Two court challenges to President Barack Obama's signature health-care reform got all the attention this week while, beneath the radar of the national media, one of that program's architects began working for the government of Vermont to help set up America's first single-payer system in 2017.
Jonathan Gruber, an MIT economist, helped establish the program now dubbed Romneycare in Massachusetts, then helped craft its national offspring Obamacare. This week, he started work on a $400,000 contract to run financial simulations on Vermont's plan.
Gruber's findings will help Vermont complete a long-awaited, long-delayed funding plan by next January that might finally answer the one nagging question that threatens to undo the landmark reform: How do we pay for this?
Dozens of variables enter the mix, such as which services will be excluded or included in Vermont's new Green Mountain Care program; what would user fees look like; what's the role for employers; would payroll taxes, or income taxes, supplant insurance premiums; and how would all these different decisions affect the quality of health care and the overall economy.
Gruber and his team will test dozens of scenarios and prepare recommendations to the state government in the coming months so that it can finally present a funding plan to the Vermont legislature.
At that point, it'll become clear how much this system will, or won't, resemble Canada's.
"That is the big question for this sytem. It's to what extent will it be Canadian-style, (as in) you have to be in the system," Gruber said in a telephone interview on Thursday.
"What's interesting is Canada is sort of a very extreme version of single-payer... There's really not much opportunity for supplementation of the government package. I mean, you can add dental and vision and stuff but in most other countries there's more, if you will, private outs from the system. Private doctors, things like that...
"I think it'll differ from Canada in a number of ways."
Americans might not be paying close attention yet to Act 48. The law was adopted by a two-thirds majority in both of Vermont's legislative chambers in 2011, creating a public entity to develop a universal system for 2017.
But if the project clears this next hurdle — financing — the country will be watching very closely.
Liberals across the land have been longing for this kind of drastic reform, and many were disappointed that Obamacare didn't go far enough. They'll now be cheering Vermont on, hoping that the first state to introduce same-sex marriage will be a progressive trail-blazer once again.
In other words, they hope that Vermont and Gov. Peter Shumlin do what Saskatchewan and Tommy Douglas did in Canada: introduce a universal health-care system that eventually sweeps across the country.
The potential isn't lost on people at senior levels of government.
"I expect that Vermont will have set out, once again, on a leadership path and that there will be a number of other states that find this makes sense for them also," said Lawrence Miller, the governor's senior adviser on health reform.
"(But) I think it's early on this end to know how that fight unfolds here."
Vermont has long been a left-wing political outlier in the U.S.
One of its federal senators, Bernie Sanders, proudly refers to himself as a democratic "socialist" — a term that, in other parts of the country, would more likely be viewed as a slur.
Conservatives, meanwhile, will be watching warily.
Some will find confirmation of a widely held conspiracy theory: that Obamacare has never been intended to function as a long-term reform, and is merely a stalking horse for the eventual spread of socialized medicine.
Gruber has a unique perspective on this debate.
He designed the key provision of Obamacare — the individual mandate, which forces everyone to buy insurance if they're not covered at work or under social programs. It's intended to pull the young and healthy into the insurance system, so that the sick can get coverage without paying astronomical premiums.
But a lesser-known provision in that law also allows states to obtain a federal waiver from Obamacare starting in 2017 if they replace it with a plan that maintains the same coverage levels without increasing the federal debt.
Gruber insists he doesn't have any latent preference for single-payer.
"To be honest, I haven't thought a whole lot about single-payer in the U.S., because it's been politically impossible to do at the national level," he said.
"Vermont is a case where it can happen. I'm excited to help make it happen, to make it structured as well as possible... But I don't have a bias coming in about whether it's better or worse than the alternatives.
"I think it's an exciting opportunity to try something new."
Americans spend 50 per cent more on health care than Canadians, without necessarily achieving better outcomes. But one area where the U.S. clearly out-performs Canada, according to OECD data, is on wait times.
That wait-times problem has been duly noted by Americans who oppose an expanded government role in medicine. During the 2009-10 Obamacare debate, the phrase "Canadian-style" was a ubiquitous insult.
So the governor's office isn't talking about Canadian-style health care.
In fact, Miller says, maybe it'll be Canada's health system that draws a lesson or two from Vermont.
He says he has high hopes, for example, for a planned state-of-the-art electronic records system through which people might be able to log in from home, type in their symptoms, and liaise electronically with their doctor.
One thing he's adamant about is the need for change in the U.S. health system.
Before his current role, Miller founded a beer company; advised businesses; was chairman of a pewter company; and was the state secretary of commerce. He calls America's unique, workplace-based health-insurance system sheer "lunacy."
It's a drag on an American business's time, resources and ultimately hinders economic investment, he says.
Like many Americans, particularly those on the left, he'd been hoping for a more sweeping reform than the one undertaken by the Obama administration.
Now the file's in his hands.
"Many of us wonder why they didn't just do Medicare for all and not go through all the nightmares we've gone through," he said. "In Vermont, we don't feel like we can wait for a national solution."Suggest a correction