The context you need, when you need it

When news breaks, you need to understand what actually matters — and what to do about it. At Vox, our mission to help you make sense of the world has never been more vital. But we can’t do it on our own.

We rely on readers like you to fund our journalism. Will you support our work and become a Vox Member today?

Can this Democrat crack the code for universal healthcare?

Amanda Janoo is running for governor of Vermont. Her health reform proposal has a twist.

Twelve years ago, Vermont Democrats tried to make their state the first in the nation to have a single-payer government-financed healthcare system — a bold experiment to push the limits of American health coverage when Obamacare was just being launched.

Their plan failed, and rebooting it became politically impossible, even in Vermont: The Democrats lost the governorship to Republican Phil Scott for what turned out to be a decade.

This year, that could finally change. A progressive political newcomer named Amanda Janoo is taking on Scott in what polls show is a tight governor’s race.

And if she wins, the state could be poised to try a whole new national experiment: one of Janoo’s central campaign promises is to create a pioneering health system where the state pays the full tab for primary and preventive care, while leaving the rest to the existing system.

Amanda Janoo, the Democratic nominee for governor of Vermont, wants to move primary and preventive healthcare to a single-payer system — where the state would pay providers for such care, make it free for patients, and cut insurers out.

Previous attempts to pass or enact full single-payer systems have failed at the state level, including in Vermont in 2014.

Janoo is trying to focus first on this one relatively smaller slice of the health system, but hopes it could be a starting point to full single-payer reform eventually.

Yet even this more limited reform faces difficult political and practical challenges.

Janoo’s candidacy is an example of the policy experiments that are becoming possible nationwide in a projected “blue wave” year, when Democrats could sweep into power in a number of states. But in the healthcare universe, her plan is also an example of how even progressive policy idealists are trying to learn from past failures and focus on what they think can actually be achieved.

Compared to the sweeping ambition of Vermont’s 2014 effort, or Bernie Sanders’s signature “Medicare-for-All” idea, Janoo’s proposal for single-payer has very specific limits. Under Janoo’s proposal for “universal primary and preventive care” (she typically avoids the term “single-payer”), the state government would pay for Vermonters seeing primary care providers such as doctors and nurse practitioners. This government coverage would be universal and free for patients, and insurance companies would be cut out.

However, other parts of the health system – such as hospitals, specialists, and prescription drug companies – would remain under the existing insurance system, for now.

Every effort so far to enact full single-payer at the state level has failed — even in blue states, bills and ballot initiatives have regularly gone down to defeat. Vermont’s previous single-payer experiment made it the furthest — it was signed into law but abandoned before being implemented, when the governor concluded it was unworkable. Wherever it’s gained steam, politicians and voters have blanched at the high costs of moving their health systems onto state budgets, and the high taxes that would be necessary to fund them.

Now, Janoo is making an attempt to refurbish single-payer as something more achievable, by cutting off a smaller slice of it.

“I think it’s clear at this point that a profit-oriented healthcare system is a terrible idea,” Janoo told me in an interview Monday. But after assessing that the state budget made it “unrealistic” to do single-payer immediately, she concluded, “we could do universal primary and preventive care,” financed by a tax on the wealthiest.

Indeed, single-payer for primary care seems more achievable precisely because primary care is a relatively less expensive part of the healthcare system. But Janoo hopes it will pay major dividends — that better preventive care will improve Vermonters’ health, reducing costs elsewhere in the system by, for instance, making some hospital visits unnecessary.

In speaking to health policy experts about this idea, I heard much sympathy for the goal of universal primary care, but many questions about the details. Would........

© Vox