Universal primary care is at the center of the race for governor. How would it work?

Proposals for universal primary care have become a central platform point in the race for Vermont’s top state office. 

The Democratic candidates for governor and lieutenant governor, Amanda Janoo and Molly Gray, tout free publicly funded primary care as their chief healthcare policy proposal leading into the Nov. 3 general election. 

Proponents of the policy say it can reduce costs by keeping people healthier in the first place, while skeptics worry it does not target the most expensive parts of healthcare and bring true affordability. 

Republican Gov. Phil Scott “supports the concept of universal access to primary care,” said Emma Shouldice, a representative for his reelection campaign. She noted that the incumbent signed a bill into law in June that would commission an exploratory report on the feasibility of universal primary care. Scott is “committed to exploring the details” of that report, she said. 

“We should be very clear, though, there is no such thing as ‘free’ healthcare,” Shouldice added, “and campaign promises that offer as much should be met with the highest level of scrutiny.”

Scott has advanced a largely deregulatory view of health insurance, to allow for age-varying premiums and plans for small businesses. He advocates working directly with hospitals to lower healthcare costs and wants to move away from relying on regulators to maintain healthcare affordability. 

The momentum that universal primary care proposals, and the candidates who support it, have gained underscores just how hungry Vermonters are to tackle healthcare affordability, said Alex Garlick, a professor of health policy at the University of Vermont. 

He thinks Vermonters are tired of incremental progress in curbing hospital costs and keeping insurance premiums from rising too steeply. At the same time, Scott “has not been proactive” on healthcare issues, he said, instead vetoing a bill that would have capped hospital prices for certain insurers this year.

“I think Amanda Janoo’s success in the Democratic primary over the summer shows there might be an appetite for newer, bolder ideas,” Garlick said. 

“But,” he continued, “I am not convinced that this particular idea would have a major return on investment that would justify raising taxes and increasing spending on healthcare.” 

So how would universal primary care work?

Higher taxes for some, care for all

Janoo proposes levying a “fair share tax” on the income of the wealthiest Vermonters in order to build a network of small-town primary care doctors across the state and pave the way toward eventual full universal healthcare.

Proposals for a tax on high earners estimate that Vermont could raise between $114 million and $344 million in annual revenue. Janoo has supported these proposals and said she hopes her administration could bring finer granularity and analysis to determining this figure to fund a universal primary care program if she’s elected. But she says the basic principle is “ensuring that no matter what, everybody has access to a primary care provider that they’re able to see for free.”

Janoo hopes to finance local community health teams, modeled after the municipally run and funded community nursing programs in the Upper Valley, where nurses are public employees.

Janoo estimates that by increasing free access to primary care providers, mental health professionals and other local healthcare coordinators, Vermonters can reduce emergency room visits and more expensive hospitalizations enough to save the state up to $300 million a year. 

But she acknowledges that it’s a rough estimate intended to gauge whether an ambitious plan for primary care would be feasible and financeable. She is open, she said, to exploring an array of options for funding the program, knowing that Vermont could raise a significant portion of revenue to fund this through an income tax, like the one on wealthy Vermonters that she advocates.

“The point for me was less like ‘it has to be funded by this specific revenue stream’ as much as I wanted to feel confident, if I was going to come out and advocate for a policy, that it was going to be something we could realistically pay for,” Janoo said. 

She called her current calculation of the revenue and cost of a universal primary care proposal a “sense check.” It’s important, she said, that it fundamentally shifts the state’s primary care away from a fee-for-service model to one where primary care providers are paid to keep people healthy, whether that’s through a salary or other types of per-patient, per-month payments.

In 2015, on the heels of then-Gov. Peter Shumlin’s failed effort for single-payer healthcare across Vermont, state analysts estimated how much it would cost to roll out a universal primary care program.

Those authors set an understanding of universal primary care as publicly financed primary care for all Vermonters, regardless of their insurance coverage. They estimated that, by 2017, universal primary care could cost the state $281.9 million in annual claims — if patients paid nothing out of pocket to share the cost of care — plus $12.2 million to $34.7 million in administrative costs. They figured that Medicaid, which is jointly funded by the state and federal governments, could pay nearly $107.4 million of those claims, with a special waiver to reroute federal Medicaid funds for primary care into this type of program.

But a decade after that report, Janoo thinks Vermont can cover the cost with a new income tax — and avoid requesting a Medicaid waiver for now.

Still, she wants an even more refined picture of how many primary care doctors or nurses or physician assistants Vermont needs to care for the entire population. To fully understand the cost requires combining that estimate with an estimate of the annual salaries for those doctors and nurses, she said. Would that include relocation incentives for rural pockets of the state? Would it also take student loan repayments into account? 

As governor, Janoo hopes she could leverage the state government’s analytical arm to find answers.  

“When I first started, there was hesitancy to talk about anything related to universal healthcare because there was some PTSD, I think, from the Shumlin administration,” she said.

But the climate has changed since 2014, Janoo and fellow advocates said.

Things are “fundamentally different now,” said Dr. Jack Mayer, a retired primary care provider and staunch advocate for universal primary care. “At that time, our hospitals were not facing bankruptcy, and our primary care system was not collapsing, and our costs were not going through the roof. Now what’s different is that every Vermonter is appreciating the personal impact that the decline of our healthcare system is having on their personal finances.” 

Starting with primary care

Mayer is now part of a group of citizen activists calling for universal primary care in Vermont who go by the name the “Little Seeds,” but he said he has been advocating for universal care since he was a medical student 50 years ago. This moment is “as close as we’ve ever gotten” to having real legislation for publicly funded health care, he said. 

He’s not alone in feeling like this year could be different: An Oct. 6 poll from the health policy group KFF found national support for a publicly funded healthcare program is the highest it’s been in the 10 years since the group started polling on the topic, with 66% of people favoring some kind of Medicare for all.

Across the U.S., midterm elections in states like Michigan, New York and Washington have similarly revived the question of state-sponsored, single-payer healthcare. 

It makes sense, to Mayer, to start with publicly funded primary care. The cost of investing in preventive care — a pill for hypertension, say — is low compared with the cost of hospital care that it can avert, such as a trip to the emergency room for a stroke. 

Also, having the state pay a set amount for primary care could be important for expanding access to rural areas.

As a young pediatrician, Mayer worked in a clinic near the Canadian border, in the rural Franklin County town of Enosburg Falls. Nearly all of his patients were uninsured or on Medicaid — which generally pays less than the cost of care, and most clinicians make up the difference by charging more from commercial insurers. 

“It’s unsustainable,” Mayer said of practicing in places like Enosburg Falls today. “Any young physician who wants to go into primary care will look at that and say it’s impossible.”

Advocates say a statewide budget could allocate funds evenly for primary care practices to remain solvent, regardless of its patient population’s insurance.

Mayer is open to the flexibility that Janoo’s proposals allow. To him, even having a high-profile candidate call for these proposals is an amazing first step.

“We need to let 1,000 flowers bloom here. We need to get lots of ideas about how we could implement this system,” he said. 

Too little or just right?

Some others say that not thinking big or broadly enough could risk leaving behind some of the most vulnerable Vermonters.

Dr. Elizabeth Hunt, a primary care physician with Timber Lane Pediatrics in Burlington, who ran for state Senate this summer, worries about specialty care becoming a luxury if Vermont transitions to universal primary care without considering how people will afford costly other care. She said cash-strapped Vermonters might drop their insurance, banking on the fact that they could access primary care without it, and then be left high and dry when they need expensive care. 

“How do we handle their catastrophic coverage if any Vermonter gets cancer or is in a terrible accident?” she said. “The costs are enormous and unforeseen, and I would be concerned that more and more people would go without.”

Garlick, the UVM professor, is skeptical about how much return on investment tackling just primary care — instead of the much bigger slices of the healthcare spending pie, like hospital care or pharmaceuticals — might yield.  

He drew parallels between the call for universal primary care and Vermont’s faltered attempt at running an accountable care organization in the wake of proposals for a single-payer model. The accountable care organization paid providers fixed amounts per patient, regardless of how much care the patient received, as a way to incentivize keeping patients healthy. Still, when the rest of the healthcare system relied on a fee-for-service model, all the preventive care in the world did not change the fact that eventually and inevitably people would need costly medications, emergency room visits or hospital care, Garlick said. There is little evidence that Vermont’s accountable care organization contained healthcare costs at all. 

“When I think about cost containment, I think there are two ways to do it,” Garlick said. “You can reduce the number of services that are consumed, or you can reduce the price of those services. (Universal primary care) would get at the number of services, reduce utilization by making people healthier, but I have not seen a lot of evidence that that would then lead to markedly fewer expensive specialist visits or emergency room visits.”

To others, the fact that primary care is a small slice of the pie is exactly the point. Ethan Parke has been a citizen advocate for universal healthcare for decades, since he worked as an independent dairy farmer trying to figure out ways to insure his family, he said.

One reason, among many, that he thinks Shumlin’s plan for wider universal care folded in 2014 was that it would cause “too much economic dislocation all at once.” 

“Why not bite off a smaller piece?” he asked. “Primary care is so much smaller, and it pays the biggest dividend in terms of disease prevention, early detection, fewer trips to the emergency room, fewer appointments with specialists. You can catch things early; people are up to date on their immunizations; they’re getting regular checkups.” 

Still, Parke worries that the scale of an undertaking like this might be too big for Vermont’s citizen Legislature to wrap its arms around in the short, monthslong clip of a legislative session. 

He hopes the state can follow the example of Oregon, where in 2023 the Legislature created a panel tasked with envisioning a plan for state-funded healthcare for every resident. Lawmakers are expected to vote on that plan in the coming legislative session or put it to a ballot vote in 2028, according to reporting from KFF Health News.   

In Vermont, an analogous outside panel could dig into the questions that Janoo has raised — on payment mechanisms, funding, delivery type and quality assurance metrics.

But regardless of who is elected to the governor’s office in November, Vermont is on track to have yet another state analysis of universal primary care, along these lines. The primary care bill that Scott signed into law in June established the Legislature’s intent to establish a program of universal primary care. It tasked the state treasurer’s office and the Agency of Human Services with working with other Northeastern states to figure out how to establish a universal primary care program across the region. Their report is due to the Legislature by mid-January. 

To Parke, as long as the basic principles remain, Vermont is on the right track: “To really achieve the savings, you have to get rid of private insurance with all its administrative cost and profit seeking. You really have to have public financing. You really have to cover everybody. If you do that, you can make it affordable and you can make it high quality.”

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