In 2011, the Vermont state government enacted a law functionally establishing the first state-level single-payer health care system in the United States. Green Mountain Care, established by the passage of H.202, creates a system in the state where Vermonters receive universal health care coverage as well as technological improvements to the existing system.

On December 17, 2014, Vermont abandoned its plan for universal health care, citing the taxes required of smaller businesses within the state.^[1]

In 2010, the State Legislature passed S 88 (which included provisions from Act 128), which enabled the state of Vermont to establish a commission to study different forms of health care delivery in the state.^[2] Dr. William Hsiao, a Harvard University professor of economics who was an advisor during Taiwan's transition to single-payer health care,^[3] was enlisted to design three possible options to reform Vermont's health care.^[4] Hsaio, along with Steven Kappel and Jonathan Gruber, presented the proposal to the legislature of Vermont on June 21, 2010.^[5]

The three options were laid out as follows:

• Option 1: As laid out by the requirements of Act 128, the first option would create "a government-administered and publicly financed single-payer health benefit system decoupled from employment which prohibits insurance coverage for the health services provided by this system and allows for private insurance coverage only of supplemental health services."^[5] The proposal considered this option to be the easiest path to single-payer, but was critical of the "complex and inefficient process" of proof of residency needs.^[5]
• Option 2: As laid out by the requirements of S 88, the second option would create "a public health benefit option administered by state government, which allows individuals to choose between the public option and private insurance coverage and allows for fair and robust competition among public and private plans."^[5] The commission noted that this option did not provide universal coverage on its own or the enforcement mechanism in place for any possible mandates put in place to achieve more coverage.^[5]
• Option 3: Act 128 allowed the commission to design a system that met the various principles outlined in Section 2 of the Act.^[2] The commission's design ultimately sought out an "approach to Option 3... by combining three studies to ascertain what type of universal health insurance, what methods of financing, and what type of single payer system is most likely to be politically and practically viable for Vermont."^[5]

The commission's proposal ultimately considered the third option to be "the most politically and practically viable single payer system for Vermont," noting that Vermont, "a small state with communitarian values," with its existing network of non-profit hospitals and a medical community that had previously shown support for state intervention, would be "uniquely poised to pass universal health reform."^[5]

Following the proposal, Democratic state representative Mark Larson introduced H 202 on February 8, 2011, titled Single-Payer and Unified Health System.^[6] The bill passed the House on March 24, 2011, with 94 votes in favor and 49 against.^[6][7] The bill then passed the Senate on April 26, 2011, with 21 votes in favor and 9 against.^[6][8] The conference report legislation passed the Senate on May 3, 2011 with 21 votes in favor and 9 opposed, and the House on May 4, 2011 with 94 votes in favor and 49 against.^[6][9] Governor Peter Shumlin signed the bill on May 26, 2011.^[6]

Dr. Hsiao, in his proposal, noted that "a two-thirds majority of Vermonters said that all Vermonters should be able to get the health care they need when they need it, regardless of their ability to pay even if this means that they would have to pay higher taxes and higher insurance premiums themselves."^[5] The bill was passed in the Vermont legislature on party line votes, with Democrats and Progressives in favor and Republicans against. The bill is considered the first single-payer bill to be passed on the state level, but private insurers can continue to operate in the state. Representative Larson has described Green Mountain Care's provisions as "as close as we can get [to single-payer] at the state level."^[13]

According to Leigh Tofferi, the director of government, public and community relations for Blue Cross Blue Shield of Vermont, the lack of initial specifics was causing "anxiety" to many providers. The Vermont Medical Society had no position on the bill or on single-payer in general. David Himmelstein, the founder of Physicians for a National Health Program, a single-payer advocacy group, was critical of the plan due to the ability of private insurers to operate in the state, arguing that the plan "give[s] up a significant part of the administrative savings by doing that," but agreeing that Green Mountain Care "lays the foundation" for single-payer.^[13]

In the 2014 gubernatorial election, Governor Shumlin was heavily favored for re-election but only received a plurality of the vote, 46.4%, to Republican Scott Milne's 45.1%. The election was decided by the Vermont General Assembly on January 8, 2015; Shumlin defeated Milne by a vote of 110 to 69.^[15] The Burlington Free Press ascribed the result, in part, to voters' dissatisfaction with the progress the state had made in instituting single-payer health care.^[16]

One of the problems found since the abandonment of the Vermont Health Care initiatives is questionable billing from Jonathan Gruber, who according to CNBC, has come under more scrutiny because of the contract.^[17] According to a Vermont State report filed by Doug Hoffer,^[18] an invoice sent by Gruber to Vermont on December 30, 2014 for $40,000 increased the amount of scrutiny on the billing.^[19]