The people who want America to adopt a single-payer health care system like to tell a story. It's about how universal care had a demo in one of Canada's less populous provinces, where it proved so popular and successful that the rest of the country couldn't help but copy it. "Saskatchewan was the first province in Canada to get universal health care," said Rep. Jim McDermott, D-Wash., outside Capitol Hill on Tuesday. "The most beloved Canadian is Tommy Douglas, who started it."
In the early 1960s, under Premier Tommy Douglas, the rural Canadian province introduced something like Medicare that covered everyone. Panic and protests ensued. The province had to import doctors temporarily to cover for the ones who'd gone on strike. But the plan worked. It was popular. By the end of the decade, all of Canada had the plan. And in 2004 Douglas was named the "greatest Canadian" in a poll, surging past Wayne Gretzky, Pierre Trudeau, and the bassist from The Tragically Hip. So that part's not hyperbole, either.
McDermott was telling this story partly to explain why he hadn't just wasted his time. He and Sen. Bernie Sanders, I-Vt., had just rolled out the latest version of their single-payer plan, the American Health Security Act (PDF). There was not much media present; there were no other members of Congress. Sen. Kent Conrad, D-N.D., cast a quizzical look at the event as he passed by walking his dog. The first question to McDermott and Sanders was about why they thought they could pass single-payer health care in 2011 when it couldn't win enough votes even when Democrats controlled both houses of Congress in the last session.
The answer: They didn't. But the state of Vermont will. On May 26, Gov. Peter Shumlin of Vermont is expected to sign legislation that will create universal coverage in the state—eventually. Vermont will use subsidies from the Affordable Care Act to help create a Canada-style system. And its system, or so the theory goes, will become so popular and cheap that the rest of America will want to copy it.
"Many of our Republican colleagues say they don't trust the federal government," said Sanders.
They don't want the federal government getting involved in health care issues across the country. And what Jim and I are saying is, OK. Let the states be the laboratories of democracy. Maintaining certain minimal standards, let those states that choose go forward and a different direction. It may well be that Vermont will lead the country. And if the Vermont experience works well, as I believe it will, I think you're going to look at other states, and they're going to say, "Gee, they're covering all their people. They're doing it at lower costs!" It may be the state of Washington, or the state of California. And then eventually you might have a universal health care system across the country.
That's an awful lot of "mays." The plan takes a very long time to go into effect—there is no instant gratification, like there was when Tommy Douglas was the toast of Saskatoon. The law creates a five-member board that studies and manages the transition. By Jan. 15, 2013, the board must settle on a plan. In 2014, the state is expected—as every state is required—to set up a health care exchange. And in 2017, the theory goes, the state will get a waiver from the Affordable Care Act to shut down its exchange and adopt a single-payer model.
"Ideally, we'd get some waivers," said Deb Richter, the head of Vermont for Single Payer, who has spent 11 years trying to pass a bill like this. "We need exchange waivers to opt out of the exchange; otherwise we're going to waste a lot of time building it and not intending to use it. We'd need half a dozen worker's compensation waivers. It's a tall order. It's complicated."
It could become easier. Sens. Scott Brown, R-Mass., and Ron Wyden, D-Ore., have legislation that would allow states to get waivers as early as 2014. If you're a state legislator who wants a single-payer system, but you don't want to build an exchange that'll become irrelevant in 36 months, here's your out. You can put together your dream health care plan and use subsidies to help pay for it. You can get it started before a Supreme Court decision or a new president threatens the Affordable Care Act's existence.
One small problem: Brown-Wyden isn't going anywhere right now. It's attracted only seven co-sponsors, none of whom is brimming with confidence about the bill's prospects. "Right now we're on spending, deficits, oil and gas," said Sen. Mark Begich, D-Alaska, one of the co-sponsors.
Wyden, no surprise, was more optimistic. "I think it's at the head of the queue," he said. "The fact is, it's the only bipartisan major policy issue on offer in the health care area."
But it's not that bipartisan. No other Republicans have gotten behind the bill. "We've heard that it's not going to happen," said Pat McDonald, chairman of the Vermont GOP. Sen. John Barrasso, R-Wy., a doctor who's been one of the GOP's point men on health care, pointed out that Republicans will oppose anything that leaves the ACA in place. It doesn't matter if residents of one state or another state will be spared a mandate. They're building the system with blueprints that Republicans desperately want to burn.
"The concern I have with Sen. Wyden's proposal is that to be able to qualify you have to meet all the obligations of ObamaCare," said Barrasso, pointedly not mentioning Brown's co-sponsorship. "Those aren't obligations people should have to live under." Barrasso was just as skeptical that Vermont's plan would become a shimmering ideal that other states would want to copy.
"I think there's at most three states this might ever apply to," he said, referring to the early waiver. "For 47 states, this won't apply, ever. I'm in favor of state's rights, but look at what we saw with the Massachusetts state plan. The waits to see a doctor are exceptionally long. Their insurance premiums are on average much higher than the rest of the country."
It is something both sides have in common: a rock-solid belief that the other guys can't possibly win. When I asked Sanders what would happen if the Affordable Care Act was overturned in full by the Supreme Court, he dismissed it as a hypothetical question, like asking if an earthquake would screw up the plan.
"I understand what some of our ultra-conservative people believe," said Sanders.
But I think the overwhelming majority of the American people—even our friends at the Supreme Court—believe the U.S. government has the right to be involved with health care. [Go] outside the Beltway, and take a walk a mile away, and say, "Gee, there are some people in Congress who think the government should not be involved in Medicare, S-CHIP, and the Veterans Administration." You find 2 percent of people who agree with that, and I'll be very surprised.
The single-payer Democrats don't want to hear about what could go wrong. They've found their Saskatchewan. They know how this movie's supposed to go. "Some of these people have trouble imagining what could happen," said McDermott. "Once they see it, they'll say, 'Wow, we can do that! We're as good as those people in Vermont, for Chrissake!' "