Oregon, Montana and Vermont want to move much faster on health care reform than President Barack Obama’s Affordable Health Care Act will allow. It’s frustrating. 

Oregon Gov. John Kitshaber said, “We want to show that health reform is something real, that it actually works. Oregon is a place that can actually make it happen.”

Oregon passed its own health care act that changes how it pays doctors and eventually will enroll state employees in the Medicaid program as a big move toward a single-payer system. To do that, however, the federal government will have to grant Oregon waivers on the way Washington funds Medicaid and from other key pillars of the federal program.

But waivers can’t be granted until 2017 under the federal law. A bill that would step up that date to 2014 has been endorsed by President Obama but is stuck in a Senate committee.

Vermont has gone even further than Oregon. It has become the first state in the nation to enact a single-payer health care system. It has started discussions with Washington about the waivers it will need to convert health insurance there into a single-payer system run by a public board. 

“We’ve had some very general discussions with the federal government about our single-payer plans. We’ll continue to press for earlier waivers,” Anya Rader Wallack, chair of the Green Mountain Care Board, told a New York Times reporter. “If we can’t have it, we can’t implement our reforms as fast as we’d like to. It’ll make a difference in terms of the degree of simplification in implementation and the savings associated with that.” 

Montana also has started exploring single-payer options. Last month, Gov. Brian Schweitzer announced he would seek permission to open up his Medicaid program to government employees and other individuals, laying the foundation for a future universal coverage program.

The governor has spent three years working on his plan that is modeled after one in Saskatchewan, the Canadian province directly north of Montana. 

THESE THREE governors are ahead of the game. They all want to create single-payer systems that will give a governing board the power to decide how health care will be administered and paid for in their states.

As Gov. Schweitzer is well aware, Canada offers his state — and the other 49 — a working model to copy. 

And as all three of those governors know, the only way to bring the cost of health in line with costs in the rest of the rich world is to control the elements that make up a nation’s health care bill. That means controlling administrative costs, prescription drug costs, hospital costs and the cost of the rest of the health care providing industry.

Single-payer systems provide the most practical way to control those costs. Up to now, that is the only way health care costs have been controlled in a modern nation.

Can it be done state-by-state in the United States? That remains to be seen. Bringing costs down means reducing income to the players. In Vermont, for example, health insurance companies will be crowded out of the game. In all three states doctors, hospitals, drug companies, along with health insurance companies, will see their income drop. Some providers — those earning the most under the current system — will be hit particularly hard. 

Costs can’t be reduced without reducing incomes and such reductions will continue to be resisted mightily.

WHETHER SUCH dramatic changes can be accomplished by Vermont, for example, while the industry remains unchanged in New York, Massachusetts, New Hampshire and Maine is problematic. Still, Canada has maintained and continuously improved its single-payer health system for all of these decades despite (or, perhaps, because of) the free market competition which has flourished in its dominant neighbor to the south. The fact that it spends only 11 percent of its GNP on health care for all Canadians while the U.S. spends nearly 17 percent, and leaves 50 million of its citizens without coverage, has become a matter of national pride.

So perhaps three or more states can show the rest of the U.S. the way to save enough on health care to balance the federal budget and have some left over for tax cuts. Worth a try.

— Emerson Lynn, jr.

Veteran senators Joe Lie-berman, an independent of Connecticut, and Susan Collins, a Maine Republican, have suggested a third year of pay freezes for federal employees.
Sens. Collins and Lieberman are both moderates, an endangered Washington species. Their middle-of-the-road politics makes it possible that their tough-minded proposal will win support from both sides of the aisle. Republicans will agree to cut spending; Democrats will remember that both Collins and Lieberman have sometimes helped them get touchy legislation passed.
Federal pay doesn’t represent a large part of the budget or the deficit, still, extending the pay freeze another year would save an estimated $32 billion, which is not to be sneezed at.
Furthermore, Collins and Lieberman propose that their package of wage freezes and pension reforms should apply to Congress and the congressional staff as well as to the rest of the government cadre. Congress should bend over backwards to see that any benefit cuts for any government workers are at least matched by cuts on their own pay package.
The pension reforms the two propose include basing retirement pay on earnings for the past five years rather than the last three years, as is currently the case. Because federal pay scales have been routinely increased every year until the current recession, this change will also save billions over time.

IT IS GENERALLY agreed that freezing federal wages can be done without any adverse effects on the function of government. The same observation can be made about most levels of government expenditures.
But there are important exceptions that must be kept in mind. At every level, local, state and federal, government spending will increase as population increases. It is reasonable to expect spending on education to rise with the numbers of students enrolled. Medicare costs not only rise with the unit cost of health care but, obviously, with the number of eligible beneficiaries.
Similar cost increases can be expected in every government function in which demands for the service performed rises year by year. It is reasonable to ask that government control unit costs; it is unreasonable to expect government to do more without spending more.
The cost of government also rises when the citizens governed demand additional services. To pick one current example: The American people have demanded that the federal government and some state governments crack down on illegal immigration. As a consequence billions more taxpayer dollars are being spent every year building fences, hiring border patrol agents, sending National Guard units to the border, prosecuting illegal immigrants and those who hire them and on the rest of the greatly stepped up immigration control effort that these public demands have required.
The attack on the United States by terrorists in 2001 resulted in the creation of the Department of Homeland Security. The current DHS budget is a little more than $32 billion.
Those are just two of the additional demands on taxpayers that government has made in the last 10 years — or, to say it as it is, the additional demands that the taxpayers have placed on their government.
We asked for it; we should be willing to pay for it.

— Emerson Lynn, jr.