants from several legislator's offices arrived, yet there were many suspiciously missing, including Kurt Bateman.  When he and others arrived later, we learned that the Security on the 31st Floor had intensified to the point that elevators full of people, including Representatives Foley, Yuko, and Heard, were intercepted on the 30th Floor and told to disembark; people were being restricted from the 31st Floor.  They were eventually escorted by State Troopers through redirected freight elevator routes and brought to the 31st Floor.

Yes indeed, Governor Kasich was on the 31st Floor in another conference room presenting Ohio's Budget and security was tight. Dozens of protesters had already found their way on to the floor and were gathered around the elevators chanting, "Kill the bill."

Inside South A, I welcomed the 30 or so attendees and the SPAN program began with a skit based on an article written by Dr. James Fieseher of New Hampshire called, "Why for Profit Health Care Makes No Sense." John Ross played a man calling 911 to report that his house is being burglarized and Deb Silverstein was the operator who 
blocked his access to the help he needed by asking for his insurance number, being told he gave last year's policy number, that his insurance plan does not cover the crime being committed, that the quality of the help that would be sent would depend on the co-pay he was willing to pay, was questioned why he didn't purchase better or supplemental insurance to increase his coverage, and that it would take quite a long time for someone to respond since the police dept. close to his home was "out of network," while his wife, played by me, was being assaulted, which was "good news" for the caller according to the operator, since assault was covered on his policy.  It was a very effective was to expose the absurdity of our current health care industry.

Dr. Ross presented an informative and interesting power point about single payer and Deb followed with a power point showing how the whole economy suffers from one industry receiving so much of the money since it can't be spent elsewhere and noted the more than $1 billion that would be saved just by Ohio schools.  Both were excellent. Kurt then gave closing remarks and some good discussions and networking followed.

How interesting that on the foreboding day of March 15th, a Budget that will cut funding from education and people's needs was released by the governor using budget shortfall as a reason, and at the same time just doors away, the Health Care For All Ohioans which would save the state at least as much money as the shortfall, stimulate the economy, create jobs, and provide comprehensive quality health care to every Ohioan was being presented.  The problem and solution were sharing the 31st Floor on Tuesday.  But access was limited.  We must share the solution until we are heard.

Patients Are Not Consumers

By Paul Krugman, The New York Times

21 April 11

Earlier this week, The Times reported on Congressional backlash against the Independent Payment Advisory Board, a key part of efforts to rein in health care costs. This backlash was predictable; it is also profoundly irresponsible, as I'll explain in a minute.

But something else struck me as I looked at Republican arguments against the board, which hinge on the notion that what we really need to do, as the House budget proposal put it, is to "make government health care programs more responsive to consumer choice."

Here's my question: How did it become normal, or for that matter even acceptable, to refer to medical patients as "consumers"? The relationship between patient and doctor used to be considered something special, almost sacred. Now politicians and supposed reformers talk about the act of receiving care as if it were no different from a commercial transaction, like buying a car - and their only complaint is that it isn't commercial enough.

What has gone wrong with us?

About that advisory board: We have to do something about health care costs, which means that we have to find a way to start saying no. In particular, given continuing medical innovation, we can’t maintain a system in which Medicare essentially pays for anything a doctor recommends. And that’s especially true when that blank-check approach is combined with a system that gives doctors and hospitals — who aren’t saints — a strong financial incentive to engage in excessive care.

Hence the advisory board, whose creation was mandated by last year’s health reform. The board, composed of health-care experts, would be given a target rate of growth in Medicare spending. To keep spending at or below this target, the board would submit “fast-track” recommendations for cost control that would go into effect automatically unless overruled by Congress.

Before you start yelling about “rationing” and “death panels,” bear in mind that we’re not talking about limits on what health care you’re allowed to buy with your own (or your insurance company’s) money. We’re talking only about what will be paid for with taxpayers’ money. And the last time I looked at it, the Declaration of Independence didn’t declare that we had the right to life, liberty, and the all-expenses-paid pursuit of happiness.

And the point is that choices must be made; one way or another, government spending on health care must be limited.

Now, what House Republicans propose is that the government simply push the problem of rising health care costs on to seniors; that is, that we replace Medicare with vouchers that can be applied to private insurance, and that we count on seniors and insurance companies to work it out somehow. This, they claim, would be superior to expert review because it would open health care to the wonders of “consumer choice.”

What’s wrong with this idea (aside from the grossly inadequate value of the proposed vouchers)? One answer is that it wouldn’t work. “Consumer-based” medicine has been a bust everywhere it has been tried. To take the most directly relevant example, Medicare Advantage, which was originally called Medicare + Choice, was supposed to save money; it ended up costing substantially more than traditional Medicare. America has the most “consumer-driven” health care system in the advanced world. It also has by far the highest costs yet provides a quality of care no better than far cheaper systems in other countries.

But the fact that Republicans are demanding that we literally stake our health, even our lives, on an already failed approach is only part of what’s wrong here. As I said earlier, there’s something terribly wrong with the whole notion of patients as “consumers” and health care as simply a financial transaction.

Medical care, after all, is an area in which crucial decisions — life and death decisions — must be made. Yet making such decisions intelligently requires a vast amount of specialized knowledge. Furthermore, those decisions often must be made under conditions in which the patient is incapacitated, under severe stress, or needs action immediately, with no time for discussion, let alone comparison shopping.

That’s why we have medical ethics. That’s why doctors have traditionally both been viewed as something special and been expected to behave according to higher standards than the average professional. There’s a reason we have TV series about heroic doctors, while we don’t have TV series about heroic middle managers.

The idea that all this can be reduced to money — that doctors are just “providers” selling services to health care “consumers” — is, well, sickening. And the prevalence of this kind of language is a sign that something has gone very wrong not just with this discussion, but with our society’s values.

A Doctor’s Push for Single-Payer Health Care for All Finds Traction in Vermont

New York Times, May 21, 2011


MONTPELIER, Vt. — Many people move to Vermont in search of a slower pace; Dr. Deb Richter came in 1999 to work obsessively toward a far-fetched goal.

She wanted Vermont to become the first state to adopt a single-payer health care system, run and paid for by the government, with every resident eligible for a uniform benefit package. So Dr. Richter, a buoyant primary care doctor from Buffalo who had given up on New York’s embracing such a system, started lining up speaking engagements and meeting with lawmakers, whom she found more accessible than their New York counterparts.

“I wrote a letter to the editor, and the speaker of the House called me up to talk about it,” Dr. Richter, 56, recalled recently. “It was astounding. In New York, I couldn’t even get an appointment with my legislator.”

Twelve years later, Dr. Richter will watch Gov. Peter Shumlin, a Democrat, sign a bill on Thursday that sets Vermont on a path toward a single-payer system — the nation’s first such experiment — thanks in no small part to her persistence. Though scores of people pushed for the bill, she was the most actively involved doctor — “the backbone,” Mr. Shumlin has said, of a grass-roots effort that helped sway the Democratic Legislature to pass it this spring even as other states were suing to block the less ambitious federal health care law.

“We wouldn’t be where we are without Deb,” Mr. Shumlin said in an interview. “She’s made this her passion. And like anyone that’s making significant social change, she has qualities of persuasiveness and leadership and good judgment that are hard to find.”

As in all states, the cost of health care has increased sharply in Vermont in recent years. It has doubled here over the last decade to roughly $5 billion a year, taking a particular toll on small businesses and the middle class. All 620,000 of the state’s residents would be eligible for coverage under the new system, which proponents say would be cheaper over all than the current patchwork of insurers. A five-member board appointed by the governor is to determine payment rates for doctors, what benefits to cover and other details.

But much remains to be worked out — so much that even under the most optimistic projections the plan might not take effect until 2017. Most significantly, Mr. Shumlin still has to figure out how much it will cost and how to pay for it, possibly through a new payroll tax. Whether he will still be in charge by 2017 is among the complicating factors.

“If we had the exact same Legislature and the same governor we could get it done,” Dr. Richter said. “It’s a big if, because the opposition has a ton more money to convince people that the governor is evil and this is socialized medicine and all kinds of other scary stuff.”

The opposition will probably include insurance companies, drug makers and some employers who say there are too many unknowns. Many doctors, too, are wary of the change and what it might mean for their income. Dr. Richter said she believed a “slim majority” of the state’s 1,700 licensed physicians were supportive.

“One of the bigger worries I have is we’ve had all this hoopla and nothing’s going to happen,” she said at a coffee shop here recently on a rare quiet afternoon. “But it might also be helpful to us, because it’s going to be hard for any opposition to be steadily pushing for seven years.”

The federal health care law has complicated Vermont’s plans, requiring the state to first create a health insurance exchange to help residents shop for coverage by 2014. The state would then need a federal waiver to trade its exchange for a government-run system.

Dr. Richter said she embraced the idea of a single-payer system as a young doctor in Buffalo, where many of her patients put off crucial treatments because they were uninsured. As a medical student, she saw a patient with a life-threatening heart infection caused by an infected tooth that had gone untreated because he lacked dental insurance.

“He was in the hospital for six weeks, and I was like, ‘This makes no sense,’ ” she said.

She went to a meeting of Physicians for a National Health Program, a group that advocates for a national single-payer system, and started researching the concept. Before long she became a vocal advocate, even becoming president of the physicians’ group, and moved to Vermont.

John McClaughry, a former Republican state senator who is against the new law, said Dr. Richter meant well but did not understand the “long-term damage” it would wreak. In particular, he said the law would drive away businesses that did not want to help pay for it. “She’ll tell you that putting in single-payer will attract businesses from all over the place,” said Mr. McClaughry, vice president of the Ethan Allen Institute, a conservative research group. “I don’t think she has any appreciation of business decisions at all.”

Since moving with her husband and two sons to a rambling old house within view of the State House, Dr. Richter has given about 400 talks on the single-payer concept, tutored lawmakers in the State House cafeteria and testified before the Legislature more times than she can remember. Once, she presented a printout of all the insurance companies her small practice in Cambridge had billed over five years.

“It was like 190 pages long,” she said. “Here we were, this tiny rural clinic having to bill all these different addresses. And all of them have different rules and reimbursements; I mean, it’s ridiculous.”

Some supporters of single-payer health care say Vermont’s law does not go far enough, mostly because it would allow at least a handful of private insurers to stay in the market indefinitely. Self-insured businesses like IBM, the state’s largest employer, could continue providing health coverage to workers under the law, though they would have to help finance the new system, possibly through a payroll tax.

Physicians for a National Health Program is among the critics, saying the law “falls well short of the single-payer reform needed.” Allowing private insurers to remain in the state will prevent meaningful savings, the group says.

Dr. Richter acknowledges that the law will not allow for “strict single-payer,” but said it still promised “health care for everybody, for less cost.”

“This is not the top of the mountain, but it’s the first time anyone has headed up the mountain,” she said. “No other place in the country has gotten this far.”

Number of uninsured skyrockets 4.3 million to record 50.7 million in 2009

Big leap points to urgency of enacting single-payer Medicare for all: national doctors' group

Sept. 16, 2010
Quentin Young, M.D.
Olveen Carrasquillo, M.D.
Margaret Flowers, M.D.
Mark Almberg, PNHP, (312) 782-6006,
Local physicians in almost all 50 states available for comment (See historical table of uninsured by state below).

Official estimates by the Census Bureau showing a dramatic spike of 4.3 million in the number of Americans without health insurance in 2009 - to a record 50.7 million - underscore the urgency of going beyond the Obama administration's new health law and swiftly implementing a single-payer, improved Medicare-for-all program, according to Physicians for a National Health Program, a 17,000-member physician group.

The Census Bureau reported that 16.7 percent of the population lacked health insurance coverage in 2009, up from 15.4 percent in 2008, when 46.3 million were uninsured.

Lack of health insurance is known to have deadly consequences. Last year researchers at Harvard Medical School showed that 45,000 deaths annually can be linked to lack of coverage.

"Tragically, we know that the new figures of uninsured mean a preventable annual death toll of about 51,000 people - that's about one death every 11 minutes," said Dr. Quentin Young, national coordinator of PNHP. Young is a Chicago-based retired physician whose private medical practice once counted President Obama among its patients.

Young said that even if the administration's new health law works as planned, the Congressional Budget Office has projected about 50 million people will be uninsured for the next three years and about 23 million people will remain uninsured in 2019.

"Today's report suggests those projections are likely too low," he said.

The jump of 4.3 million uninsured is the largest one-year increase on record and would have been much higher - over 10 million - had there not been a huge expansion of public coverage, primarily Medicaid, to an additional 5.8 million people.

The rise in the number of uninsured was almost entirely due to a sharp decline in the number of people with employer-based coverage by 6.6 million. In 2009, 55.8 percent of the population had such coverage, having declined for the ninth consecutive year from 64.2 percent in 2000.

The record-breaking number of uninsured - exceeding 50 million for the first time since the Census Bureau started keeping records - includes 10 million children.

The biggest jumps in the percentage of uninsured were in Alabama, Oklahoma, Ohio, Missouri, Georgia, Delaware, North Carolina and Florida. In terms of absolute numbers, the biggest increases were in California, Florida, Texas, Ohio, Georgia, North Carolina, Illinois, Alabama, Michigan and Pennsylvania. In Massachusetts, 295,000 people remain uninsured despite that state's 2006 reform. (See link below for historical tables of the uninsured by state.)

"The only way to solve this problem is to insure everyone," Young said. "And the only way to insure everyone at a reasonable cost is to enact single-payer national health insurance, an improved Medicare for all. Single payer would streamline bureaucracy, saving $400 billion a year on administrative overhead, enough to pay for all the uninsured and to upgrade everyone else's coverage."

Dr. Olveen Carrasquillo, a PNHP board member and chief of general internal medicine at the University of Miami's Miller School of Medicine, noted that the Census Bureau was once again silent on the pervasive problem of "underinsurance."

"Not having health insurance, or having poor quality insurance that doesn't protect you from financial hardship in the face of medical need, is a source of mounting stress and poor medical outcomes for people across our country," Carrasquillo said.  New research has found that about 14.1 million children and 25 million non-elderly adults were underinsured in 2007, a figure that is likely much higher today.

"The government subsidies under the new health law will not be sufficient to provide quality and affordable coverage to the vast majority of Americans," he said. "Tens of millions will remain uninsured, underinsured and without access to care. We need more fundamental reform to a single-payer national health insurance program."

State-by-state data on the uninsured from 2006-2009 can be found here:

Physicians for a National Health Program ( is an organization of more than 17,000 doctors who support single-payer national health insurance. To speak with a physician/spokesperson in your area, visit or call (312) 782-6006.


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