Vermonters are now being subjected to the most intense, well-funded propaganda campaign I have ever seen in Vermont.

Beginning in January of this year, the group, Vermonters for Health Care Freedom (VHCF), began to carpet bomb the airwaves with a media campaign targeting Act 48, the health reform law signed into law last May. The campaign uses the standard propaganda techniques of fear-mongering, distortion, and appeal to conspiracy theories.

Reality Check

The ads allege that a secret cabal of health reformers plan to raise our taxes by $5 billion to fund the new single payer system, that these conspirators already know how they plan to impose these taxes, and that they are hiding this information from the public.

Every element of this message is nonsense. Here’s the reality check:

$5 billion represents total health spending in Vermont currently. As is the case in most states, over half of Vermont’s health care money comes from federal sources. This includes funding for federal employees, the military, the VA, Medicare, and the majority of Medicaid funding. And Act 48, the reform bill, has been designed to ensure that we continue to receive all of the federal funding we normally receive. Furthermore, most of the remainder of the $5 billion is money we’re already raising. This encompasses out-of-pocket spending, health insurance premiums, and local and state taxes that are already funding health care for state and local employees, teachers, prisoners, VScript, Catamount, and Vermont’s portion of Medicaid spending.

So whatever additional revenue is required will represent only a small fraction of total health spending—not even close to $5 billion.

The ads never mention that Green Mountain Care—the proposed single payer plan– does not go into effect until 2017.  Think about it: Is it realistic to expect those who are just beginning work on the reform effort to have already determined its entire funding structure—five years in advance? And that there is some sort of conspiracy related to Green Mountain Care’s funding for 2017? Next thing you know, they’ll claim a conspiracy if the Agency of Transportation or the Corrections Dept are unable to announce their 2017 budgets five years in advance.

Get real.

The truth is that the reform effort we are undertaking is a major change, and it is refreshingly honest and appropriate that Act 48 obliges our lawmakers to identify a funding mechanism 4 full years in advance of its implementation—in 2013. This timing allows us to speak with legislative candidates in the coming election season and share our opinions on how our future health care should be funded.

Will the propaganda campaign succeed?

While the assertions of these propagandists are ridiculous, this does not mean that the propaganda campaign will fail. Reality doesn’t matter when the microphone available to the propagandists is so loud, and when the message the microphone is blaring is incessant. Prior propaganda campaigns have taught us that if you repeat a lie often enough, people will come to believe it.

And based on what we’ve seen in the last month, there appears to be no limit to the amount of money this organization has available to spew its disinformation. While many Vermonters may oppose or have doubts about the health reform effort, the scale and costliness of this media campaign make it quite unlikely that the campaign is funded within Vermont. My bet is that almost all of the funding is coming from pharmaceutical and health insurance companies. For these companies to spend all it takes to prevent single payer reform from succeeding—even in one state– is far less expensive in Vermont than it would be in most other states.

But we’ll never know. The key information that is being very consciously hidden from the public has nothing to do with what VHCF is alleging. What is being hidden from all of us is this question: Who is funding this propaganda campaign?

Green Mountain Care will bring all Vermonters into a system of health care they can access throughout their lives. And as is the case with single payer systems across the world, only this type of reform has the ability to control health care costs and provide care to every single citizen throughout their lives. The international track record is crystal clear:  Single payer systems control costs, and they are very popular – far more popular than the nasty game of musical chairs that passes for a health care “system” here in the U.S.

But this reform threatens those powerful corporations who are quite content with the health care system just the way it is. And now we see them fighting back using the technique that usually works: Throwing unlimited amounts of money to create a propaganda offensive.

How can Vermonters respond?

1.  Local media outlets should not air any media spots by organizations that refuse to disclose their funding sources

2.  Local media outlets should provide airtime free of charge to local organizations and individuals who are able to provide sensible balance when such media campaigns support primarily the interests of well-funded corporate conglomerates whose media buys are orders of magnitude greater than what regular Vermonters could possibly afford.

3.  If they are willing to air ads from such mysterious organizations, then local media outlets should severely limit the number of times the ads air so that they are not serving as passive conduits for disinformation campaigns. Effectively, they become complicit when they profit from propaganda that is harmful to the public interest.

4.  If our local media outlets continue to serve as conduits for a propaganda campaign—and this definitely includes this case—then concerned citizens around the state should organize pickets and call-in campaigns directed at these stations. Media outlets have a duty to serve the public in an ethical and balanced manner. They need to respond appropriately to this new development in a manner that demonstrates their role of service to the public.

5.  Host a public forum or public debate. Supporters of health reform are available around the state who are ready to speak publicly on the issue. I have personally offered to debate the opponents of reform in any suitable venue. I made this offer on WDEV’s Mark Johnson show last month—and Mark agreed to host such an event. Unsurprisingly, there has been no response so far.

Every Vermonter who wants to create an affordable and humane health care system for our state has a stake in this effort.

Marvin Malek, MD is a physician who practices internal medicine at Central Vermont Hospital.

There has been a lot of discussion about the Exchange – about “bronze,” “silver” and “platinum” plans. Vermont is required by federal law to implement the Exchange in 2014. How can Vermont’s legislature best configure the Exchange?  Many people are wondering what this all means for them.

Let’s remember that the Exchange is just about a format to purchase private insurance. It is not the same as the single payer system that Vermonters will be allowed to implement in 2017.  Single payer is about financing health care for all Vermonters directly – without the waste and overhead of insurance company middlemen.  A single payer system guarantees health care, divorced from employment, funded directly by the public.  If you lose your job, you will still have health care in a single payer system.  If you are a small employer, you will not have to spend hours shopping around for different plans.  

We all know that if the Exchange was able to deliver health care to all Vermonters when they needed it, and to control costs, we wouldn’t need a single payer system in Vermont.  However, we can’t establish a single payer system until 2017, because we can’t get a waiver from the Exchange until then.  Therefore, we  have to think about the Exchange as temporary, and try to take advantage of the one thing the Exchange does have to offer, namely federal dollars to help people purchase insurance premiums and to subsidize some out of pocket costs.   Once Vermont establishes a single payer system, we will be able to access these same federal dollars, but put them directly into our new single payer system.

In the short run, we will have to devise rules for the Exchange that do the least harm.  We know that having plans with different levels is not what health care is all about!  But, we also know that many small employers are well meaning, and if they could afford private insurance plans with more coverage, they would have purchased them in the first place.

The House Health Care Committee and the Shumlin administration have been trying their best to wrestle with these issues.  I suggest that they let two guiding principles help them through this morass, and that they keep in mind that the Exchange is temporary.  First, despite the inclusion of bronze plans, there should be ways to create maximum incentives for “silver” plans.  I agree, you cannot force a small business to purchase a plan they can’t afford.  However, incentives can maximize the choices of silver plans, and this may bring in more federal dollars, as well as keep to a minimum the number of people who are left holding the bag with high out of pocket costs.   Second, it will be very important to make sure that people currently on VHAP and Catamount experience as little deterioration in their experience of cost and coverage as possible.  If the Exchange results in a sharp deterioration of coverage or increase in cost, this will create real hardships for people.  Such bad experiences with the Exchange may also poison the well for single payer, because people will be turned off to the very idea of reform.

As we go through this process, however, let’s remember that single payer is based on completely different principles than the Exchange.  With single payer we will no longer be talking about “bronze,” “silver” and “platinum” plans, but guaranteed health care for all Vermonters without the excess cost of the insurance company middlemen.  Single payer is the only real solution for individuals, for businesses, and for all Vermonters.

Partisan politics, not sound statistical analysis, underlies recent attacks on Vermont’s plan to create a single payer health care system. Rutland City Treasurer Wendy Wilton has attracted media attention with her off-the-cuff number crunching. Bruce Lisman (a retired investment banker at JPMorgan Chase) and Lieutenant Governor Phil Scott have both been warning that single payer health care is too risky in these difficult economic times. And Robert Letovsky (a business professor at St. Michael’s College) has maligned the Canadian system in an attempt to discredit Vermont’s initiative.

Wilton’s curious refrain has been that single payer revenues do not match single payer expenses. She asserts that by 2019 Vermont would be $2 billion in the red if a single payer plan is adopted. The allegation is odd because to date there has been little attempt to formulate a revenue plan for the single payer program, and estimates of costs and savings are usually given as ranges. There are simply no hard numbers to debate. However, Wilton uses the lack of a financing plan as the basis to attack the whole premise of universal health care.

I agree with Wilton that it would be nice to have a complete picture of health care reform all at once.   As Rutland City treasurer she must certainly gain satisfaction from analyzing the cost of a new dump truck, calculating its return on investment, and pinpointing the effect of the purchase on the city tax rate. Unfortunately, changing the health care system of an entire state, providing coverage for all its residents, and controlling costs is a much more complex task. Since no state has yet made this move, there is no fixed price tag, no iron-clad quantification of savings and health status improvements, and no perfect comparison models.

Furthermore, as much as we would wish it, single payer in Vermont cannot happen in one fell swoop. The Legislature has taken a cautious approach, commissioning a thorough study and enacting a framework for future action. The Green Mountain Care Board has recently published a study of expected single payer savings, as required by statute. The next steps may include development of payment reform models, outlining a benefits package, and working out the ways that federal health care reform can provide a transition to single payer.

Wilton raises the specter of “the largest tax increase in the history of Vermont.” This was the same fear tactic that was used to defeat health care reform in the 1990s. Yes, if you replace private health insurance premiums with taxes, the increase in state revenue will be huge. It would be irresponsible for the Legislature to levy such taxes without also eliminating the waste, fraud, and redundancy in the current system, and creating a transparent and accountable means of administering such revenue. It would also be irresponsible to saddle businesses that currently provide excellent health benefits to their employees with taxes exceeding the projected costs of private insurance. Preliminary studies indicate that such challenges can be surmounted, but we must be patient.

Truth be told, we do not currently have a transparent and publicly accountable system. We do not now have adequate ways to control costs or to prevent personal bankruptcy from health care bills. And Vermonters die because they do not have access to affordable medical care. Ms. Wilton admits the current system is unsustainable, but if she has a better idea how to solve these problems, I have not heard it.

One final point: It is easy to pull out tiny pieces of the health care puzzle and say this or that should be changed. Ms. Wilton intimates that if people behaved in a healthier manner, health care costs would be lower. She also cites Vermont’s chronic disease management program (the Blueprint for Health) as a way to reduce costs. But if Vermont were perfect in both these areas, overall health care costs would still be too high. Institutional fixed costs would remain the same and would rise with inflation. Providers would continue the insane chase of paperwork involved in billing and insurance reimbursement. And costs would continue to shift from one area to another without any overall rationale. In the absence of unified financing, we will never be able to keep the lid on our health care spending.

If we want to give our businesses a break, if we want to rescue our economy, if we want to be a society that has the decency to make health care available to everyone, regardless of assets or income, then, despite the uncertainty involved, we must continue on our present path toward single payer. We know that a public process and legislative action will be necessary at each step along the way. We must not be distracted by those who would derail reform in order to score political points.

What are the potential savings from a single payer system in Vermont? A recent report from the Joint Fiscal Office and the Department of Banking, Insurance and Health Care Administration (JFO and BISHCA) has led some single payer opponents to claim that significant cost containment can occur without single payer.

This is a spurious claim that misinterprets the report and challenges the fundamental precepts of the study the Legislature commissioned last year by Harvard health economist William Hsiao. The Legislature should invite Professor Hsiao back to Vermont at his earliest convenience to analyze and clarify the findings of the BISHCA report, which in fact reaffirms that a single payer financing system is the only way to simultaneously control costs and provide comprehensive health care coverage to all Vermonters.

Indeed, since 2001, the state has commissioned four official studies of our health care system and tested the proposition of whether a single payer system would be able to cover all Vermonters and contain costs.  Every single time, the answer has come out in the affirmative, whether it was the Lewin study of 2001, the Thorpe study of 2006, the Hsiao study of February 2011, or the follow-up that was just released by the state of Vermont last week under the auspices of JFO/BISHCA (Joint Fiscal Office and Department of Banking, Insurance, and Health Care Administration).

It is true that the latest study is more conservative, but even this study concludes that with a single payer system we can provide an equitably financed system with comprehensive coverage for all Vermonters (something that is not the case now), and contain the rise in costs while doing so.   Let us not lose sight of this important insight – we can cover everyone with a comprehensive package and contain costs.  Isn’t this better than the current situation?  Right now, by everyone’s admission, costs are uncontainable, and 200,000 Vermonters are either uninsured (43,000) or underinsured (160,000) according to a March 2011 report prepared for the Vermont Office of Health Access.

That said, some important questions have been raised about the latest study and they should be addressed.  First, the study concludes that fraud reduction and clinical reform will actually save a much greater percentage of health care costs than administrative savings from the implementation of single payer.   This might lead some people to conclude that single payer is the least necessary piece of the reform package.  However, this would be a misreading of the evidence.  We should remember that fraud reduction and clinical reform will never be truly effective if they are not part of a unified financing system – that is single payer.  Also, fraud reduction and clinical reform on their own can never get us to universal coverage for all Vermonters – again, let us not lose sight of this goal!

Second, the study’s definition of administration included such things as billing, personnel management, and even hospital laundry.  But did it have a measure of costs to the system as a whole for having the complex financing  [structure or non-system] which we have now?  For instance, did it count the costs to the system now that arise when people delay treatment because they have inadequate coverage, or when people have to fill out (and others have to process) mountains of paperwork each time their incomes rise or fall to apply to different programs.

Still, let’s not forget the bottom line.  With single payer all Vermonters can have access to comprehensive coverage, equitably financed. Every study has validated this, and no other alternative to comprehensive cost effective coverage for all Vermonters has ever been put forth.  Professor Hsiao, who is a world renowned expert at examining the way different parts of a health care system interact and affect  one another,  should also come back to shed light on the latest study.

Governor Shumlin’s plan for transitioning Vermont to a publicly funded universal health care system in 2017 is truly exciting and should be just the solution for our health care crisis. However, beginning January 1, 2014 (and running until our single payer system is in place) Vermont must have in place a Health Care Exchange as mandated by the federal Patient Protection and Affordable Care Act. How this Exchange is created will not only be an important foundation for Vermont’s universal health care system, but it will determine the quality and affordability of health care for small business owners and their employees, the almost 50,000 Vermonters in Catamount and VHAP and the estimated 47,000 uninsured Vermonters.

Even though 2014 seems like a long way away, the 2012 legislature which convenes in January will have to make several critical decisions about health care for the estimated 100,000 Vermonters who will be accessing health care through the Exchange beginning in 2014.

In the new Exchange, all health insurance plans will be offered by private insurance companies like Blue Cross Blue Shield and MVP. VHAP and probably Catamount Health will no longer be offered and these enrollees will have to purchase other private insurance. People in households under 400%FPL (about $90,000 for a family of 4 and $44,000 for a single person) will receive federal subsidies towards their premiums.

This brings us to a problematic issue: the affordability of the plans in the Exchange, particularly for the low and middle income Vermonters currently on Catamount Health and VHAP. Right now if you are on Catamount, you have an annual out of pocket (OOP) maximum of $1,050 in addition to your monthly premium; if you are on VHAP, the only OOP cost you have other than your premium are prescription drug co-pays of $1 or $2 and a $25 emergency room visit fee. In the Exchange any VHAP or Catamount enrollee who is over 133%FPL (about $1,230/mo gross household income for a single person and $2500/mo for a family of four) will have up to a $1,964 and $3,987 OOP limit respectively And this is on top of an increased monthly premium in the Exchange! The bottom line is that the federal subsidies aren’t nearly enough to make private health care affordable for low and middle income Vermonters.

Given that half of all the uninsured in Vermont are currently eligible for a public health care program and that high OOP costs are repeatedly identified as the number one reason people don’t enroll, the 2012 Vermont legislature needs to act to make sure health care is truly affordable in the Exchange. One option available to Vermont is to provide an additional subsidy on top of the federal subsidy people under 400%FPL will receive in the Exchange. Unless the state acts through an additional subsidy of its own, many thousands of Vermonters will either lose the relatively affordable coverage they had through VHAP and Catamount or just remain uninsured.

The other major issue after the affordability of health care through the Exchange is the comprehensiveness of coverage. All plans offered through the Exchange will be mandated by the government to offer similar benefit packages but what will largely differ is the cost sharing arrangement of each particular insurance plan, i.e. deductibles, co-pays, co-insurance etc. The federal government is expected to announce the list of mandated benefits for all plans in the Exchange sometime early next year. But since Vermont has traditionally mandated that private insurance plans covers services they typically don’t cover, it is the expectation that many benefits we are used to seeing in private plans offered in Vermont (such as naturopathic coverage) won’t be mandated by the federal government and therefore the state legislature is going to have to ensure are still offered. We need the 2012 legislature to act to make sure all plans in the Exchange cover a truly comprehensive range of services.

While the two issues mentioned above are the most critical for the upcoming legislature to deal with, there are several other very important flaws in the Exchange that must be address before 2014 including:

1. Reconciliation: If over the course of the year, household income turns out to have been greater than projected the government may have paid the enrollee more for premium subsidies than they were entitled to. In this case, the enrollee must pay the difference back and, if final annual income exceeds 400% FPL the entire tax credit must be repaid. Having to pay the government back money at year’s end for health care could be a serious financial hazard for many people causing them to drop coverage or suffer serious financial harm.
2. Limited open enrollment periods: The initial open enrollment period for plans in the Exchange will be from October 1, 2013 through February 28, 2014. Starting with the January 1, 2015 benefit year, open enrollment for the Exchange will be October 15 to December 7 of the previous year only. Though there will also be “special” enrollment possible for those newly eligible for the premium subsidy, who lose employer coverage, or whose household changes through marriage, divorce, etc, for most people this means they will only have a very short time in which to enroll, otherwise they will have to remain uninsured for the rest of the year.

Some have suggested that Dr. Hsiao’s plan to finance the new system will not work. But this is the wrong place to start. Dr. Hsiao submitted a proposal; it is not the state’s plan. Rather, it is a point of departure for further research and debate.

Dr. Hsiao recommended using a payroll tax to finance the new system. For a variety of reasons, including administrative convenience, the payroll tax should be part of the eventual funding scheme. However, using ONLY the payroll tax is both unfair and impractical.

For example, there are a number of Vermonters below retirement age that don’t work. Some of the non-working folks have substantial non-wage (“unearned”) income from capital gains, interest, and dividends. A universal health care system that does not require contributions from wealthy non-working Vermonters would be an insult to the rest of us.

And furthermore, if someone earns $100,000 in wages and an additional $100,000 from other sources, his or her effective rate would be half of that paid by everyone else. That is, assume the payroll tax is 8%. A person earning $40,000 would pay $3,200. The person earning $200,000 with only half from wages would pay $8,000, which is only 4% of total income. Does that seem fair to you?

In addition, limiting funding to payroll would exclude a substantial amount of taxable income. After subtracting wages for federal employees (who will not be part of the system), total Vermont payroll in 2010 was $11.1 billion. In contrast, total adjusted gross income in 2009 (latest year available) was $15 billion. Thus, even after subtracting federal wages, there would be well over $3 billion of income NOT taxed for the new system. This makes no sense.

Finally, the expected cost of the system is the predicate for conversations about financing. Unfortunately, the opposition has been trumpeting an “analysis” that assumes the system will cost much more than is expected (almost twice; see John Franco’s op-ed) and that it will be financed solely with a payroll tax. Not surprisingly, using these assumptions leads to substantial deficits and an unsustainable system. But the analysis is fatally flawed and is poisoning the discourse.

So let’s not get ahead of ourselves and let’s insist that all the parties stick to the facts.

When Governor Peter Shumlin signs the new health care bill into law on May 26^th, many people may wonder how we came to this point. Why is it that Vermont is the first state to pass legislation that acknowledges that health care is a public good, and that the best route toward universal access and cost control is to create a health care system that is publicly funded?  There are still many more steps to go before we reach this goal.  Nonetheless, it is worth pausing at this important juncture to ask what makes Vermont different.

One thing that makes Vermont different is that the campaign for single payer in this state has been broad based and involved multiple organizations and thousands of individuals at the grassroots level over almost two decades.

The Vermont Workers Center (VWC) is one of the groups that have done a superb job of organizing people from 2008 onwards – focusing on health care as a human right.   Their organizing built upon the earlier and still continuing efforts of many other individuals and groups — creating unparalleled energy around this issue. In 2009, for instance, public meetings were held all over the state on health care and for single payer.  Many were part of the VWC campaign.  Other meetings were organized by independent groups including religious and community groups. Senator Bernie Sanders also held many health care related events around the state.

These 2009 meetings followed on the heels of a 2008 campaign for H304 – a single payer bill for hospitals. Hundreds of people traveled to the statehouse for several large events to advocate for H304 in the winter of 2008, organized by Vermont Health Care for All (VTHCA). Additionally, Dr. Deb Richter of VTHCA traveled the state and spoke at over 400 forums between 2000 and the present, introducing the concept of single payer to numerous citizen groups.

Earlier in the decade, in 2005, former state Senator Cheryl Rivers, in coordination with Richard Davis of Vermont Citizens Campaign for Health organized for single payer on town meeting day, and succeeded in getting many towns to vote in support of the concept.

Large statewide demonstrations for single payer have been organized by VTHCA (1200 people at the Statehouse in 2002) and the VWC (over a 1000 people coming to their May Day rallies in 2009, 10 and 11).  Smaller demonstrations for single payer also occurred almost every year at the statehouse, and in other venues – such as a 2009 rally of several hundred people at the Obama administration’s regional health care summit in Burlington.  Unions and even business groups have also organized around the concept: several groups come to mind here including the AFL-CIO and other unions, Vermont Businesses for Social Responsibility, and even the League of Women Voters.

Because so many groups have been involved, and so many citizens have weighed in on the issue, this state was fertile ground for lawmakers and candidates who advocated for single payer. Not all of them won, but they helped make the issue prominent.  I don’t have space to list everyone here, but Anthony Pollina and Cheryl Rivers come to mind. And, of course, Governor Shumlin made single payer prominent in his campaign and won, and Senator Bernie Sanders has long advocated for single payer and helped legitimize the reasons for it to a broad public.  We should also not forget that it was Peter Shumlin, as Senate President Pro-Tem, who first contacted Professor William Hsiao in December 2009 for the express purpose of inviting him to testify in the upcoming legislative session.

All these efforts, and probably many more than space allows me to include, made for an ideal scenario in advancing the cause of single payer in the legislative agenda.  Because Vermont is a state where citizens really get involved in issues, it is still possible to see legislation pass that advances the common good.

Despite the politics and war of words, the health care proposal now before the Senate makes relatively modest steps towards a single payer health care system, while also taking steps to start controlling costs.

It is true that many questions about costs and financing are still unanswered. That is because the “plan” is not yet determined. I support a single payer system. It works in many places and can work here. But, I do not see this proposal locking us into a single payer at all. (Some will like this, others will not). Instead, the bill is designed to start controlling costs, to answer the questions we all have and to bring a plan to the Legislature, which we will accept or not. Here is what it does.

It establishes a Board to answer questions about what Green Mountain Care (the single payer) may look like. So, over the next few years a benefits package will be designed, costs and provider payments determined and a financing plan recommended. The Legislature will then vote to approve or disapprove it. This is expected in 2013 but may not happen until 2017, leaving much time for questions, answers and debate on the issues.

While this is a path to a possible single payer, it can only happen if certain requirements are met: there must be a comprehensive coverage plan, we must know the cost and how we will pay for it; the federal government must provide waivers and our Legislature must vote to approve it.

Certain values will guide the plan. It must cost less; with significant savings in the initial stages, followed over time by slower and lower cost increases than in our current system. It must include comprehensive benefits, including mental health and wellness; fair reimbursement for providers and protections for consumers. And, those on Medicare and other federal health care and retiree benefit programs (i.e. military programs) will keep their benefits. They will not see lower benefits.

It establishes a health insurance exchange as required by the federal government. The exchange is a way to help us comparison shop for health insurance and for some to receive subsidies to help pay. A variety of plans will be in it, including two new multistate plans required by federal law. Other plans will be available outside the exchange. It does allow us to move towards common administrative forms and other efficiencies. It should be operational in 2014 for individuals and small employers and for others in 2017.

And, it establishes pilot projects to start controlling costs by changing how health care is paid for and delivered. Costs will be lowered and outcomes improved by having physicians work with a team of others (i.e. prevention, mental health). They will be paid on a per-person – per month basis not the current fee for service method. And, be rewarded financially for keeping us healthier. This is already underway in our Blueprint for Health program.  Finally it makes better use of technology and electronic data to further cut costs.

The bottom line: there are a lot of questions to be answered. This bill only gets the process started.

My husband and I (61 and 62 years of age) had health insurance through  Blue Cross Blue Shield of VT. The only plan we could afford was the high deductible one ($5,000 stacked). We were paying  about $480 a month with no benefits. We decided to apply for Catamount Health coverage but in order to do so we had to be off  Blue Cross Blue Shield for 1 year. We took the risk and after one year got on Catamount’s Premium Assistance plan and finally were able to get good coverage. After one year on this plan we were notified upon yearly review that our income was $66.00 over the limit for premium assistance and that we would have to do a full pay of $830.00 a month.  That is unaffordable for us, (about 1/4th of our income), so we are now back to being uninsured.  Catamount turned out to be very disappointing for us. Single payer is the only true way to go for Vermonters.