Healthcare for all

Health-care policy can sound remote and technical: prescription-drug purchasing, primary-care payment models, hospital-service notices, and reference-based pricing. Beneath those terms, however, is a question that reaches into every Vermont household:

When someone becomes ill, should access to care depend mainly on what that person can purchase alone, or should we build shared institutions that place a dependable floor beneath everyone?

This is not a choice between having markets and abolishing them. Vermont will continue to rely on private doctors, pharmacies, insurers, and hospitals. The real choice is about the rules within which those institutions operate — and whether the condition of the patient or the purchasing power of the customer becomes the primary driver of care.

When a market is not enough

Markets can distribute many ordinary goods effectively. If one product costs too much, a consumer may delay the purchase, select a substitute, or decide to go without it. Health care is different. A person cannot safely postpone insulin, negotiate during a heart attack, or comparison-shop meaningfully when only one nearby hospital provides an essential service.

When access is tied too closely to income, health care can become a form of market-based displacement. People may not be forced from their homes, but they can be pushed out of timely treatment, financial stability, employment, and full participation in community life.

Class enters health care through more than wages. It includes paid time off, transportation, internet access, proximity to providers, the ability to understand a complicated system, and the capacity to absorb a large bill. Two people may formally possess the same “choice,” while only one has the money and freedom needed to use it.

The community-centered response is not that government should make every medical decision. It is that markets should operate inside public obligations: patients should retain meaningful choice, providers should remain viable, communities should have a voice, and no Vermonter should be treated as disposable because illness costs more than that person can pay.

Two directions

Neither side has a monopoly on every idea. Republicans sometimes support collective purchasing or rural-hospital protections, and Democrats also use competition and private institutions. But the general directions remain different: market-centered policy places greater faith in individual purchasing, price information, and competition; community-centered policy places greater weight on shared access, pooled power, continuing relationships, and public accountability.

What four Vermont bills show

All four measures discussed here were sponsored by Democratic legislators and advanced through a Democratic-controlled General Assembly. Three became law with the approval of Republican Governor Phil Scott, demonstrating that Democratic leadership can produce measures with broader support. The clearest conflict concerned S.190, which the Legislature passed and the governor vetoed.

H.577, now Act 132: purchasing together

H.577 created the Vermont Prescription Drug Discount Card Program, administered by the State Treasurer. It uses pooled purchasing power with other states to reduce prescription-drug costs and is available to every Vermont resident. The law also requires insurers and pharmacy benefit managers to count qualifying prescription payments made without using insurance toward a person’s deductible and out-of-pocket maximum, provided the individual supplies proof of payment.

The law does not abolish the prescription-drug market. It changes the position from which Vermonters enter it. Instead of facing pharmaceutical pricing entirely alone, a resident gains access to a larger purchasing group. This is community power applied to a market: the medicine remains privately produced and sold, while the public program gives individuals leverage they would not possess by themselves.

S.197, now Act 173: primary care as a continuing relationship

S.197 expresses Vermont’s intent to invest in primary care and establish a program of universal primary care. It requires data collection, payment reforms, spending targets, and reports needed to build that system. Beginning in 2027, insurers must make payments to the Blueprint for Health at levels at least equal to Medicaid payments. The act also explores a regional universal-primary-care program with other Northeastern states.

This distinction matters: Act 173 establishes direction and machinery; it does not instantly provide every Vermonter with fully implemented universal primary care. Its direction is nevertheless important. Primary care is treated as a continuing relationship through which illness can be detected earlier, chronic conditions managed, and patients kept connected to care — not merely as a collection of isolated transactions after illness has become a crisis.

S.189, now Act 146: a public voice when essential services are threatened

S.189 requires hospitals considering the elimination of specified services — including emergency departments, primary care, obstetrics, and inpatient psychiatric services — to provide preliminary notice and explain the financial effects, alternatives considered, and reasons for the proposed change.

If a hospital continues toward closure, it must give formal notice, publish the proposal, present a transition plan, conduct at least one public hearing, solicit public comments, and respond to them. Regulators may examine ways to preserve the service or address the conditions threatening it. The Green Mountain Care Board may also consider whether savings should reduce insurance premiums or be reinvested in primary care, prevention, or community-based services.

The law creates notice, scrutiny, consultation, and public participation. It does not give a community an absolute veto over a hospital closure. That is an important limitation — but it also means that the disappearance of obstetrics, psychiatric care, primary care, or an emergency department can no longer be treated only as a private spreadsheet decision.

S.190: common standards for hospital prices

S.190 would have directed the Green Mountain Care Board to use reference-based pricing to reduce hospital prices incrementally toward national median prices by 2030. It would have required greater public reporting of prices in dollars and as percentages of Medicare rates. It also contained an earlier implementation mechanism affecting qualified health plans and Vermont Education Health Initiative school-employee plans, along with provisions addressing hospital outsourcing, possible reinsurance, and public price information.

Governor Scott vetoed the bill. His administration argued that its approach could create cost shifts and place hospital stability at risk. Supporters argued that Vermonters needed earlier, enforceable relief from prices that exceed reasonable benchmarks.

The underlying policy challenge is real. If a benchmark is too restrictive or imposed carelessly, it can destabilize vulnerable providers. But when hospitals or insurers possess concentrated power, simply giving patients more price information does not create a functioning market. Good policy must restrain excessive prices while protecting essential rural services.

What these directions mean in daily life

Under a more market-centered path, a patient receives more information but remains chiefly responsible for finding, comparing, and financing care. A health savings account is most useful to someone with income left to save. A high deductible may reduce the monthly premium while making treatment difficult to use when illness arrives. In a rural region with few providers, the promise of competition may exceed the number of choices that actually exist.

Under a more community-centered path, purchasing power is pooled, primary care is treated as infrastructure, threatened hospital services receive public scrutiny, and powerful institutions must explain their prices against common standards. This approach is not free of risk. Public rules can be badly designed, and hospitals must remain financially capable of caring for their communities. Accountability therefore has to run in both directions: institutions must answer to the public, and public policy must protect access and provider stability.

The patient must remain at the center

The deepest question is not simply “market or government?” Both approaches use public rules and private institutions. The better question is:

Does the system organize itself primarily around the condition of the patient and the health of the community — or around each person’s ability to purchase access?

My direction is clear. Vermont should preserve individual choice, professional medical judgment, and financially stable local providers. But those values must exist inside a shared promise: illness will not make a person disposable, and a rural community will not lose essential care without notice, public voice, and a serious search for alternatives.

Health care should help Vermonters remain healthy, rooted, and able to participate in the shared life of their towns. That is not government replacing community. It is democratic government doing what community asks of it: bringing people together so none of us must face concentrated economic power — or illness — alone.