MONTPELIER, Vt. - The question Rep. Paul Poirier hears from Vermonters most is, "What the heck are you going to do about these premiums that keep going up and up?"

Vermont statehouse. (Photo: Rutland Herald) Poirier, a Barre City state representative, has a long memory of health care reform. The former Democratic House Majority Leader, now an independent, was at the center of health care reform debates at the Statehouse in the 1980s.

Lawmakers still are having that same debate - with similar proposals floated to cut costs, insure more people and encourage a healthier state - more than 20 years later.

"We're way past the point of doing nothing," said Poirier, who has been meeting with fellow lawmakers and advocates since the end of this year's legislative session promoting the idea of a Vermont public health insurance option. "Doing nothing will bankrupt us."

Health care reform has been a perennial debate among lawmakers, but with the exceptions of some efforts - the launch of Catamount Health and the Blueprint for Health - these changes have been mostly described as band-aids or minor tweaks.

With Washington, D.C., debating vast changes to the country's health care system (the U.S. Senate was scheduled to vote late Saturday on their version of the Democrat's bill), reform efforts in Vermont for 2010 are in a holding pattern as lawmakers and advocates take a wait and see approach.

"By now, we would normally have a better idea of what's on the agenda for next year," said Peter Sterling, the executive director of the Vermont Campaign for Health Care Security, an organization that promotes opportunities to expand health care access. "But no one knows what's going to happen with health care reform on the federal level."

The second half of the Legislature's session begins in early January and there have been a handful of major and minor health care reform proposals bubbling up, including the loose coalition that Poirier is building for his Vermont public option plan.

Over in the smaller of the Legislature's two chambers, Sen. Doug Racine, D-Chittenden, the chairman of the Senate Health and Welfare Committee and a 2010 gubernatorial candidate, is taking a unique approach to advancing one reform option that has been discussed here for decades: A single-payer health care system.

Racine said he will focus his committee's work in 2010 on investigating the mechanics of such a system would work in Vermont. The possibility of creating such a system - a public system that would provide universal health insurance to residents, essentially Medicare for all - has been widely debated in the halls of the House and Senate over the years.

"I would love to see a single-payer system nationally," Racine said. "But I have some questions about how it would work on the state level."
An example of those questions would be the conundrum of Dartmouth Hitchcock Medical Center in Lebanon, N.H., right over the river from White River Junction. An estimated one-third of the patients at the hospital are Vermonters, making the possibility of setting up a state-wide hospital budget - a key part of controlling costs under a single-payer system - a daunting task.

"If we present them with a budget, they could easily just say, 'No thanks, we don't need Vermont,'" Racine said.

Rep. Francis 'Topper' McFaun, R-Barre, has also been thinking about hospital budgets. He said he plans to bring back his proposal from 2008 that would essentially create a single-payer hospital care system in Vermont by creating a statewide budget for all the facilities, funded through taxes, and offer free care to Vermonters.

McFaun's proposal two years brought hundreds to the Statehouse for health care reform rallies - but Democratic leaders gave it little attention. He said the redrafted version of the bill will rely on a sales tax to fund the hospital budget, as opposed to a payroll tax contained in his original proposal.

He's also considering beefing up the proposal by attaching options such as tort reform, the ability to buy insurance across state lines and forgiving college loans for new doctors practicing in the state.

"We can control costs by setting up a budget for all the hospitals," McFaun said. "Another way to control costs is tort reform. If we do it right, we won't be seeing these outrageous premiums."

Dr. Deb Richter of Montpelier, a vocal single-payer supporter who worked with McFaun on his bill two years ago, is optimistic about the chances that the Legislature could take a major step toward a full single-payer system in 2010.

She said the Senate single-payer health care bill already has 15 sponsors - half of the Senate's members. Democrats hold a strong majority in both chambers, including vastly outnumbering Republicans in the Senate.

"We just need one extra vote and it passes the Senate," she said. "There is momentum on our side."

Richter is less optimistic about health care reform from the federal government (she supports a more progressive system than any of the Washington proposals create), especially for Vermont, a state that is considered by many to be more ahead of the game compared to other states in reforming key parts of the health care system.

"The best thing the federal bill will do is bring the rest of the country up to speed to where Vermont is," Richter said. "Maybe we'll get some more money to support our efforts here. But what is clear is that we need to use this opportunity to move beyond what we've already done."