"The Affordable Care Act doesn't do a whole heck of a lot for Vermont," says Deb Richter, MD, president of Vermont Healthcare For All. "Most of the provisions in it, we've already done. It's kind of a shame, in a way. We would have momentum, and probably could've gotten further with single-payer, if the ACA had not happened."

Vermont comes by its reputation for progressive politics honestly. And one of its signal achievements on that front is a piece of legislation known as Act 48, signed into law by Democratic Governor Peter Shumlin in June 2011, which lays the initial groundwork for the Green Mountain State to make the pioneering move to a single-payer system.

[See also: Obamaneycare: Trotskyite takeover or big company bail out?]

"Because of the growth of our healthcare expenditures every year, we had to do something," says Peg Franzen, president of the Vermont Workers' Center, which labored for years to build momentum behind the bill. "Insurance companies are doing what they're supposed to do; they're making profits for their shareholders. But that's not the way we should have a health system set up. Healthcare shouldn't be a commodity."

But there's a long road ahead before so-called Green Mountain Care – tagged by opponents with the predictable epithet of "ShumlinCare" – becomes a reality in Vermont. Political pitfalls on the state and national level mean a single-payer future is far from certain. But since Act 48's passage a year ago, work on the policy front has been ongoing, aimed at improving the state's healthcare system, regardless of the outcome.
Seeking to offer near-universal coverage for Vermont's 626,000 citizens, the state-funded insurance pool is still years away from coming to fruition, and has many questions still to be answered.

One not-inconsequential detail: how it will be funded. A variety of new taxes are under consideration, but won't be voted on in the near future.

Act 48 also contained provisions to launch a health insurance exchange as required by the ACA, set up pilots to explore medical home and bundled-payment reforms and established the Green Mountain Care Board – a panel of policy experts to set rates, design benefits packages and suggest funding strategies.

[Political Malpractice: South Dakota, Montana push back on insurance exchanges.]

Those are just first steps. As noted above, one stumbling block along the way could be the federal Affordable Care Act – which itself is up in the air, of course – with the Supreme Court ruling due by June’s end.
Vermont hopes to use money disbursed by the ACA to help build those insurance exchanges. The federal law says every state must have one by 2014, but it also allows states to petition for a waiver from the national rules if they can prove they're providing equal or better coverage of their own.

"One major advantage it could (provide) is help bring in federal dollars when people buy health insurance on the exchange," Richter says. "And then that sum of money is what we would expect to get as a subsidy when we finally do single payer."