Universal Primary Care: The Antidote to Health Reform Paralysis?

Could a state, or the federal government, set up a system of universal primary care as a first step toward comprehensive, publicly funded health care for all? The experience of Vermont suggests that such a program is worth looking at, if for no other reason than to ease the economic dislocation involved in replacing employer-sponsored insurance and other private plans all at once with tax-financed care.

A decade ago, Vermont was poised to implement a universal health care program that would have been the first of its kind in the U.S. Three and a half years prior, the state legislature had passed Act 48, a bill that committed the state to creating a universal program financed by progressive taxes. Act 48 would have maximized use of federal dollars, would have achieved significant administrative savings, and would have covered all residents with a high actuarial value plan, leaving little to be picked up by patients out of pocket. All that remained was for the state to negotiate an Affordable Care Act waiver with the federal government, to refine the benefit package, to devise the infrastructure to pay providers, and to raise the necessary taxes.

To the dismay of many Vermonters, but to the joy of conservative ideologues, insurance companies, and other vested interests, after three years of working with the Obama administration on federal funding, and studying financing mechanisms in anticipation of making a recommendation to the legislature, Governor Peter Shumlin, who had campaigned on a promise of universal health care, halted all efforts at implementation of the new law.

“In my judgment,” he said at a press conference, “the potential economic disruption and risks would be too great to small businesses, working families, and the state's economy.”

News outlets throughout the U.S. took the governor's pronouncement as proof that no state could possibly fund health care for all its citizens — that the price tag was just too high. However, a closer read of the governor's comments suggests that he was talking about the suddenness of the shift from premiums to taxes — a financial upheaval that might temporarily rock the economy, but in no way sink it. In fact, the governor stated: “At a growth rate of four percent, [Act 48] would yield savings of $378 million over the first five years of the program relative to current predicted trends.”

Dr. Deb Richter

In reality, the abandonment of Act 48 was due to a failure of nerve on the part of the governor and the Democratic controlled legislature. A number of ill-timed events contributed to this erosion of confidence or lack of political will — a bungled roll out of the state's Obamacare insurance exchange, a brewing scandal in state government unrelated to health care, and a poor performance by the governor in his reelection bid.

It's anyone's guess whether, with stronger leadership and a more favorable political climate, Act 48 might have moved forward, but in any scenario, implementation of Act 48 would have been a heavy lift, since the revenue needed to finance the program would have doubled the state budget. That was enough to scare most lawmakers, even though all but the wealthiest Vermont households would see higher net family income as a result of not having to pay premiums and out-of-pockets; they'd also get more coverage in the bargain.

One thing is clear: Governor Shumlin, in pulling the plug on Act 48, welcomed the possibility of other approaches to implementing universal, publicly financed care. In releasing a detailed report of his administration's analysis, he wrote that “I hope these materials provide a foundation for future efforts to usher in a publicly-financed health care system that is more equitable than the one we have now, when the time is right.”

In the almost 10 years since the governor wrote those words, health care costs have risen dramatically. The crisis of the uninsured has become the crisis of the underinsured. Disparities have widened in the adequacy of people's insurance against a major health care event. Medical debt has soared. Public programs have “cliffs” where coverage suddenly ends due to age or income. Payment reform, also known as the All Payer or ACO Model, has failed to control costs or improve quality, and as administrative burdens have increased, clinician burnout has become endemic, especially in primary care.

The time may now be right for a different approach, where sectors of care become publicly funded in sequence, rather than all at once. This approach would be more palatable to politicians, provided however, that each sector of care must be designed to be universally available and not limited by a means test, or by an age limitation, or by any other eligibility restriction. Public funding for increments of non-universal care bring a different sort of political liability, whereby some residents are taxed for services for which they themselves are not eligible. On the other hand, universally offered programs don't have this liability and therefore have the best chance of gaining popular support.

Primary care would be a logical first sector to publicly finance. Why primary care?

First, everyone needs primary care, even healthy people. Primary care clinicians diagnose and treat all the routine illnesses and injuries that people incur over their lifetimes. They get to know their patients and are trained to look for symptoms of ill health that can be addressed in a timely fashion. Because primary care is the only sector of care that everyone needs, it therefore lends itself most readily to the argument that it should be a public good.

Second, primary care is relatively inexpensive. In Vermont a study showed it comprises less than 6 percent of total health care spending, and that includes mental health and substance use disorder services. And yet, for its modest cost, primary care pays big dividends in population health because it emphasizes prevention and early intervention.

Third, to be most effective, primary care must be readily available to everyone. To achieve the best results in population health, primary care must be free at the point of service, and primary care clinics must be adequately staffed and conveniently located for the people they serve. The effectiveness of universal primary care has been demonstrated in developed countries around the world, and even in developing countries, such as Costa Rica and Brazil, which have implemented publicly financed primary care as a first step toward a comprehensive universal system.

There is little debate about the benefit of primary care. It is the only sector shown to improve the health of the population when freely available. With accessible primary care, people live longer, fewer babies die in the first year of life, quality of life improves, and total costs decrease. No one disputes this anymore. 

As a primary care physician in Vermont who, for over a decade, worked tirelessly in the public sphere to advance Act 48, I now advocate for universal primary care as a pilot program to demonstrate both the economic feasibility and the positive health outcomes of public financing. 

The main purpose of primary care is to improve the health of the public by providing easy access to medical care. It also focuses on the whole individual rather than on the illness of a specific organ, system or disease. Our job as primary care providers is to specialize in you and all that that entails — getting to know you, your family, your job, your mental health, and so on.

Because primary care is a small portion of overall health care spending and because its emphasis on prevention pays big dividends in avoidance of costly interventions later on, universal primary care would be a frugal and wise investment of public dollars. And it might loosen the political paralysis that now hinders movement toward universal care, especially in states such as Vermont, which has a veto proof Democratic majority in the state legislature.

During the last session of the Vermont legislature, identical companion bills were introduced in the House and Senate that would guarantee primary care to all Vermonters. The definition of primary care included mental health and substance use disorder services. More than a third of state representatives added their names as co-sponsors, as did a third of state senators. But neither bill advanced, or even got a committee hearing.

Advocates in Vermont are now gearing up for yet another legislative biennium, making the point that Act 48 of 2011 is a law still on the statute books. It is the stated intent of that law “to create Green Mountain Care to contain costs and to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless manner regardless of income, assets, health status, or availability of other health coverage.”

Act 48 anticipated a short interval between its passage and its implementation. It has now been thirteen years, and no move toward universal coverage has occurred. To break the logjam, advocates are offering a phased approach, starting with primary care and moving to other sectors once the dust settles. It's either that or accept perpetual dysfunction, with all the human suffering and inequity that comes with it. In a modern world, in the richest country on earth, no person with a conscience should be content with the latter.

Deborah Richter, M.D., is a family medicine physician in Montpellier, Vermont with more than 37 years of experience in the medical field. She graduated from the State University of New York at Buffalo.