Vermont’s universal healthcare law, Act 48, lays out a road map for Vermont to become the first state in the nation to create a system of healthcare as a public good. To guide the transition to Vermont’s unified healthcare system, Green Mountain Care, Act 48 established an independent five-member board, which is scheduled to begin its work this week. We consider it useful and appropriate, as the work of this board commences, to remind ourselves of the board’s mandate, the principles written into Act 48 to guide its work and the social movement that led to the enactment of legislation codifying these human-rights principles in law.
Vermont has a long history of healthcare reform and at least a couple of decades worth of frustrated efforts to turn these incremental initiatives into a single unified healthcare system like those of the rest of the developed world. Recognizing that the principal obstacle to this kind of fundamental change is the corrupting influence on government of powerful interests vested in the status quo, three and a half years ago the Vermont Workers’ Center began an effort to shift the balance of power, to allow the needs of ordinary Vermonters to hold sway in the halls of power — to create a healthcare system that puts people first — the Healthcare Is a Human Right campaign. Through this campaign, thousands of Vermonters have joined together to demand and win legislation aimed at creating a healthcare system that satisfies the human rights principles of universality, equity, accountability, transparency and participation — legislation declaring that our healthcare system must be a public good.
The purpose of Green Mountain Care is to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless and equitable manner regardless of income, assets, health status, or availability of other health coverage (33 V.S.A. § 1821).
To guide the decisions of the Green Mountain Care board, Act 48 lays out a set of principles. It does so not once but twice, in order to incorporate these principles into the same statutory subchapter that establishes the board (18 V.S.A. Chapter 220, Subchapter 1). The intention of the general assembly and of the thousands of Vermonters who struggled together to incorporate human rights principles into Act 48, is to make it clear that these principles are not just a lofty preamble; they are real guidelines carrying the force of law. These principles are:
— universality —
The state of Vermont must ensure universal access to and coverage for high-quality, medically necessary health services for all Vermonters.
— equity (of access) —
Systemic barriers, such as cost, must not prevent people from accessing necessary health care.
— transparency and accountability —
The health care system must be transparent in design, efficient in operation, and accountable to the people it serves.
— participation —
The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms of the health care system.
— equity (of finance) —
The financing of health care in Vermont must be sufficient, fair, predictable, transparent, sustainable, and shared equitably.
— and explicit recognition of government’s obligation to fulfill these human rights —
State government must ensure that the health care system satisfies the principles expressed in this section (18 V.S.A. § 9371).
Together, the purpose and principles laid out in Act 48 make the mission of the board and the administration clear. That mission is to create a healthcare system focused on caring for the health of every Vermonter. All of the means to that end, along with the ancillary benefits of a unified healthcare system, are and must remain no more than secondary considerations. Act 48 reflects our recognition that the current healthcare non-system is fundamentally broken. Clinging to old habits and traits — such as out-of-pocket charges for care or the isolation of oral health — offends the spirit of this law.
In drafting Act 48, the Vermont general assembly recognized the constraints, obligations and opportunities of 2010’s federal healthcare law, the so-called “Affordable Care Act” — in particular the establishment of a “health benefit exchange.” The general assembly made clear in Act 48 that infrastructure created in order to comply with federal law should be used as the mechanism to create Green Mountain Care (33 V.S.A. § 1801 (a)). Thus, any decision regarding a Vermont health benefit exchange must treat the exchange as only a required transitional step toward Green Mountain Care. A health benefit exchange cannot satisfy the purpose of providing, as a public good, publicly financed health care, so the work of the Green Mountain Care board must be done with the intention of moving as quickly as possible to Green Mountain Care.
Many challenging decisions lie ahead. Among these is the challenge of satisfying the two components of the equity principle — equity of finance and of access. The board will be responsible for the development of Green Mountain Care’s budget and for the definition of its benefit package. Equity in both its forms, embodied in these proposals, is a priority of the people of Vermont and will remain a priority of the Healthcare Is a Human Right campaign. We intend not just to hold the board accountable in these regards but to lead by developing our own proposals.
The Green Mountain Care board is composed of experts. In its wisdom, the general assembly required that the board establish an advisory group, including some of the people that the healthcare system is supposed to serve, to provide input and recommendations (18 V.S.A. § 9374 (e) (1)). It also required the board to provide a process for soliciting public input generally (18 V.S.A. § 9378). We urge the board to keep in mind the principles of transparency and participation upon which an accountable healthcare system depends.
While we look forward to a healthcare system that serves the needs of the people of Vermont as a public good — a system that is accountable to the people that it serves — we are concerned by current events. At odds with the principle of accountability is the privatization by for-profit corporations of critical healthcare services. For-profit corporations are accountable to their shareholders and are generally managed in the interests of their top executives; they are not accountable to their “customers” or to the public. Fletcher-Allen healthcare is currently seeking to sell five regional renal dialysis clinics to a for-profit, multi-national corporation, Fresenius. Beginning in July 2012, the board will be responsible for approving such sales, and its decisions will accord with the principles of Act 48. In the meantime, following Act 48’s dissolution of the public oversight commission, responsibility for review of hospital budgets falls upon the Department of Banking, Insurance, Securities and Health Care Administration (BISHCA). This pending sale presents a clear choice between a healthcare system that serves our communities as a public good and healthcare services treated as commodities to be bought and sold in the interest of private profit. We look to the administration to demonstrate its commitment to the vision of Act 48 by holding this proposed sale up to the standard called for by its human rights principles.
In working toward a healthcare system that puts people — not profit — first, Vermonters have come to understand that this standard must be applied more generally. The banner of Put People First has become an umbrella under which the Vermont Workers’ Center’s People’s Budget campaign has joined the Healthcare Is a Human Right campaign as a movement of Vermonters demanding government that respects, protects and fulfills our human rights. In the same way that we demand equity in the financing of our healthcare system, we will demand equity in the financing of all public services. In the same way that we demand a healthcare system that serves the needs of all Vermonters, we will demand all of the public programs that serve our needs.
As much as Vermonters have embraced human rights as a unifying framework for public policy, we have recognized that it is our joining together with neighbors in our communities that makes change possible. Holding government accountable requires the participation of the people that government is supposed to serve, and Vermonters in growing numbers are stepping up to this responsibility. It has been a movement of ordinary Vermonters that created Act 48, and it is this movement of ordinary Vermonters that will hold the board, the administration and the legislature accountable for keeping the promise expressed in this law.