Pretty much everyone agrees the political battlefront in 2014 and stretching into 2016 will be the future of Obamacare. Democrats want to preserve it. Republicans want to repeal and replace it, though with what isn't certain.
However, looming just over the 2016 horizon is another alternative — the Vermont experiment with a single-payer health care system that could go into effect in 2017.
The Affordable Care Act moves toward universal access to health insurance by trying to fill the gaps in the previous system of employer-provided health insurance, individually purchased self insurance, Medicare and Medicaid. And that doesn't include the health insurance available to military personnel and their families.
Yet gaps remain. There is an entire network of public health clinics serving the homeless, rural poor, low-income children in schools and Native Americans on reservations. And there is gap between those who qualify for Medicaid and who can afford to buy their own insurance under the Affordable Care Act's state health insurance exchanges.
Even sympathetic critics of the current hodge-podge system of health insurance and health care delivery say it is inefficient, doesn't address cost control and fails to establish a reliable pricing system to allow health care to operate in any semblance as a market.
To bridge that final gap requires imposing an entire new system. There aren't a lot of choices.
Political conservatives have touted a system centered on individuals, using tools such as Health Savings Accounts. Political liberals have argued for a single-payer system such as what is in place in much of Europe and Canada. And in 2017, in Vermont.
Green Mountain Care was approved by the Vermont legislature in 2011. Its implementation has been delayed by a federal requirement to establish state-level health insurance exchanges this year and the need to find a mechanism to pay for the single-payer plan. One idea was an 11 percent payroll tax, It could face further delays as wary politicians assess cost estimates, which some say could force Vermont to double the size of its state budget.
Kaiser Health News described Green Mountain Care 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." The basic idea is to create a single, large buyer with the clout to negotiate the best prices at hospitals, clinics and medical practices, without unduly limiting choice. Not everyone believes a government-run and financed system can accomplish that herculean task.
In addition to nailing down a funding source, Vermont also needs a federal waiver to launch Green Mountain Care. If Republicans claim the White House in the 2016 election, that waiver may be hard to obtain. Then again, both political parties have a reason to let the experiment run its course — for Democrats to prove it can work, for Republicans to prove it won't.