Intended for healthcare professionals

Feature US Health Reforms

America’s first single payer system

BMJ 2014; 348 doi: (Published 10 January 2014) Cite this as: BMJ 2014;348:g102
  1. Owen Dyer, freelance journalist
  1. 1Montreal, Canada
  1. owen_dyer{at}

Almost unnoticed in the furore over the Affordable Care Act, one state is striking out in a different direction. Owen Dyer reports on a single payer model that has long been the Holy Grail of American liberalism

Vermont has never fitted into the mainstream of US politics. The state that boasts America’s only self described socialist senator, Bernie Sanders, expects to be on the leading edge of social change. It has already decriminalized possession of marijuana and passed an “aid in dying” measure in 2013.

But Vermont’s single payer plan, known as Green Mountain Care, represents a far deeper commitment. In 2017, most private coverage will lapse, leaving a $1.65bn (£1bn, €1.21bn) hole in the state’s medical coverage that will be financed by new state taxes levied on its 626 000 inhabitants.1

The exact form of this taxation has yet to be decided, but indirect taxes alone are unlikely to raise the needed sum, about $2500 per Vermonter each year. Payroll taxes are the most commonly mentioned solution but would have to run over 10% to furnish the $1.65bn on their own. Even in communitarian Vermont, support for single payer healthcare softens when tax hikes are mentioned. Asked if they support publicly financed healthcare, 52% of Vermonters said yes, while 30% said no. Asked if they support single payer healthcare financed by a payroll tax, 43% said yes and 36% said no.2

The state is committed to its course, signed into law as Act 48 in 2011. Polling last year had actually shifted slightly in favor of single payer care since 2012, but the state’s temperature has not been publicly taken since the rocky rollout of the Affordable Care Act, otherwise known as Obamacare. The fairly disastrous early performance of Vermont’s own health exchange website will have done little …

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