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Posted at 2:54 PM ET, 11/18/2010

Sen. Bernie Sanders: 'Vermont stands a chance to be the first state in the nation to pass single-payer'

By Ezra Klein

sanderstalkingh.jpgSen. Bernie Sanders (I-Vt.) has long supported state waivers in the health-care bill, and for a very specific reason: He'd like to see Vermont create the first single-payer system in the nation, as he believes it'll demonstrate enough cost and quality advantages that other states will want to follow suit. We spoke by phone last night, and a lightly edited transcript of our conversation follows.

Ezra Klein: You worked hard on getting the original version of the state waiver into the legislation. Why? Liberals aren’t usually associated with federalist approaches.

Bernie Sanders: As a single-payer advocate, I believe that at the end of the day, if a state goes forward and passed an effective single-payer program, it will demonstrate that you can provide quality health care to every man, woman and child in a more cost-effective way. So we wanted to make sure that states have that option, we wanted it to be available when the bill gets implemented in 2014. But we ran into the most insane objections from the Congressional Budget Office.

Is that why it got pushed back to 2017?

Our argument was we don’t want any more money from the federal government. When the bill is implemented, let the states use the money the federal government would already be paying to implement single-payer. The CBO came up with one of the weirder counterarguments we’ve ever heard. The CBO said we think the states are smarter than the federal government and they’ll outmaneuver the feds to get more money. So we were forced by the CBO -- not by anybody in the Congress -- to push it back to 2017. And I agreed to that very reluctantly.

So what happens if Scott Brown and Ron Wyden get their way and the waiver moves up to 2014? Will Vermont use it?

We believe Vermont stands a chance to be the first state in the nation to pass single-payer. The governor-elect campaigned on it, and we have support in the House and Senate. We’re not asking for one nickel more than we’d otherwise get. The other thing we think we have an opportunity to do is reach out to our conservative friends and say, hey, Vermont wants to go forward with a single-payer system, and Mississippi and Alabama don’t, but maybe they have other ideas. Now, we’re conscious of the need to make sure that the health-care reform bill’s standards aren’t diminished. So everyone needs to provide the same quality of health care as the bill provides and at the same, or lower, price. But if they can do that, then they should be able to go for it.

And then the various models can compete with one another and, presumably, spread to other states if successful?

Absolutely. And that’s what we wanted from it. In my state, it’ll be single-payer. In California, I think there’s a chance it could be single-payer. In other states, it will be something else. This makes the states laboratories for the system, and then other states can copy them. Now, you need a minimum level for coverage and quality. You can’t go lower than health-care reform.

Photo credit: By Toby Talbot/Associated Press

By Ezra Klein  | November 18, 2010; 2:54 PM ET
Categories:  Health Reform, Interviews  
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I'd agree that single payer could work in Vermont.

I'd also state there's absolutely NO WAY it would work in california.

With what doctors need to charge to make their overhead costs etc they could never afford what Medicare would pay alone. Then you'd have access issues and God forbid the single payer would not pay for something I'm SURE they'd be screaming about that out there, right?

Also there's no way they could bring it in under the required costs. I mean this is California, the home of the 20+ billion budget deficit. As long as they don't fudge the numbers that would make Enron's scandal look like forgetting to carry the one its DOA no matter what they say in Sacramento.

Posted by: visionbrkr | November 18, 2010 3:09 PM | Report abuse

Vermont has a population of about one fifth the size of San Diego county and is probably one of the least diverse states in the union. What they do there for health care coverage is even less relevant to the rest of country than what Sweden or Norway do. I agree that the states should experiment and we should learn from their experiments in health care delivery, but an experiment in Vermont isn't terribly predictive of what would happen in our neck of the woods.

Posted by: Beagle1 | November 18, 2010 3:13 PM | Report abuse

speaking of California the yields on their bonds are dropping FAST as is the rate in which they're being purchased.

I'm betting if they passed single payer they'd drop even lower.

oh and lookey here at who's to blame for healthcare costs as per a new study from the non-profit Center for Studying Health System change. I'm thinking Ezra's going to gloss over this because it doesn't fit his model of who to blame for healthcare costs.

Posted by: visionbrkr | November 18, 2010 3:18 PM | Report abuse

I wonder if under Wyden-Brown states could band together in their plans. Maybe Vermont doesn't have much in the way of size or diversity, but maybe it could start a single payer system in a coalition of Northeast states.

Posted by: MosBen | November 18, 2010 3:45 PM | Report abuse

Bernie Sanders is a self-avowed Socialist and is one of the few Democrats that admit to being a member of the Democratic Socialists of American (DSA).

So, who's surprised that he wants single-payer Big Government solutions?

Posted by: WrongfulDeath | November 18, 2010 4:39 PM | Report abuse

Fine with me, there's more than one way to develop a good system. But there will need to be a reasonable set of incentives (not just standards) for states to meet standards of coverage and quality.

It also takes a lot of political pressure off the Federal government and gives it to the states, many of whom avoid raising taxes by relying on Federal subsidies. I'm talking to you, Mississippi.

Tie Medicaid and/or other health care-related Federal funding to system performance.

Make them an offer they can't refuse. If they don't perform or abide by clear ground rules, they'll be answerable to their constituents for why the Feds pulled their money.

There's precedent. Louisiana might like an 18 drinking age, but they sure won't sacrifice millions in highway money for it. Same principle.

States shouldn't get all the benefits from their relationship with Washington and none of the obligation. Hold those legislatures accountable and they'll sink or swim.

You take cash, you're subject to rules. Don't like it? Secede.

I already feel like I need a passport, Berlitz guide, and all my shots up to date in some of these places.

Posted by: itstrue | November 18, 2010 4:50 PM | Report abuse

"So, who's surprised that he wants single-payer Big Government solutions?"

It's really a small government solution, seeing as it's the people of Vermont who want it.

Blah blah socialism. Blah blah big government. Are you a bot?

Posted by: itstrue | November 18, 2010 5:00 PM | Report abuse

"oh and lookey here at who's to blame for healthcare costs as per a new study from the non-profit Center for Studying Health System change. I'm thinking Ezra's going to gloss over this because it doesn't fit his model of who to blame for healthcare costs." -- visionbrkr

I don't think it's fair to say that Ezra has avoided discussion of hospital overcharging of insurers.

Here's a few examples I found with a few minutes of Google:

And here's two more posts that deal specifically with hospital consolidation and the effects that has on cost:

Ezra is no certainly no friend of the insurance industry, but I don't think the evidence shows that he has deliberately or deceptively avoided the issue the WSJ article raised. The health care cost problem is complicated -- as I have learned from this very blog among other sources, there is not one "villain".

Posted by: vvf2 | November 18, 2010 6:27 PM | Report abuse

This is an enlightening interview. CBO is probably right that Section 1331 gives states more ways to squeeze money from the feds. I expect opponents of Wyden-Brown will make that argument in the coming weeks.

Posted by: bmull | November 18, 2010 6:30 PM | Report abuse

As a liberal who lived through 8 years of GWB, I'm actually a pretty huge supporter of federalism. I think there's a strong argument to be made that the US wouldn't even have made its current modest efforts on climate change without California's leadership. It's also important to note that the healthcare system also has a whole lot of federalism already built into it -- states are the primary health and insurance regulators, and they have very broad latitude to design their Medicaid programs. There's a reason why state-by-state exchanges made sense even though they'll have less ability to risk pool than a national exchange.

But there IS one big problem with federalist solutions: the fact that you're still dealing with a national market. That could complicate some of these rosy scenarios.

Say Vermont and Texas both qualify for 1331 waivers -- so they both achieve roughly the same cost and coverage results. Vermont sets up a perfect single payer system (and somehow finds a way to finance it). Preventive care rates go through the roof, primary care docs are getting paid better, there's almost no emergency department wait, and everything costs less thanks to state market power. But specialists, hospitals, pharma, and device manufacturers are making less money.

Then you have Texas' perfect conservative exchange. More out of pocket costs (but strong HSA's), longer ED wait times, and more people choosing to delay or forgo care (especially early in their diseases) but much more money for specialists, hospitals, etc... which in turn means many more options for patients.

In this example, despite Vermont's arguably running a better (or at least equal) system, what keeps the specialists and health system capital from all flowing to Texas?

Posted by: NS12345 | November 18, 2010 7:01 PM | Report abuse

No matter what course Vermont takes, the Federal governmnet will get stuck with most of the bill.

Also their model will not work for the rest of the nation, since Vermont has largely been bypassed by time. They have comparatively speaking very few problems associated with illegal aliens, crime, urbanization, and a whole host of other ancillary issues that go with them.

Posted by: 54465446 | November 18, 2010 8:03 PM | Report abuse


Regarding your post, the latest rumour is that the Fed is going to buy California munis to support their market and stave off the inevitable default. How's that grab you?

Posted by: 54465446 | November 18, 2010 8:05 PM | Report abuse


like some California Dems that currently run the House pushed them to do it so it kind of sickens me. As a taxpayer from another state why are we funding their ridciulous pet projects/schemes? I mean if Silicon valley happened to be in any other state California would have imploded years ago. Either that or they'd be the equivalent of Mexico.

Posted by: visionbrkr | November 18, 2010 9:02 PM | Report abuse

NS1234 said, "In this example, despite Vermont's arguably running a better (or at least equal) system, what keeps the specialists and health system capital from all flowing to Texas?"

...the fact that not everyone who becomes a doctor does so solely for the money. Seriously, if you're already making 6 digits in Vermont (the first of which a squiggly number), how much more would they have to pay you to live in Texas, of all places? Good riddance to anyone who would make that move for a mere $100k.

Posted by: DavidinCambridge | November 18, 2010 9:21 PM | Report abuse

What keeps specialists from all moving to Texas?

Well, for starters, the reality of having to live in Texas. Texas has the fewest insured children and adults, the 3rd highest poverty rate, and the fewest percentage of high school graduates. Why in hell would anyone go live there?

Posted by: susanthe | November 18, 2010 10:58 PM | Report abuse

"As a liberal who lived through 8 years of GWB, I'm actually a pretty huge supporter of federalism."

I'm a big supporter of federalism, Canadian-style, where there's not the sense that the provincial level of politics is somehow reserved for kooks, crooks and mediocrities while the talent heads off to DC as soon as possible. Tommy Douglas, after all, was a provincial premier, not federal prime minister.

"what keeps the specialists and health system capital from all flowing to Texas?"

I think Atul Gawande covered this on the micro level of his two Texas cities: while American doctors have to think about where the money's going to come from the moment they start med school, not everyone becomes a dermatologist. Medicine is still a calling, at least in part, as much as it is a career choice.

Posted by: pseudonymousinnc | November 19, 2010 1:03 AM | Report abuse

You guys should stop complaining because, one the health care we have now isnt as good as it was supposed to be. also the law has just been signed so give it some time. so if u want to say u have the right to choose tell that to ur congress men or state official. If you do not have insurance and need one You can find full medical coverage at the lowest price check .If you have health insurance and do not care about cost just be happy about it and trust me you are not going to loose anything!

Posted by: rebeccahkim | November 19, 2010 2:52 AM | Report abuse

I guess "on the margins" would be a better phrase than "all" to use here. I still think that, with a national market for doctors but a state-by-state distribution of payment systems, you'd have some comparative access issues in lower-cost states. Even if the quality metrics for those who ARE able to see docs come out about the same.

Even if only like 10% of docs are making purely economic decisions, that would still reduce supply in lower-cost states. Especially since those dollar-focused docs are much more likely to go into the really esoteric specialties.

(Not that anyone is still reading this but still...)

Posted by: NS12345 | November 19, 2010 1:36 PM | Report abuse

There is so much more to single payer than meets the eye. As one person wrote, there are areas that single payer will not support itself.
Sweden and Norway perhaps because the people are all willing to work. But there are places that we don't have the same demographics that will support it.
There are places in world where the population could not even function within the framework of a democracy. They would corrupt and destroy it.

We have that here in this country now with the hispanic community. Politics and corruption go hand in hand! It's the nature of the people with political aspirations. You may think to change it but you won't. You are dealing with a genetic trait. And yes we are not all alike!!!!!
Certainly all people are prone to corruption but some more than others.

Single payer may work in Vermont because we are the whitest state in the union. You will have much less luck in California where the La pop is now about 46% hispanic, 10% black, white 35% -+ and Asian plus a mix of other. I will give you stats on murder rates simply to show that there is a difference between the groups of people. I know because I had a friend murdered so I accidentally ran across the LA stats. 46% by hispanic, 46% by black, 5% by white and the balance asian and other. Black people have the highest murder rate.

I say this people you have to take into account the people you are going to service with this. If you think all people will work equally well you are sadly mistaken. And perhaps you are.

I now travel abroad more than I used to and very definitely our politicians on all sides of the aisle really are relatively clueless. Perhaps it's the general ignorance combined with arrogance that does this.

I am personally embarrassed to talk to people about politics and the American way. They know it and realize it too. Many now can see the end of the US as we knew it. Perhaps when that time comes change the name to Socialist Provinces of Middle America or something like that. That way we can talk about the good ole USA. And bury it with dignity.

It's simply to bad that people in your positions do not have the analytical minds so necessary to correctly identify the root of our problems and then establish solutions that will work naturally.

I've said my peace.

If I didn't have children in the USA I would move out in a heart beat!!!!! I am do disgusted with the stupidity displayed by those that should be fixing things. Just amazing.

One more point. China does not have much respect for Obama. He's considered relatively stupid. China would prefer to trade with the US. However at this moment and it will most likely happen, Europe will become China's biggest trading partner. The US will find itself left out if it doesn't watch what it is doing.

Do people here realize it? Not a hint, or enough to make any positive changes.
We are cooked!!!!!!!!!!!!!!

Posted by: denniscarman | November 19, 2010 5:08 PM | Report abuse

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