MONTPELIER, Vt.—Even now, Dr. Deb Richter is haunted by images of some of the patients she saw at inner-city clinics where she worked in Buffalo, N.Y., during the 1980s.
One young man without health insurance didn't get the early intervention he needed for diabetes. He went blind, got an infection and died at 21. His sister, who also had lived with juvenile diabetes, delivered a baby three months premature. The baby died. Two years later, the 25-year-old woman suffered a heart attack and died during coronary bypass surgery.
"I had patients who were dying at young ages of preventable diseases," Richter said.
One common symptom: Lack of health insurance.
The experiences prompted Richter, 55, to become an activist. She joined Physicians for a National Health Program. After moving with her family to Vermont in 1999, she continued to pursue her goal of a publicly financed universal health care system.
Richter watched last week as the Vermont Senate voted 21-9 to pass a bill setting the state on a path toward the universal, unified health care system that, she and other backers say, will take administrative costs and insurance company profits out of health care, cover all Vermonters -- including the 45,000 now without health insurance -- and save the state money.
"This is a step in the right direction -- finally," Richter said after the Senate vote on legislation previously passed by the House. "This is the first time a state is actually establishing a true health care system, where everyone will be included. It's going to have a budget. We're going to have uniform payments, which will help reduce administrative costs."
Richter came on the Vermont scene not long after an effort to bring about universal health care in the 1990s fizzled, and she quickly began trying to make political contacts.
She found it a lot easier in a state of 620,000 -- she met fellow physician Gov. Howard Dean at a chicken dinner in Barre -- than in New York, with its population of nearly 20 million, where she couldn't get a meeting with her state representative.
She traveled around Vermont, giving more than 400 talks to Rotary Clubs, Chambers of Commerce and other groups.
She offered dramatic Statehouse testimony when she and a friend unfolded a list of the addresses of insurance companies and government insurance programs to which her five-doctor medical practice in Cambridge had to send bills.
The list was 190 pages long.
Even some of those who voted against the health care bill that passed last week credit Richter for her persistence.
"She began to advocate for a single-payer system soon after the last effort collapsed (in the 1990s), and oftentimes was a lone voice in the wilderness," said Sen. Vincent Illuzzi, R-Essex-Orleans.
Those who share Richter's support for a single-payer system sing her praises.
"The fact that we are as close as we are to passing a single-payer health care bill in Vermont is a tribute to a lot of grassroots work, but Deb Richter is the backbone of that work," Gov. Peter Shumlin said. "She's a doctor who practices every day, sees what's wrong with the system and wants to right it. ... She's tenacious. She's smart. She's tough."
The bill passed by the House and Senate would set up a new clearinghouse for health insurance policies in Vermont called an "exchange," meeting a requirement that states establish such entities laid out in the federal health reform law passed last year.
It also would set up a new Green Mountain Care Board to set parameters for what health benefits would be offered. The administration would be responsible for coming up with a way to pay for the new system by January of 2013. A legislative consultant recommended a new payroll tax shared by workers and employers.
Not everyone agrees the bill goes far enough. Physicians for a National Health Program, the group Richter joined 22 years ago, said the bill stops well short of its goal of single-payer health care because it would still allow multiple insurers to operate in the state.
"The Vermont plan promises a public program open to all residents of the state in 2017, but even then it would allow a continuing role for private insurance," the group said in a statement. "This would negate many of the administrative savings that could be attained by a true single-payer program, and opens the way for the continuation of multi-tiered care."
Richter, though, says the bill puts Vermont on a path to real progress. "They want to get to the top of the mountain in one step. I'm willing to take smaller steps. ... We just disagree."
Richter said she has learned an important lesson during her years of advocacy. She began by seeing health care as a moral issue, but came later to believe that the way to get people to change their minds about it was to get to them through their wallets, rather than their hearts.
James Haslam, coordinator of the Health Care Is A Human Right campaign at the Vermont Workers' Center, called Richter "awesome." He said the work of Richter and her group Vermont Health Care for All and that of the Workers' Center were complementary.
Richter's strength is "particularly bringing voice on this issue to providers, to other doctors and also to the business community. She's incredibly gifted at reaching them and going to where they're at. We've been more focused on ordinary Vermonters and working-class folks," Haslam said.
Richter said she strives for a practical approach that will appeal to all audiences. The health care system is like the fire department, she says -- something people don't want to use, but want in place, just in case.
Most people's first impulse is to say, "You don't want to pay for Joe," and his hospitalization, Richter said. "But Joe's in the bed you're going to be in tomorrow. That's why we have to have health care as a public good."