Reviving Progressive Activism: How a Human Rights Movement Won the Country’s First Universal Health Care Law

I. Introduction

     On May 26, 2011, Vermont became the first U.S. state to enact a law for a universal, publicly financed health care system. As Governor Shumlin signed Act 48,[1] he set Vermont on course toward implementing a single payer system by 2017.

     This first breakthrough in the decades-long struggle for universal health care in the United States—after thwarted or pared down federal efforts by the Clinton and Obama administrations—alters the landscape of health reform advocacy in this country and has the potential to set in motion a state-based dynamic for progressive reforms. National and state commentators have compared Vermont to the province of Saskatchewan, which half a century ago spearheaded the establishment of universal health care in Canada.

     The passage of Vermont’s universal health care law is equally significant for the development of progressive activism in times of federal and state austerity measures, dismantling of the public sector amidst a rising wave of privatization, and a roll-back of labor rights that have trapped progressives in a defensive mode. The Vermont breakthrough was made possible by an emerging human rights movement, based on intensive grassroots organizing and principled policy advocacy, and as such could serve as a model for progressives elsewhere in devising proactive strategies for advancing economic and social rights.

II. Vermont’s Health Care Breakthrough

1. The universal health care law and the transition process

     The Act relating to a Universal and Unified Health System (2011) creates a path toward universal public health insurance in Vermont. It states that Vermont will establish the publicly financed Green Mountain Care to provide comprehensive coverage as a public good for all residents, regardless of income, assets, health status or employment. The law incorporates a number of human rights principles as a basis for governance and implementation of Green Mountain Care. A five member independent board will be accountable for upholding these principles as it directs the transition process and oversees Green Mountain Care.

     For the multi-year transition phase the state will plan to establish an insurance exchange, as required by federal law, while also seeking a waiver to replace the exchange with a universal system. Several key decisions about this new system have been postponed to future legislative sessions, to be taken after further studies, board recommendations, and federal waiver decisions. Most importantly, plans have yet to be drawn up about the system’s financing mechanism and its health benefits package. The law’s timeline calls for financing proposals by January 2013, a federal waiver application by 2015—earlier if Congress permits—and implementation by 2017 at the latest.

     The decision about a financing mechanism for Green Mountain Care will likely be the site of the most important struggle ahead. Self-insured corporate employers and private insurance companies have signaled their opposition to any type of public financing, after mounting strong attempts to divert and hijack the reform process. Yet human rights campaigners succeeded in inserting a requirement for equitable, public financing into the law, and have consistently argued that the law’s explicit commitment to providing coverage as a public good necessitates funding through equitable, income tax-based contributions from residents and businesses.

2. The Healthcare Is a Human Right Campaign

     As with all significant political and social progress in the United States, the country’s first universal health care law did not come about simply because of politicians’ leadership, interest group lobbying, or even Vermont’s presumed liberal political climate. Instead, the state’s plan for universal health care is rooted in a broad-based people’s movement and depends on the sustained growth of this movement for its successful implementation.

     This grassroots movement was built by the Healthcare Is a Human Right Campaign, led by the Vermont Workers’ Center. The Campaign used the intractable issue of health care reform to develop slowly and deliberately a fresh take on old-fashioned organizing for political change. It employed the human rights framework for engaging and mobilizing people, as well as for policy analysis and advocacy. Through long-term, sustainable, one-on-one organizing, the Campaign succeeded in changing the public discourse on health care and created the political space for action by elected officials. The vision of health care as a human right captured the public imagination and created a positive narrative of change that led to a reform process grounded in human rights principles.

     Many commentators[2] have recognized the Vermont Workers’ Center’s important contribution to health reform in the state, yet the extent and nature of the Campaign’s role as driver of political change, and the key ingredients of its model, are not generally well understood.[3] This analysis seeks to rectify this.

III. The Vermont Workers’ Center Model

1. A new approach to health care advocacy

     The Vermont Worker s’ Center, a small, largely volunteer-led workers’ rights organization established in 1998, launched the Healthcare Is a Human Right Campaign in early 2008. Previously, it had mainly run local campaigns, for example for livable wages and the right to organize, and it continues to operate a workers’ hotline. The hotline has also enabled the organization to gauge evolving needs, including problems of accessing health care, as expressed in an increasing volume of calls on this topic over the past years.

     Seeking to respond to this need, the Workers’ Center became involved in state-wide health advocacy coalitions, which helped shape Vermont’s numerous incremental reforms. For many years, groups such as Vermont for Single Payer tirelessly advocated for single payer health care, including by annually introducing a single payer bill in the legislature. Yet after years of blockage by the legislature and the administration, this advocacy approach had reached an impasse. The Workers’ Center was particularly struck by how little grassroots participation had been part of these efforts for systemic change. Moreover, many advocates appeared to follow politicians’ propensity for addressing the crisis through incremental reforms that preserved the market-based system, such as Catamount Health in 2006, a publicly subsidized coverage program for uninsured people, sold by two private insurance companies. These reform measures required increasingly time-consuming internal negotiations and coalition agreements between advocates, and the Workers’ Center saw its central policy goal—to treat health care as a human right, independent from employment and financed publicly—watered down to reflect a lowest common denominator position about what was assumed to be politically possible. Therefore, while continuing to collaborate loosely with health reform groups, the Workers’ Center decided to step outside this advocacy circle and reach out to the people of Vermont who clearly lacked a voice in these debates.

     The Healthcare Is a Human Right Campaign has its origins in a pragmatic assessment of the shortcomings of traditional health reform advocacy, coupled with the Workers’ Center’s openness to changing the way it worked and developing a new approach. In the past, the organization had largely focused on local actions for workers' rights, often centered in a single workplace and its local community. Yet health care reform, as a state policy and budget issue affecting Vermont’s population as a whole, required state-wide organizing and thus offered an opportunity for organizational expansion. Taking on the issue of health care also called for new framing and messaging in order to reach broader constituencies and sustain a long-term, open-ended process of movement building.

     From the beginning, the Healthcare Is a Human Right Campaign was conceived as a vehicle for building a broad-based movement for social change, encompassing a social and economic justice agenda beyond the single issue of universal health care. The Workers’ Center identified the barriers to health care reform as systemic, rooted in the commodification of care and exemplified in the market-based, private insurance model, according to which “consumers” buy the level of access to care they can afford. The Campaign therefore determined that a victory would require a struggle over the fundamental question of whose needs must be served—those of the people or the market. To change the health system’s focus on market imperatives, which primarily benefit insurance companies and other corporate interests, the Campaign had to build the power of the people. This struggle over power is different from a struggle over policy. In other words, universal health care would not be achieved through putting forward the best policy arguments or the most rational legislative proposals—which have been all but ignored for many years—but necessitated a fundamental shift of power and ideology. The human rights framework, which places people at the center of policy and practice, offered an appropriate approach for building grassroots power, situating the experiences of those most affected within a broader struggle, uniting constituencies, and developing an alternative vision for a system focused on people’s health rather than market imperatives.[4] The Workers’ Center’s roots in workers’ rights struggles enabled it to interpret and use the human rights framework as a vehicle for addressing unjust power relations in an economic context, fully aware that this would entail a confrontation with opposing interests.

     The Workers’ Center used the human rights frame holistically, for the process of building people power and for the substantive shift in ideology needed to drive systemic reforms. The Healthcare Is a Human Right Campaign’s initial steps concentrated on documenting, discussing and framing unmet health care needs as human rights violations, with a view to engaging people, foregrounding their experiences and reframing the debate. This process involved collective actions and events, which, over time, began to build a constituency. It was followed by generating a consensus on human rights principles, which in turn constituted the foundation for developing and advocating for policy positions. The substantive understanding of human rights evolved gradually, starting with a basic affirmation of human rights as manifested in the Universal Declaration of Human Rights and reflective of democratic aspirations throughout U.S. history. Only after an extensive period of collecting and sharing people’s health care experiences did the Campaign adopt basic principles to guide the struggle for the human right to health care.

     Universality and equity form the cornerstone principles of the Campaign’s vision for a rights-based health care system. As human beings, everyone is entitled to comprehensive, quality health care. Everyone must be able to get the care they need and contribute what they can. The Campaign also emphasizes the procedural principles of accountability, transparency, and participation, which require people’s inclusion in health system decision-making processes and, ultimately, oversight by the people of the provision of health care as a public good, shared by all. Importantly, all of these principles apply not only to the policy issue at hand—health care reform—but also inform the internal ethos and organization of the Campaign.

     While some of the Campaign’s many thousand supporters have yet to engage with human rights at the deeper level of principles, most of its constituency has embraced an understanding of human rights as arising out of people’s needs, along with the state’s obligation to meet those needs. This in itself presents a significant ideological shift from a market-centered, pull-yourself-up-by-your-own-bootstraps individualism to an appreciation of collective rights and responsibilities—a shift that has spread into public discourse more broadly, as reflected in the print media.[5] The Campaign argued successfully that the market model of consumer competition excludes and impoverishes an ever increasing number of people while rewarding corporate profiteering. As an alternative vision, the Campaign highlighted the goal of providing health care as a public good, requiring the non-market, collective provision of needed services on an equitable basis.[6] While the notion of a public good was not new to health reform advocacy in Vermont, the Campaign pushed for an economic understanding of public goods in explicit opposition to a market-based system characterized by the stratified and exclusionary supply of health coverage products. To date, the Campaign has not only achieved the explicit inclusion of health care as a public good in the Vermont statute, but also built awareness of the public financial obligations entailed in the provision of a public good. As the advocacy push for implementing the publicly financed health system develops, the Workers’ Center intends to link this with a campaign for state budget policies that meet all of Vermonters’ fundamental economic and social needs.

2. Human rights-based grassroots organizing

     The Healthcare Is a Human Right Campaign is rooted in a grassroots organizing strategy that seeks to expand outreach to an ever-growing number of people while successively consolidating each person’s active engagement in the campaign. Participatory and democratic by design, the Campaign is driven by the engagement and leadership of those most affected by the health care crisis and guided by shared normative principles that unite a broad constituency, thus forging sustainable networks for collective action.

     This open-ended and iterative process has progressed through three distinct stages since its inception, starting with a state-wide human rights documentation and dialogue in 2008, expanding capacity and adopting human rights principles in 2009, and then maturing into intense legislative advocacy that culminated in the passage of Act 48.

     a. Human rights documentation and dialogue

     In its first year, the Campaign focused on one-on-one outreach to people across the state, documenting their health care stories and conducting organizing conversations about the relationship between unmet needs and the human right to health care. Key tools included a survey administered by organizers and activists (which engaged around 1200 interviewees; 95% of whom believed health care should be treated as a human right), eight human rights hearings in which people gave testimony about their health care experiences and put the market-based system ‘on trial,’ and a large Human Rights Day conference that brought together organizers, advocates, and community members. The Campaign also asked each supporter to pledge their participation in a state-wide rally for the human right to health care, and to obtain additional pledges from their friends. The rally on May 1, 2009 at the Statehouse in Montpelier—possibly the largest weekday rally in Vermont history—marked the concluding highlight of this phase.

     At this point, the Campaign had built a considerable network of supporters state-wide, connected with new rural and middle-class constituencies, involved those new to political activism as well as those most affected by the crisis, and taken the dialogue about human needs, rights, and the role of government into the public realm, with potential long-term benefits not just for health reform but other economic and social rights issues. The Campaign had begun to internalize the human rights frame at various levels of their operation and generated a values-based narrative that resonated with people beyond those directly affected by the health care crisis. It had situated the manifold individual hardship and suffering within a human rights crisis affecting all Vermonters. This was a precondition to unifying people and building an inclusive movement for change. Viewed as a human right, health care became a concern for everyone, not just for the uninsured, or for insurance policyholders struggling to pay their bills, or for workers seeking to hold on to benefits. The Campaign was able to engage people as collective agents claiming their rights, not as individual casualties of the system. Instead of being victimized through their suffering, people became empowered to take action.

     Expanding capacity, constituency, and support for human rights principles

     In the next phase, after the first successful May Day rally, the Worker’s Center expanded its organizational capacity and created a structure for developing supporters into an active constituency that could be mobilized for targeted actions. To date, many of the Campaign’s tasks are divided among volunteer-run committees, with policy, media, education, and local organizing committees devising and managing their own work programs, in coordination with a state-wide, member-run Steering Committee and the two permanent staff at the Center. Paid staffing has fluctuated depending on funding, which tends to correlate with peak periods of organizing and advocacy, and has at times supported up to three additional paid organizers and a couple of part-timers. In contrast to traditional organizing models that place more emphasis on paid professional staff, the Workers’ Center proactively fosters and genuinely relies on the voluntary work of its members in the committee system, which is also where most formal decisions are taken. The committee work offers engagement and leadership opportunities, and the Workers’ Center conducts structured trainings on a regular basis, ranging from issue-based education to an intensive leadership school. The scope and depth of the committee work illustrates members’ serious commitment as well as their growing confidence to engage with the political system, the media, and the wider public in roles traditionally occupied by experts. Much of the development of an active constituency has taken place in the local organizing committees across the state, which have gradually expanded to almost all Vermont counties. Developing leaders, instituting democratic structures, and engaging people regularly in tasks, actions, and governance has been key both to expanding the capacity of the Workers’ Center and to building a sustainable movement.

     Capacity building also required developing analytical and advocacy tools. Over the course of 2009, the Campaign prepared a set of human rights tools that translated the vision first into principles and then into very general policy positions. The principles of universality, equity, accountability, transparency, and participation were agreed upon as the core principles of the campaign, serving as the basis for developing and assessing policies and as a frame for outreach and communications. The Campaign’s Policy Committee assembled a People’s Toolkit, a comprehensive guide for activists with detailed information on the campaign, human rights, health care policy, legislators, and legislative proposals. This was placed online and updated regularly, with new editions issued annually.

     With an active constituency and tools for rights-based advocacy in place, the Campaign was ready to engage more directly with the political and legislative environment. Its approach was proactive, aimed at bringing human rights principles to policymaking. The goal was not to play on politicians’ own turf and adapt to the legislature’s discourse, but to motivate elected officials to take a fresh look at old debates. The Campaign’s two main organizing and engagement tools in that phase consisted of a mass postcard petition and a state-wide series of People’s Forums with community members and legislators. The postcards—thousands were delivered at the statehouse on the first day of the 2010 legislative session—called for taking legislative action to make the human right to health care a reality in Vermont. A corresponding message was conveyed at the forums: the Campaign asked legislators to come and learn about the human right to health care and to listen to stories illustrating the human rights crisis. Community members testified about their health care experiences, activists explained the human rights principles, and legislators were given the opportunity to endorse this normative framework and commit to moving legislation that would advance the right to health care. More than 800 people participated in these forums, along with over 70 state legislators. Confronted with reports of a human rights crisis and proposals for a values-based solution, the vast majority of politicians, including the chair of the Senate Health Committee, expressed their general support.

     c. Mobilizing for legislative advocacy

     The sustained level of public pressure on politicians generated at the 2009 forums indicated that the Campaign was ready to move into the phase of legislative advocacy. The legislative session that followed confirmed that the Campaign had started to change what politicians considered politically possible. Legislators’ musings on the infeasibility of a single payer system had turned into support for a principles-based procedural bill that would launch a reform process. By May 2010, just after its second large May Day rally, the Campaign achieved its first major policy win: the integration of human rights principles into a new law, Act 128,[7] which committed the state to move toward universal health care by hiring an expert to design different models for such a system. In other words, the Campaign succeeded in engaging the state in a process that closely mirrored its own strategy: using a normative framework and democratic process to advance and build support for systemic change.

     This success propelled the Campaign to scale up its policy-oriented mobilization, coinciding with the 2010 election of a new governor. Joining forces with two allied groups—the Vermont Center for Independent Living and Vermont Early Educators United—the Workers’ Center organized 15 People’s Candidates’ Forums across the state, at which over one thousand community members put rights-based policy demands directly to a total of 130 candidates. Their tenacity paid off: the winner of the gubernatorial race, Democrat Peter Shumlin, declared he would make health care a right for all Vermonters, less than a year after he had denounced such an agenda as not politically viable.[8]

     Toward the end of 2010, the Campaign had built sufficient grassroots power to seriously influence the political and legislative process. Grounded in intensive one-on-one outreach, education, communications, and mobilization, the Campaign’s mass organizing efforts ― e.g. surveys, postcard and photo petitions, annual rallies ― have directly engaged over 11,000 Vermonters (close to two percent of the state’s population), and indirectly reached a far wider segment of the population through member-led media strategies.

     From the outset, the Campaign had sought to develop its media capacity, based on an understanding of communications as a crucial tool for organizing, mobilizing, public outreach, and advocacy. Early on, videos produced by the Campaign became an important element of organizing, and as capacity increased, self-produced media were also deployed in support of policy advocacy. Earned media coverage as well as media-making has grown steadily, coordinated by the Media Committee, which monitored coverage, ran letter-to-the-editor campaigns, met with editorial boards and helped produce videos, public service announcements, and op-eds. The Campaign received the editorial endorsement of a major state newspaper,[9] and during the 2011 legislative session placed around 150 letters to the editor and several opinion pieces, in addition to producing four video PSAs alongside longer educational videos.

     As it matured, the Campaign also increasingly used the human rights framework to forge solidarity among different groups and networks. The Workers’ Center’s experience of learning from and supporting diverse workers’ rights struggles in Vermont and across the country informed the Campaign’s aspiration to foster broader social movement building. The model for the campaign itself had been influenced by a human rights struggle in a very different context, namely that of the North Carolina Public Services Workers Union, which built a grassroots constituency capable of taking their rights claims all the way to the International Labor Organization. Thus, the Healthcare Is a Human Right Campaign was from the outset imbued with an awareness that experiences could be shared across demographic, state, and issue-based boundaries, and that such exchanges not only strengthened the capacity of all groups involved but also encouraged solidarity actions. Early on, the Campaign invited organizations and small businesses to endorse its annual May Day rallies, and hundreds have done so each year. The Campaign’s state-wide reach and organizational capacity were enhanced by collaborations with progressive labor unions and workers’ rights groups—in particular, the Vermont Federation of Nurses and the Vermont Migrant Farmworker Solidarity Project—disability rights organizations and refugee groups, as well as national alliances and partnerships with Jobs with Justice, Grassroots Global Justice, and the National Economic and Social Rights Initiative (which provided hands-on support to many aspects of the Campaign).

3. Human rights-based policy advocacy

     While taking a step back from policy advocacy during the early part of its campaign, the Workers’ Center was convinced from the outset that the human rights framework would serve as a powerful tool for policy analysis and advocacy, as long as sufficient grassroots power had been built. Throughout the campaign, the Worker's Center kept the focus on a rights-based, principled approach to health care reform, in marked contrast to the federal reform debate.[10]

     In preparation for developing policy positions, the Campaign sought to shift the advocacy voice from experts, such as physicians and academics, to patients and community members. Redefining patients and “consumers” as endowed with human rights, not just patient and consumer rights, the Campaign recast all Vermonters as participants in health policy decision-making, in line with a broader agenda of reclaiming democracy. It emphasized people’s health as the overarching social goal trumping the interests of insurance industry profiteers as well as those of politicians and advocates touting cost containment. Crucially, by developing an agenda of collective rights, the Campaign recognized the obligation of government to protect and fulfill those rights and thus situated democratic government, and more specifically the public sector, at the center of people’s lives, a space currently occupied by the market.

     As the Campaign began introducing human rights principles in organizing and advocacy conversations, it advanced not only the concepts of universality and equity, but also an understanding of the essential role of public goods in meeting human needs. While the notion of health care as a public good had already been part of single payer advocacy in Vermont, it was mainly regarded as a moral imperative akin to identifying a healthy society as a common good. The Campaign sharpened the understanding of public goods as a form of economic organization of resources essential to realizing a common good. In other words, the commitment to public goods necessitates a system of collective, non-market provision of health care, schools, fire services, etc., through equitable public financing and administration. Ultimately, the Campaign not only had a significant role in popularizing the concept of public goods, but also laid the groundwork for an economic vision of fulfilling rights through tax-funded public services.

     a. Developing and using human rights advocacy tools

     The Campaign developed its policy advocacy gradually, led by its all-volunteer Policy Committee. Starting in the second half of 2009, activists used the five human rights principles to devise a set of key policy questions for assessing health reform proposals in the 2010 legislative session. This gave activists a compass for navigating the maze of complex policy issues without getting bogged down in technical details or pulled into policy negotiations. The Policy Committee prepared a human rights report card and accompanying human rights analysis, and disseminated this to activists as part of its legislative People’s Tool Kit. A People’s Team, consisting of Campaign volunteers, had a daily lobbying presence on the Statehouse floor and in committee rooms, creating transparency and fostering participation. Throughout the session the Campaign mobilized constituents from across the state to appear at legislative hearings and give testimony about the human rights crisis and the demand for a rights-based health care system.

     The advocacy goal for the 2010 legislative session was to pass a bill that would put Vermont on the road to treating healthcare as a human right and public good. Since the human rights analysis identified the single payer bill as coming closest to that goal, the Campaign demanded that the legislature, after several years of inaction, take up that bill. Driven by grassroots pressure, the bill made its way through the Statehouse, taking on the shape of a planning initiative. Signed into law in May 2010 as Act 128, it committed the state to designing a health system that provides health care as a public good, ensures universal access, and uses an equitable financing mechanism. It called for a consultant to prepare three different models for a system that could meet these goals and to deliver the proposals to the 2011 legislature. The passage of Act 128 constituted the Campaign’s first advocacy success, as it compelled the state to recognize and implement all key principles of the human right to health care. The Campaign’s definitions of universality, equity, accountability, transparency and participation had been incorporated into Act 128 as a foundation for the reform process.

     Yet it was also clear that Act 128 merely set up a process with guiding principles, not the new health care system itself, as was originally intended by the drafters of S.88/H.100. A major advocacy push would be needed to hold the state to its commitment and to ensure the integrity of the process. The Policy Committee sought to inform the design process and advocated for its transparency. Committee members testified at hearings of the Health Care Reform Commission, which had selected Dr. William Hsiao, a Harvard professor best known for designing the Taiwanese single payer system, to develop the models for a new system. They also communicated regularly with Dr. Hsiao’s team to ensure that the proposals under development respected the principles of Act 128 and accounted for the strength of the grassroots movement to overcome political resistance and make the implementation of a rights-based model politically possible.

     To evaluate Dr. Hsiao’s designs and any subsequent legislative proposals, the Policy Committee developed an analytical tool based on the human rights principles of Act 128, and asked activists and legislators to use this for measuring the emerging proposals against the requirements of the law. After Dr. Hsiao presented his models in January 2011, in a Statehouse room crowded with human rights activists, the Campaign published its own human rights assessment of the proposals.[11] Even though none of Dr. Hsiao’s models fully met human rights standards, the assessment showed that his proposal for a publicly financed and administered single payer system, with comprehensive health benefits, best conformed to the principles of Act 128. Yet the bill introduced subsequently by Governor Shumlin did not track this model, but opted for a modified single payer system with potential private administration. Shumlin’s bill also sidestepped a decision about the financing mechanism for the system—a significant omission that opened the door to much public speculation and political maneuverings.

     Since the Campaign had supported the process set in motion by Article 128, grounded as it was in the Campaign’s own principles, it did not consider abandoning it in light of a disappointing bill. Instead the Campaign focused on strengthening the policy proposals. The emphasis of a principles-driven approach, rather than advocacy for one specific policy, precluded jettisoning the reform process at this stage, and as a result it created a unique opportunity for achieving fundamental health systems change.

     b. Developing and driving policy

     The Campaign prepared a human rights assessment of Shumlin’s bill, H.202,[12] and throughout the 2011 legislative session submitted detailed suggestions for revisions and amendments to strengthen the bill as it made its way through the Statehouse. Members of the People’s Team were present during all committee and floor debates, activists presented testimony and amendments at committee hearings, Campaign members from across the state dominated state-wide public hearings conducted by the House and Senate via remote television links, and an army of red ‘Healthcare Is a Human Right’ T-shirts overwhelmed the Statehouse at special public hearings for patients, providers, and businesses. In the press, hardly a day passed without a letter, editorial or article by or about the Campaign, while legislators were asking the Policy Committee to propose language for bill amendments. Workers’ Center staff and committee chairs coordinated the information flow between the different volunteer committees, from communicating policy positions to organizing and media committees, training activists as media spokespeople, tracking policy asks in media messages, and ensuring that legislators knew at every point that advocates spoke with the voices of thousands of Vermonters behind them.

     The Campaign was a formidable presence during the 2011 legislative session and won many important policy fights. Most dramatically, the moral outrage expressed by Campaign members prompted the defeat of a last minute measure that would have excluded undocumented immigrants from universal health care. Within a matter of days, and in close cooperation with allied organizations, the Campaign mobilized hundreds of Vermonters to stand up for the human rights principle of universality, and thus generated tremendous moral and political pressure that led to the striking of the anti-immigrant amendment, even though it had previously been passed by a bipartisan Senate majority.[13] The significance of this unusual victory goes beyond the contentious issue of including everyone in a truly universal system. Vermonters’ readiness to identify a classic divide and rule tactic and reject division along lines of race, ethnicity or national origin raises the bar for activists elsewhere when confronted with the use of immigration as a wedge issue. The Campaign’s inclusive, explicitly anti-racist and rights-based approach has built strong relationships of solidarity and a unified constituency that has gained—even in Vermont’s racially homogenous setting—a deep understanding of the divisive forces within an inequitable society.

     This impressive achievement invites reflections on the Campaign’s strength as well as its strategy. If a last-minute victory on a notoriously difficult issue was possible, could the Campaign have achieved other important policy wins through a similarly proactive stance and concerted grassroots actions? To make matters more complicated, the immigration issue may have served as a distraction from other crucial sticking points: the potential role of private insurance companies competing with universal public coverage and the likely subcontracting of the system’s administration to a private insurer—two priority issues which the Campaign sought to influence. Should these concerns over profit-making and privatization have constituted non-negotiable lines in the sand, akin to the exclusion of undocumented immigrants? If so, would the Campaign have been victorious or would it have overplayed its hand and lost influence? Internal discussions identified two criteria for making those strategic decisions: the finality of the legislative provision in question, and the level of people power built. With regard to the former, there is a clear qualitative difference between closing the door to a population group (as attempted by the anti-immigrant amendment) and keeping the door open for insurance companies—a provision that can be rectified at a later stage in law or during implementation. Act 48 creates a pathway to universal health care with many open doors, and activists are aware of the struggles that lie ahead to ensure that future decisions are guided by the principles incorporated in the law. Most of all, they recognize that to influence key systemic decisions, particularly those of financial and economic nature, the Campaign’s grassroots power must match its policy demands. Policy wins correlate directly with the people power built to achieve them, not with arguments developed by advocates. An even stronger relationship between the Campaign’s policy and organizing arms would be necessary for prioritizing complex policy issues that lack the straightforward moral appeal of immigrant inclusion.

     Yet the immigration issue constituted by no means the Campaign’s only direct policy win. In fact, the Campaign succeeded in strengthening the bill to reflect each of its human rights principles. In addition to ensuring universal eligibility for coverage,[14] the Campaign secured specific language that requires the new system to provide health care as a public good, based on a financing plan consistent with principle of equity.[15] The Campaign also won a provision requiring a process for public input in decision-making about the new system.[16] Finally, as guidance for establishing the new system and to ensure accountability, the human rights principles were incorporated into statutory language as basis for governance and implementation.

     Yet the Campaign’s exemplary role in driving systemic health reform failed to receive public recognition from leading politicians. At the bill signing ceremony in front of the Statehouse, the governor shared the limelight with fellow elected officials, experts, and professional advocates. No mention was made of the many thousands of Vermonters whose engagement made legislative action possible in the first place. Yet the cameras revealed the obvious: behind a row of dapper politicians and professionals, a large cluster of red T-shirts crowded the steps of the Statehouse.

IV. Strategic lessons: movement-building and the role of human rights

     The Healthcare Is a Human Right Campaign has built a broad-based people’s movement guided by normative principles rather than technical policy positions. It expanded the narrow focus on policy advocacy into an open-ended organizing process centered on collective needs and rights. By placing people at the heart of policy and practice, the Campaign was able to challenge dominant power relations and create the political space for systemic change.

     The Campaign has advanced rights-based concepts in public discourse, public policy, and policy-making processes. This fostered the passage of the country’s first universal health care law, increased the prospects for a successful transition to such a system, and created the foundation for an expansion of people’s rights to social and economic needs beyond health care. The Campaign has employed the human rights framework to

• identify people’s fundamental needs and elevate the voices of the crisis of unmet needs,

• claim people’s rights and recognize the government’s obligations to protect and fulfill those rights, and

• inspire and support people’s agency in effecting political change.

     The effectiveness of this approach derives from the active interplay between these strategic elements, which reinforce and build on each other, as do the corresponding practical actions: mass organizing would fail without leadership development, policy advocacy requires exploring and communicating people’s needs, and the clarion call for human rights must be matched by popular education. The strategic lessons for the Vermont Worker’s Center and its members, partners, and allies are manifold and reach across state boundaries and beyond the confines of the health care debate. The Healthcare Is a Human Right Campaign has made a valuable contribution to addressing four basic questions that are integral to progressive activism:

How can we change public discourse?

How can we change currently prevailing policy priorities?

How can we overcome corporate influence over politics?

How can we ensure sustainability and create solidarity?

 

While public discourse is saturated with facts and arguments, the underlying thrust is about people’s values, or ideological principles, which shape a particular narrative. Much of the discourse about health care, housing, education, and jobs in the United States is infused with an individualistic market ideology. The Healthcare Is a Human Right Campaign created a principled, positive counter-narrative based on a powerful human rights vision. This also enabled it to inject normative force into a complex, technocratic debate stuck in a cost containment frame. The Campaign prioritized personal experiences and enabled people to reach out to politicians and the media and tell their own stories.

 

Political and policy change rarely starts with legislative proposals or legal proceedings; it starts with organizing people to demand change. To build people power, the Healthcare Is a Human Right Campaign deployed a grassroots organizing strategy that included one-on-one outreach, participatory processes and actions, leadership development, communications, and mass mobilization; all serving as the foundation and backbone of policy advocacy. It engaged a broad spectrum of people by focusing on shared normative principles. The Campaign’s actions and demands were mostly proactive rather than defensive, thus setting a new, unifying agenda instead of competing for concessions within the current policy paradigm. It recognized that the struggle for change entails no endgame, no win or lose situations, and that the value of each policy step can be measured by its utility for sustained organizing.

 

The Campaign identified this as a question of power, necessitating a power analysis and a strategy centered on building the power of the people. It sought to generate awareness and organization among the people, not among politicians or corporations. This simplified understanding of a basic antagonism—between the people, who must be won over, and those in power, who must be confronted—helped the Campaign to focus its energies, develop realistic advocacy goals, and assess the feasibility of policy demands.

 

The Campaign has used the human rights framework to create unity and inclusiveness, both among people and across issues. By starting with people’s experiences and shared values, by facilitating participation and raising awareness about divisive issues and opponents’ divide and rule tactics, the Campaign fostered solidarity and sustained collective engagement. By avoiding the readymade argument for cost savings through health care reform—an argument that undermines the urgent spending needs in other areas of economic and social rights, such as housing and education—and by popularizing concepts such as equity and public goods, it built the foundation for demanding the equitable distribution of resources to meet all of people’s needs. The Campaign understood the importance of raising people’s expectations about what to demand and expect from society as a whole, and from government in particular.

Notes

1. General Assembly of the State of Vermont, Act No. 48. An Act Relating to A Universal And Unified Health Care System.

2. See, for example, Dave Gram, “Lobbying on Vt. Health Bill Extensive but Unknown,” Associated Press, July 25, 2011; and Nancy Folbre, “Vermont’s Move Toward Single Payer Health Insurance,” The New York Times, June 6, 2011.

3. This is despite the Workers’ Center’s careful efforts to document and publicize the Campaign’s strategy and progress. See, especially, Jonathan Kissam, “The Vermont Breakthrough: Grassroots Organizing Moves a State towards Health Care for All,” Social Policy, Summer 2011.

4. For a policy analysis of components of a rights-based approach to health care reform, see Anja Rudiger and Benjamin Mason Meier, “A Rights-Based Approach to Health Care Reform,” in: Rights-Based Approaches to Public Health, ed. Elvira Beracochea, Corey Weinstein, and Dabney P. Evans (New York: Springer Publishing Company, 2011), 69-86.

5. See, for example, Editorial, “Adventure in Democracy,” The Times Argus, May 5, 2011.

6. For a helpful discussion of health care as a public good, see Milton Fisk, A Case For Taking Health Care Out of the Market, in: Not For Sale: In Defense of Public Goods, ed. Anatole Anton, Milton Fisk, and Nancy Holmstrom (Boulder, CO: Westview Press, 2000), 393-438.

7. General Assembly of the State of Vermont, No. 128. An act relating to health care financing and universal access to health care in Vermont.

8. See, for example, one of Shumlin’s first statements after the election: Bob Kinzel, "Shumlin Already Lobbying President Obama On Health Care," Vermont Public Radio, November 5, 2011.

9. Editorial, “Inherent Compassion,” The Rutland Herald, October 8, 2009.

10. For a human rights analysis of the early stages of the federal health reform debate, see Anja Rudiger, ”From Private Profits to Public Goods? A Human Rights Assessment of Health Care Reform,” in Where Do We Go From Here? American Democracy and the Renewal of the Radical Imagination, ed. Mark Major (Lanham: Lexington Books, 2010), 49-69.

11. William C. Hsiao, Steve Kappel, and Jonathan Gruber, Act 128. Health System Reform Design, February 17, 2011; Vermont Workers’ Center, <a href'http:="" www.workerscenter.org="" sites="" default="" files="" hchr_hsiao_assessment.pdf"="">Human Rights Assessment of the Hsiao Healthcare System Design Options, February 2011.

12. <a href'http:="" www.workerscenter.org="" sites="" default="" files="" hchr_hsiao_assessment.pdf"="">Vermont Workers’ Center, Human Rights Assessment of H.202, February 2011.

13. Yvonne Yen Liu, “Vermont Breaks Ground in Health Coverage for Migrant Workers,” Colorlines, June 10, 2011.

14. The principle of universal access to comprehensive care was also included as a guiding principle: “The state of Vermont must ensure universal access to and coverage for high-quality, medically necessary health services for all Vermonters. Systemic barriers, such as cost, must not prevent people from accessing necessary health care. All Vermonters must receive affordable and appropriate health care at the appropriate time in the appropriate setting.” (Sec. 3. 18 V.S.A. chapter 220, § 9371, (1))

15. The principle of equitable financing was also included as part of the law’s guiding principles: “The financing of health care in Vermont must be sufficient, fair, predictable, transparent, sustainable, and shared equitably.” (Sec. 3. 18 V.S.A. chapter 220, § 9371, (11))

16. The principles of participation, accountability and transparency were also included as guiding principles: “The health care system must be transparent in design, efficient in operation, and accountable to the people it serves. The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms of the health care system.” (Sec. 3. 18 V.S.A. chapter 220, § 9371, (3))