Source: https://www.hhrjournal.org/2015/12/the-impact-of-human-rights-on-universalizing-health-care-in-vermont-usa/
Timestamp: 2019-04-18 11:39:04+00:00

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In 2010, Vermont adopted a new law embracing human rights principles as guidelines for health care reform, and in 2011, Vermont was the first state in the US to enact framework legislation to establish a universal health care system for all its residents. This article reports on the Vermont Workers’ Center’s human rights-based approach to universal health care and the extent to which this approach influenced decision makers. We found the following: (1) by learning about the human right to health care and sharing experiences, Vermonters were motivated to demand universal health care; (2) mobilizing Vermonters around a unified message on the right to health care made universal health care politically important; (3) using the human rights framework to assess new proposals enabled the Vermont Workers’ Center to respond quickly to new policy proposals; (4) framing health care as a human right provided an alternative to the dominant economics-based discourse; and (5) while economics continues to dominate discussions among Vermont leaders, both legislative committees on health care use the human rights principles as guiding norms for health care reform. Importantly, the principles have empowered Vermonters by giving them more voice in policymaking and have been internalized by legislators as democratic principles of governance.
In this light, this article documents the results of an explanatory case study on the impact of an HRBA to universalizing health care in Vermont. Following this introduction, the article explains the design and methodology of the study. Drawing on related literature, legislative history, media coverage, and interviews, it then examines the Vermont Workers’ Center’s Health Care Is a Human Right campaign, including the reasons the Center decided to use an HRBA to advocate for universal health care and the strategies it employed to educate and mobilize Vermonters. The article then looks at the 2010 and 2011 health care legislation, which includes human rights principles, and considers how these principles have influenced decision-makers and discussions on health care reform. Finally, the article summarizes lessons learned from the study, including the impacts of an HRBA to universalizing health care in Vermont and reflections on the study methodology.
Using multiple qualitative methods, our study sought to investigate and describe what happened, explore corollary and causal relationships, and develop a theory of explanation.23 Qualitative methods were elected for their ability to generate understanding and analysis of meaning in social context. As Jamie Baxter and John Eyles explain, we “set out to learn to view the world of individuals or groups the way they themselves see it.”24 We had three initial theories: (1) human rights provided a unifying concept and focus for the campaign; (2) human rights provided a compelling moral and normative argument for mobilizing Vermonters and for influencing legislators; and (3) human rights provided a consistent framework for assessing and responding to policy proposals.
The initial step for our 2015 research project was to update the review and analysis of legislative history, media coverage, and the Center’s website. For the second step, we employed semi-structured in-depth interviews to update the earlier project on how the campaign worked to educate and mobilize Vermonters, and to consider how the campaign influenced leaders on health policy reform in Vermont. We selected leaders to interview from the legislature, the executive, and nongovernmental organizations based on their visible role in leading health care reform in Vermont. During March 2015, one member of the team interviewed twelve of these leaders (five advocates, three legislators, and four staff in the executive branch). This allowed for the triangulation of interview findings from different participant types. While the interviews focused on the two main research questions and drew on a 15-question guide developed by our team, each interview was tailored to the specific role—activist, legislator, or executive staff—of the interviewee. Participants were asked about the role and influence of human rights on the health care reform discussions and legislation, and were prompted to explain their perspectives in more detail (where necessary). Moreover, the interviews were semi-structured, such that the interviewer probed participant responses to capture additional insights.
All 12 interviews were transcribed in full. The transcripts were first analyzed by a social scientist, who used software (QSR NVivo 10), and then by two Vermont lawyers with expertise on the international human right to health, HRBAs, and Vermont health care reform, who drew out excerpts relevant to our research questions and emergent themes. We then categorized and coded the findings using narrative analysis and prepared a draft report. All five members of our team reviewed the draft, and the lead author made substantial revisions based on their feedback. The full report of over 16,000 words, submitted to the World Health Organization in June 2015, is summarized in this article.
Universality is the principle that human rights must be afforded to everyone, without exception. It is by virtue of being human, alone, that every person is entitled to human rights.
Equity is the principle that every person is entitled to the same ability to enjoy human rights. Healthcare resources and services must be distributed and accessed according to people’s needs, not according to payment, privilege or any other factor. Disparities and discrimination in healthcare must be eliminated, as must any barriers resulting from policies or practices.
Accountability is the principle that mechanisms must exist to enable enforcement of human rights. It is not enough merely to recognize human rights. There must be means of holding the government accountable for failing to meet human rights standards.
Transparency is the principle that government must be open with regard to information and decision-making processes. People must be able to know how public institutions needed to protect human rights are managed and run.
Based on these rationales, the Center developed a multi-year campaign strategy. For the first year (2008–2009), the campaign focused on educating Vermonters about health care as a human right and providing a forum for residents to share stories about their experiences with the health care system. The campaign implemented these strategies by staffing tables at farmers’ markets, marching in local parades, writing letters to the editor, and canvassing neighborhoods. The Center also carried out a short survey, collected stories about how the current health care system jeopardized the health and finances of Vermonters, and held human rights hearings throughout the state at which Vermonters testified about their experiences with the state health care system. On December 10, 2008, in celebration of the 60th anniversary of the Universal Declaration of Human Rights, the Center released the report Voices of the Vermont Healthcare Crisis.32 Finally, on May 1, 2009, the Center held a rally at the Vermont Statehouse, at which 1,200 people attended—the largest weekday rally in the state’s history.
In the second year (2009–2010), the campaign began a concerted effort to convince legislators that there was a health care crisis in Vermont, that universal health care was the best policy response, and that such a policy was politically feasible. The Center’s strategies included organizing a series of “people’s forums” in 10 counties, which were attended by more than 70 legislators; preparing a “people’s toolkit” with analytical and advocacy tools, including a human rights report card, which provided a guide to compare the various health care proposals put forward at the beginning of the 2010 legislative session; delivering thousands of postcards to the Statehouse on the first day of the 2010 legislative session, calling for legislative action to make health care a human right in Vermont; and forming “people’s teams” with a daily presence on the legislature floor and in committee rooms, increasing transparency and fostering the participation of ordinary Vermonters.
It is not yet clear what impact the “public good” language will have on health care reform in Vermont. The dismissal of health care as a “human right” is consistent with the dismissal of economic and social rights more generally in the US. Unfortunately, this makes it more difficult for advocates to use international human rights standards on the right to health persuasively on substantive issues regarding health care. On the other hand, the human rights principles, which encompass civil and political rights, align more closely with US tradition and therefore appear to have been easier for legislators to incorporate into Vermont law.
In sum, the adoption of the principles of transparency and participation into Vermont law has advanced opportunities for Vermonters to have meaningful participation in policymaking on health care reform at multiple levels. The principles of universality, equity, and accountability remain policy goals for health care in Vermont, which continues to move gently toward health care as a human right for all.
Third, in December 2014, Governor Shumlin, who campaigned on a platform for single-payer health care, announced that he was not going forward in implementing a single-payer universal health care system because he believed that it was too costly at this time.62 Reports on the cost of implementation indicate that Shumlin selected the most expensive option for universal health care and that acceptable less expensive options were feasible.63 Moreover, experts agree that the single-payer system would clearly have economic advantages by simplifying the system—one payer, one benefit package—and would also save on fraud and abuse detection.64 Importantly, Vermont’s legislature has not abandoned moving forward on universal health care. Indeed, the legislature adopted a bill in May 2015 calling for Vermont’s Agency of Administration to study the cost of providing universal primary care, without cost-sharing, beginning in 2017, when the PPACA allows a waiver from the health insurance market exchange.65 In addition, Governor Shumlin announced on June 8, 2015, that he would not seek another term as governor, leaving the 2016 election open to a candidate willing to recognize health care as a human right. While a full universal single-payer system of health care may not be realizable this year in Vermont, all of our interviewees indicated that Vermont would continue to move, at least incrementally, toward this goal.
Third, using the human rights framework allowed the Vermont Workers’ Center to respond quickly to new policy proposals in a principled manner, which helped mobilize allied organizations and individual Vermonters to support the Center’s position. Fourth, the Vermont Workers’ Center was successful in convincing the legislature to adopt the human rights principles into Vermont law as guidelines for health care reform. On the other hand, legislators had mixed reactions to the moral and normative argument of health care as a human right and preferred to recognize health care as a “public good.” Fifth, once adopted, the human rights principles have been internalized by policy makers as the guidelines for health care reform in Vermont. Thus, duty-bearers also learned to fulfill their obligations, at least with respect to transparency and participation in governance. These findings are plausible in that they are consistent with previous research on the impact of the Vermont Workers’ Center’s HRBA, were supported by most interviewees in this case study, and align with multiple disciplinary perspectives on the evidence, thereby ruling out other potential explanations.68 In short, the HRBA used by the Workers’ Center was plausibly effective in many respects.
Importantly, these human rights principles have empowered Vermonters by giving them a more powerful voice in policymaking and have been internalized by legislators and the Green Mountain Care Board as democratic principles of governance. The universal right to health care has not yet been achieved in Vermont; however, the campaign is not over, and the Workers’ Center continues to use a human rights framework to advocate for health care as a human right. This case study demonstrates that an HRBA to health has the potential to positively shape laws and policies on health care, and may be implemented at the subnational level even where the national government has not recognized the right to health.
This case study benefitted from the interdisciplinary nature of our research team in several ways. According to Bernard Choi and Anita Pak, “[i]nterdisciplinarity analyzes, synthesizes and harmonizes links between disciplines into a coordinated and coherent whole.”69 Here, our team had expertise in health policy, applied social science research methods, HRBAs to health, and Vermont constitutional and civil rights law. Across disciplines, we share a common goal to advance the health and human rights of individuals, communities, and populations, and an assumption that by working together, we can achieve greater insights from our research toward reaching this goal.70 The design, methods, and analysis of this case study were informed by this understanding, and our disciplinary perspectives and approaches infused discussions on the formulation of research questions, methods, and data analysis as the project progressed, ensuring that each step made sense across the disciplines. Further, the multi-method qualitative approach strengthened the study, as our analyses of the legislative history, media coverage, and interviews from multiple perspectives complemented one another and deepened our understanding of the impacts of the HRBA. Finally, the interdisciplinary nature of our team ensured that our case study report would be understandable to a wide audience of people from different fields.
Nonetheless, there were several limitations to this study. First, we faced time and resource constraints, and thus all interviews had to be compressed into the month of March 2015, an extremely busy time at the Vermont legislature. Consequently, it was difficult to schedule interviews for longer than 20–25 minutes with most leaders, and two important leaders were not available at all that month. While it might have been useful to interview more leaders, the responses we received were largely consistent with one another and with the literature, indicating convergence. We also reached a point of data saturation at which interviewees began to share similar elements in their narratives. This made the small number of interviewees less important than it might otherwise have been. Finally, the study was both retrospective and concurrent, requiring the team to be flexible in adjusting the study to constantly changing circumstances. Just after our study proposal for funding was granted in November 2014, Governor Shumlin announced his decision not to pursue single-payer health care legislation that legislative session; however, the negotiations over this legislation had been one of the key subjects of our proposed study. Moreover, each week during the study, there was another major development at the Statehouse to fill this gap in leadership. Despite these difficulties, the results of the study, particularly the recognition among leaders that these human rights principles are regularly used to guide health care reform in Vermont, add substantially to the previous literature on this case.
This study was partially funded by the World Health Organization. It received Internal Review Board approval number 2015020 from the University of Massachusetts Boston on February 26, 2015.
Gillian MacNaughton, JD, MPA, DPhil, is Assistant Professor in the School for Global Inclusion and Social Development at the University of Massachusetts Boston, USA.
Fiona Haigh, BSocSci, LLB, MPH, is Research Fellow at the Centre for Health Equity Training Research and Evaluation, University of New South Wales and the Ingham Institute, Australia.
Mariah McGill, BA, JD, is an attorney residing in Vermont and Senior Fellow with the Program on Human Rights and the Global Economy, Northeastern University School of Law, Boston, USA.
Konstantinos Koutsioumpas, BSc, MSc, is a PhD student at the School for Global Inclusion and Social Development, University of Massachusetts Boston, USA.
Courtenay Sprague, Joint MA, PhD, is Associate Professor with a joint appointment in the Department of Conflict Resolution, Human Security and Global Governance and the College of Nursing and Health Sciences at the University of Massachusetts Boston, USA.
Please address correspondence to Gillian MacNaughton. Email: gillian.macnaughton@umb.edu.
Copyright © 2015 Macnaughton, Haigh, Mcgill, Koutsioumpas, and Sprague. This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.
K. Davis, K. Stremikis, D. Squires, et al., Mirror, mirror on the wall, 2014 update: How the US health care system compares internationally (New York: Commonwealth Fund, 2014), p. 8.
A. K. Hoffman, “A vision of an emerging right to health care in the United States: Expanding health care equity through legislative reform,” in C. M. Flood and A. Gross, (eds), The right to health at the public/private divide (New York: Cambridge University Press, 2014), pp. 348–350.
M. E. Martinez and R. A. Cohen, Health insurance coverage: Early release of estimates from the National Health Interview Survey, January–September 2014 (Washington, DC: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics, 2015), p. 1.
Davis et al. (see note 1), p. 7; Organisation for Economic Co-operation and Development, OECD health statistics 2014: How does the United States compare? (Paris: OECD, 2014), p. 8.
OECD (see note 4), p. 8.
See International Covenant on Economic, Social and Cultural Rights, G.A. Res. 2200A (XXI), (1966), Art. 14.
Hoffman (see note 2), pp. 368–369.
See Belden, Russonello, and Stewart, Human rights in the U.S.: Findings from a national survey (Washington, DC: Belden, Russonello, and Stewart, 2007). Available at https://opportunityagenda.org/pdfs/HUMAN%20RIGHTS%20REPORT.PDF, p. 4.
The Patient Protection and Affordable Care Act of 2010, Public Law 111-148, US Statutes at Large 124 (2010), § 1101.
H. M. Leichter, “Health care reform in Vermont: A work in progress,” Health Affairs 12/2 (1993), pp. 71–81; H. M. Leichter, “Health care reform in Vermont: The next chapter,” Health Affairs 13/5 (1994), pp. 78–103; A. M. Fox and N. J. Blanchet, “The little state that couldn’t could? The politics of ‘single-payer’ health coverage in Vermont,” Journal of Health Politics, Policy and Law 40/3 (2015), pp. 447–485.
See W. C. Hsiao, “State-based single-payer health care: A solution for the US?” New England Journal of Medicine 364/13 (2011), p. 1188. See also W. C. Hsiao, A. G. Knight, S. Kappel, and N. Done, “What other states can learn from Vermont’s bold experiment: Embracing single-payer health care financing,” Health Affairs 30/7 (2011), pp. 1236–1237.
M. McGill, “Using human rights to move beyond the politically possible,” Clearinghouse Review Journal of Poverty Law and Policy 44 (2011), pp. 459–460.
M. McGill, “Human rights from the grassroots up: Vermont’s campaign for universal health care,” Health and Human Rights Journal 14/1 (2012), p. 106.
An act relating to health care financing and universal access to health care in Vermont, 2010 Vt. Acts & Resolves, § 9401, Act No. 128. Available at http:// www.leg.state.vt.us/DOCS/2010/ACTS/ACT128.PDF; An act relating to a universal and unified health system, 2011 Vt. Acts & Resolves § 1, Act No. 48. Available at http://legislature.vermont.gov/assets/Documents/2012/Docs/ACTS/ACT048/ACT048%20As%20Enacted.pdf.
Act No. 128 (see note 15) § 2; Act. No. 48 (see note 15) § 1a.
McGill (2012, see note 14), pp. 106–117; A. Rudiger, “Reviving the progressive activism: How a human rights movement won the country’s first universal health care law,” New Politics (2011). Available at http://newpol.org/content/reviving-progressive-activism-how-human-rights-movement-won-country’s-first-universal-health; J. Kissam, “The Vermont breakthrough: Grassroots organizing moves a state towards health care for all,” Social Policy 41/2 (2011), pp. 4–8.
Hsiao (see note 12); Hsiao et al. (see note 12); A. R. Wallack, “Single payer ahead: Cost control and the evolving Vermont model,” New England Journal of Medicine 365/7 (2011), pp. 584–585.
Fox and Blanchet (see note 11), p. 477.
See P. Twomey, “Human rights-based approaches to development: Towards accountability,” in M. B. Baderin and R. McCorquodale (eds), Economic, social and cultural rights in action (Oxford: Oxford University Press, 2007), pp. 45–49.
United Nations Development Group, The human rights based approach to development cooperation: Towards a common understanding among UN agencies (NY: UNDG, 2003).
R. K. Yin, Case study research: Design and methods, 4th ed. (Thousand Oaks, CA: Sage Publications, 2009).
J. Baxter and J. Eyles, “Evaluating qualitative research in social geography: Establishing ‘rigour’ in interview analysis,” Transactions of the Institute of British Geographers 22/4 (1997), p. 506.
McGill (2011, see note 13); McGill (2012, see note 14); G. MacNaughton and M. McGill, “Economic and social rights in the US: Implementation without ratification,” Northeastern University Law Journal 4/2 (2012), pp. 365–406.
D. C. Radley, D. McCarthy, J. A. Lippa, et al., Aiming higher: Results from a scorecard on state health system performance, 2014 (New York: Commonwealth Fund, 2014), p. 12; Hsiao et al. (see note 12), p. 1234.
See McGill (2011, see note 13); McGill (2012, see note 14); Rudiger (see note 17); Vermont Workers’ Center, Building a grassroots movement for the human right to healthcare. Available at http://www.workerscenter.org/building-grassroots-movement-human-right-healthcare.
Vermont Workers’ Center (see note 27).
Interview with James Haslam, Executive Director, Vermont Workers’ Center, March 5, 2015.
Interview with Mary Gerisch, Steering Committee and Health Care Committee, Vermont Workers’ Center, March 12, 2015.
Vermont Workers’ Center, Voices of the Vermont healthcare crisis: The human right to healthcare (Burlington, VT: Vermont Workers’ Center, 2008). Available at http://workerscenter.org/sites/default/files/Voices_of_the_Vermont_Healthcare_Crisis.pdf.
Interview with Robin Lunge, Director of Health Care Reform, Shumlin administration, March 23, 2015.
Interview with Sarah Copeland Hanzas, House Majority Leader, Vermont House of Representatives, March 11, 2015.
Interview with Ellen Oxfeld, Vice President, Vermont Health Care for All, March 12, 2015.
Interview with Daniel Barlow, Public Policy Manager, Vermont Businesses for Social Responsibility, March 16, 2015.
Interview with Cornelius “Con” Hogan, Member, Green Mountain Care Board, March 11, 2015.
Act No. 128 (see note 15) §§ 2, 8.
Act. No. 48 (see note 15).
The Patient Protection and Affordable Care Act of 2010 (see note 10) § 1332.
Copeland Hanzas (see note 34).
Interview with Virginia “Ginny” Lyons, Vice Chair, Health and Welfare Committee, Vermont Senate, March 25, 2015.
Interview with William Lippert, Chair, Health Committee, Vermont House of Representatives, March 23, 2015.
A. Goodnough, “In Vermont, frustrations mount over Affordable Care Act,” New York Times (June 4, 2015).
J. E. McDonough, “The demise of Vermont’s single-payer plan,” New England Journal of Medicine 372/17 (2015), pp. 1584–1585.
Fox and Blanchet (see note 11); but compare McDonough (see note 62).
Hsiao et al. (see note 12); McDonough (see note 62).
An act relating to health care (S. 139), passed May 16, 2015.
J. P. Habicht, C. G. Victoria, and J. P. Vaughan, “Evaluation designs for adequacy, plausibility and probability of public health programme performance and impact,” International Journal of Epidemiology 28/1 (1999), pp. 10–18; F. Bustreo, P. Hunt, S. Gruskin, et al., Women’s and children’s health: Evidence of impact of human rights (Geneva: World Health Organization, 2013), pp. 88–89.
B. C. K. Choi and A. W. P. Pak, “Multidisciplinarity, interdisciplinarity and transdisciplinarity in health research, services, education and policy: 1. Definitions, objectives, and evidence of effectiveness,” Clinical and Investigative Medicine 29/6 (2006), p. 351.
See Bustreo et al. (see note 68), p. 6.

References: Art. 14
 § 1101
 § 9401
 § 1
 § 2
 § 1
 § 1332