COLORADO: OK, Single Payer Fans: Here's your chance to make it happen.

Many single payer advocates have been either confused or angry with me (to put it mildly) for not being a fan of Bernie Sanders's proposed national SP plan.

I've explained repeatedly that while I am a SP proponent, I just don't see it happening at the national level all at once. There are too many barricades and too many logistical, economic and political problems in doing so to make it remotely feasible to bring SP to the country in this fashion. In addition, I have major problems with the utter lack of detail in Bernie's plan.

HOWEVER, I've also repeatedly stated that I do strongly support getting the ball rolling at a smaller level first--either by partially expanding existing SP programs such as (Medicare, Medicaid, CHIP); consolidating existing private systems into larger risk pools (ie, merging the risk pools of the individual & small group markets, as a few states have done already); and/or by getting SP enacted at the state level, then using that as a model for other states and/or as a national model if it works out.

Vermont infamously attempted to do this a few years ago. Given the state's heavily liberal population and government, as well as one of it's Senators being a staunch SP advocate, the state legislature did get as far as passing the Green Mountain Care law in 2011:

The signing of H. 202 led to the creation of Green Mountain Care, described by Kaiser Health News as "a state-funded-and-managed insurance pool that would provide near-universal coverage to residents with the expectation that it would reduce health care spending."[10] Governor Shumlin, in a blog post at Huffington Post, described the plan as "a single payer system" that he believed "will control health care costs, not just by cutting fees to doctors and hospitals, but by fundamentally changing the state's health care system."[11]

So far, so good...except for the funding of the law, which is what led to it's downfall:

As of January 2013, Vermont was still working out the role of Green Mountain Care and the responsibilities of the bill, as well as how to fund the program. Dr. Hsiao, for example, had proposed an 11% payroll tax on employers, and the administration was required under Act 48 to provide a financing system in 2013.[12] The state also had to align Green Mountain Care with provisions in the Patient Protection and Affordable Care Act, passed by the United States federal government in 2010, which required the creation of a health care exchange in individual states. To launch fully, Green Mountain Care would have had to gain approval from the federal government to use federal health finances to fund the state program.

As of April 2014, Vermont had yet to craft a bill that would address the $2 billion in extra spending necessary to fund the single-payer system,[13][14] and by the end of the year, the state abandoned their plan for universal health care, citing the taxes required of smaller businesses within the state.[15]

There are a lot of reasons why SP failed in Vermont. Some had to do with the specific way in which the plan was structured, while others had to do with the specifics of Vermont itself. For instance:

  • it would've provided for a 94% actuarial value for everyone in the state, which is even more generous than the 90% offered by the ACA's Platinum plans
  • Vermont has a tiny population, which means not enough of a tax base to absorb the costs
  • Vermont only has a couple of insurers to begin with, meaning a less dramatic reduction of red tape/paperwork to be had

Other reasons are noted in this 2014 Politico article by Sarah Wheaton:

  • large businesses that operate in multiple states would have been exempt
  • it was unclear whether or how enrollees in federal plans like Medicare and TRICARE could be integrated into the state’s plan.
  • Insurance companies, which would be essentially put out of business, are fiercely opposed

McGuire, president of California OneCare, said he wasn’t surprised that Vermont backed away. “There ultimately has to be so much pressure that it’s like a volcano goes off and it happens, and that pressure has to be deep and wide in the voting public,” he said.

...and so forth.

Still, other states can learn from Vermont's failure, which brings me to ColoradoCare.

As I've noted several times before, Colorado voters will have a chance to decide for themselves on whether to adopt (near) single payer healthcare this November:

Amendment 69: ColoradoCare would ensure comprehensive, quality, accessible, lifetime health care for every Colorado resident. Premiums would be collected based on income, securing health care regardless of financial circumstance. This efficient, universal system would operate in the interests of Coloradans. By eliminating layers of bureaucracy and reducing administrative and other non-medical costs, ColoradoCare would cover all residents, cost less than the current system, and eliminate deductibles and co-pays for primary and preventative care.

...Comprehensive benefits must include primary and specialty care; hospitalization; prescription drugs and medical equipment; mental health and substance use services, including behavioral health treatment; emergency and urgent care; preventive and wellness services; chronic disease management; rehabilitative and habilitative services and devices; pediatric care including oral, vision and hearing services; laboratory services; maternity and newborn care; and palliative and end-of-life care. Additional benefits can be provided.

ColoradoCare replaces the medical portion of Workers’ Compensation. There will be no deductibles. Designated primary and preventive care services have no co-payments. Any other co-payments or cost-sharing must have ColoradoCare’s prior approval and can be waived to insure access to proper care. ColoradoCare will assure statewide access to emergency and trauma services. Beneficiaries will choose their primary care professionals. Beneficiaries temporarily living or traveling in another state will receive coverage.

...In order to assume responsibility for the financing of health care in Colorado, the Board will seek all necessary waivers, exemptions, and agreements to receive all available state and federal health care funds.

The Colorado Department of Revenue will collect transitional operating fund taxes (TOFT) from residents beginning July 1, 2017 at the following rates: 0.6% of payroll from employers, 0.3% of payroll from employees, and 0.9% from non-payroll income.

The month prior to ColoradoCare’s assumption of responsibility for health care payments, the Department of Revenue will cease collecting TOFT and will collect and transfer premium taxes (PT) to ColoradoCare as follows: 6 2/3% of employer payroll; 3 1/3% of employee payroll; and 10% non-payroll income. Because these are taxes they are deductible when filing income tax forms.

For both TOFT and PT much of Social Security and pension income would be exempt as defined by tax law. Income taxable for premiums will be capped at $350,000 for individuals and $450,000 for those filing jointly, with annual adjustments for inflation.

Employers may choose to pay part or all of their employees’ share of TOFT or PT.

ColoradoCare will serve as a supplemental plan to Medicare and will apply to become a Medicare Advantage Plan. For any other health insurance plans that are in effect, ColoradoCare will be a secondary payer, up to the payment level of ColoradoCare coverage.

ColoradoCare must undergo annual independent audits. Additionally, the Board will publicly report on the financial state of ColoradoCare and present options for economies, benefits, refunds, reserves and premium adjustments. PT may not be increased more than once per year and only if the majority of voting Colorado members approve the increase.

...During the 2017 legislative session the General Assembly will pass legislation to ensure a smooth, lawful transition to ColoradoCare. This includes transferring the resources of the Health Benefit Exchange; the responsibility for Medicaid, Children’s Basic Health Plan, and the medical portion of Workers’ Compensation; and allowing ColoradoCare to receive funding provided by the Affordable Care Act.

There are some criticial things to note here:

  • Colorado has appx. 5.46 million residents total. This is over 8.5x as many people as Vermont, so the tax base shouldn't be nearly as much of an issue.
  • Colorado is over 104,000 square miles (in a big square shape), nearly 11x as large as Vermont; I presume there's far less of an issue with out-of-state employees or residents to be dealt with. Furthermore, while Vermont has multiple major out-of-state cities in close proximity, i'm pretty sure they're hundreds of miles away from anywhere near the Colorado border.
  • Unlike "true, universal" single payer, ColoradoCare would not replace Medicare, the VA, TriCare or the Indian Health Service.
  • Around 785,000 CO residents are already on Medicare. Another 247,000 are enrolled in TriCare. I'm not sure how many are enrolled in the VA or the IHS, and some of those enrolled in each program may overlap (ie, they may be enrolled in more than one), but it sounds like roughly 1.3 million or so Colorado residents (around 24%) would keep their current healthcare system in place, but would have supplemental coverage to fill in the gaps.

So, what we're really talking about here is roughly 75% of the population switching to Comprehensive Single Payer, and the other 25% keeping what they have but adding supplemental coverage.

The coverage itself would not be as comprehensive as Bernie Sanders's SP plan, but it would still be very good:

  • No deductibles
  • No annual or lifetime limits
  • No co-pays for primary or preventive care
  • Co-pays waived for financial hardship
  • Outpatient services for primary and specialty care
  • Hospitalization
  • Prescription drugs and durable medical equipment
  • Mental health and substance abuse treatment
  • Emergency and urgent care
  • Preventive and wellness services and chronic disease management
  • Rehabilitative services and devices
  • Pediatric services including oral, vision, and hearing
  • Laboratory services
  • Maternity and newborn care
  • Palliative and end-of-life care
  • Long-term services and support (nursing home care), at least at the current level specified by standards for people eligible for federal health care benefits
  • Local health care services when temporarily in another state

Dental, vision, and hearing benefits

Amendment 69 and the waivers require limited dental, vision, and hearing services for adults. The Amendment gives the Trustees authority to expand benefits as funds are available. The analysis upon which the Premium Tax was based anticipated that $1.1 billion will be available annually for expanded dental coverage. If the Trustees determine that the funds are indeed available, they may expand coverage into the areas of health care that have usually been neglected by traditional health insurance — dental, vision and hearing.

In other words, this would be better coverage than under the best ACA policies, if not quite as good as Bernie's "everything covered for everyone at no out of pocket cost!".

ColoradoCare is not without it's problems. The lack of any cost sharing of any sort is concerning for reasons I've noted earlier, and there are some other serious issues to be debated and discussed. Others more knowledgeable about the specifics may have bigger issues or full defenses of all of them.

For me, however, ColoradoCare addresses many of the criticisms I've had of Bernie's plan. I'm not actually "endorsing" it here (I still have a lot more to learn about the details and the criticisms before I can do so), I'm just saying that it's more realistic and far better thought out than Bernie's national plan is. This is the best opportunity for achieving single payer that you're likely to see anytime soon.

More to the point, it's actually on the ballot in six months.

So if you're a Colorado resident who's serious about universal, comprehensive single payer, this is your chance to have it. If you live outside Colorado, this is your chance to help get the ball rolling in one state.

Every other state will be watching very closely to see how ColoradoCare turns out...and how it works out if it manages to pass.

So if you're serious about achieving Universal, Comprehensive, Single Payer Healthcare, stop attacking me over Bernie's plan and start supporting ColoradoCare.