Deborah Richter: Make primary care free to all

Editor’s note: This commentary is by Deborah Richter, M.D., a practicing physician who lives in Montpelier.

For the past 25 years, Vermont has searched for ways to better manage health care costs. In all that time a solution – one that has worked everywhere it has been tried – has been overlooked: Make primary care free to all.

Primary care is the care received from family doctors and pediatricians and, in Vermont, includes mental health care and substance abuse treatment. Where it is freely accessible, it improves the health of a population and the quality of health care while lowering overall costs.

There is a ton of evidence to this effect. Even without it, the idea appeals to common sense because much of what primary care practitioners do is help prevent the progression of disease, addressing problems before they become expensive illnesses.

Primary care is comparatively inexpensive. Of the estimated $5.6 billion we expected to spend on health care this year, less than 5 percent goes to primary care.

For a relatively small investment we could achieve what we have spent decades striving to do and failing.

Here’s how it would work.

Every Vermonter would get a card entitling him or her to free primary care.

Some positive effects would be:

• There would be no cost barrier for anyone seeking primary care.

• Health insurance premiums would go down proportionately.

• Vermonters would be freed from worrying about the cost of routine health care.

How do we know it would work?

Almost all other industrialized countries have better access to primary care than we do. One result is that their overall costs per person are half of ours. Also, lifespans are longer, fewer babies die in their first year, and general health outcomes are better than ours. [1]

Almost all other industrialized countries have better access to primary care than we do. One result is that their overall costs per person are half of ours.


Last year, the Vermont Legislature began studying this idea. The findings, released in December, showed that for $48 more per person per year than what we are now spending on primary care we could make primary care free for all.

Beyond the obvious (better health, better outcomes, better cost management over the long term) there are other advantages.

The proposal fits in nicely with ongoing reforms. In fact, the two main reforms in their infancy (the accountable care organization and all-payer model) depend directly on a strong primary care sector.

Management of cost trends in health care can only effectively take place on a sector basis. Choosing population groups by age or income will help members of those groups, but it does not help with overall management of cost trends.

Primary care is an important sector. It is where your health care starts. There are other sectors, such as hospitalization costs. But hospital care is 38 percent of overall health care spending. Its size makes it tougher to address.

Primary care is far, far smaller, and is the most promising candidate for positive change.


[1] For an interactive chart comparing countries see the Organization for Economic Co-operation and Development (OECD)’s “Health Statistics 2014.” A small selection of other unpaywalled studies and articles can be found here, here, and here. These articles are paywalled, but offer useful synopses: here and here.

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  • Walter Carpenter

    “Almost all other industrialized countries have better access to primary care than we do. One result is that their overall costs per person are half of ours.”

    Not to mention that you would never lose your primary care provider or access to due to changes in “networks,” through employer-sponsored insurance or because you are priced out of health insurance.

    • Judy Olinick

      I hope that voters will press the gubernatorial candidates closely on their positions on healthcare and make it clear that this is a top priority for Vermonters in choosing among them.

      • Lydia Cale

        That’s why I voted for Peter Shumlin. He promised and delivered single-payer.

        Oh, wait.

  • Thank you Dr. Richter for this wise piece. For far too long we have followed the dictum that what works in other industrialized countries somehow won’t work here. This is an isolationist attitude that makes absolutely no sense! Who wouldn’t want to cut medical costs in half? Everyone should support universal primary care.

    • Neil Johnson

      The monopoly has complete control of our health care. Who wouldn’t pay $48 per month for primary care? We don’t even have that option! I’d sign up for that immediately!

  • Kathy Callaghan

    “Make primary care free for all”. There is no such thing as “free for all” health care. No matter how you dress it up or what you call it, somebody has to pay for it, and it is always the taxpayers. Any rational discussion should at least begin with the premise that nothing, including health care, is ever “free for all”. One might check the tax rates of these other “countries” for starters.

    • “One might check the tax rates of these other “countries” for starters.” The tax rates in other countries may be higher,(except for those who can take advantage of tax loopholes such as off shore accounts etc.) but all of the “extras” we pay for such as health care deductibles and co-pays, university education, family leave time off, less paid holidays and vacation etc. etc. makes our bottom line actually higher.
      We need to wake up to reality, and not have a knee jerk reaction to taxes that would benefit most of us.

      • Randy Jorgensen

        Yes, and their economies have been doing what over the last decade?

        Hint: There central bank interest rates are in negative territory.

        • Walter Carpenter

          “There central bank interest rates are in negative territory.”

          And what is ours?

    • Jon Corrigan

      Dr. Richter states: ‘Almost all other industrialized countries have better access to primary care than we do. One result is that their overall costs per person are half of ours.’ One of the primary reasons for the lower costs/person is the lower pay for health care professionals. Since you’re advocating ‘free for all’ primary care, would you be willing to provide that care at lower than Medicaid reimbursement rates, and how many of your colleagues would remain here if that happened?

    • Walter Carpenter

      “Make primary care free for all”

      But it could be “free” at the point of delivery, like Medicare more or less is now. No one ever said it would be “free.” Yet, what is different here is that all of us, rich or poor, would share in it, and not one paying for another like we do now.

      “One might check the tax rates of these other “countries” for starters.”

      Yes, we should do this. Let’s see how much they pay versus us, then let’s add in what they do not pay for that we have to shoulder in things like student debts, medical debts, daycare fees, and so on and on. The rates then are not that much different. Then add the absence of stress and worry in those countries, compared with the unimaginable stresses that we live under, like not being able to afford a primary care doc because you just lost your insurance, and on and on.

  • Jason Kelley

    Vermonters who think twice about financial barriers to primary care under the present system – co-pays, deductibles, etc. – will welcome this meritorious and proposal. Just schedule an appointment with your long term doctor or provider, show your card, get the services you need, and leave without any cash transaction.

    Another unspoken benefit of universal health care is that it leads to social cohesiveness and dampen efforts to divide citizens into separate groups. Universal primary care will end the continual blame games that so often attempt to divide Vermonters. No longer will there be a shaming of the usual scape goats who are blamed for the high costs of health care – the disabled, the elderly, the HIV positive, those using illicit medications, the obese, etc. Vermonters can and should have a primary care financing system to be truly proud of.

    • Kathy Callaghan

      “Just schedule an appointment with your long term doctor or provider, show your card, get the services you need, and leave without any cash transaction.”

      It all sounds so wonderful! If this works I think I’ll just schedule an appointment with my local Mercedes dealer, show my card, get the car I need and drive off without any cash transaction. Little did I know!

  • Ann Raynolds

    Providing Primary Care for all Vermonters is truly good health policy, not a financial bandaid to the already broken for-profit insurance we’ve been forced to buy to pay for the big gamble we’d go bankrupt without it. Primary care is the frontline of healthcare and over time will actually save money (not to mention lives) by getting care when you most need it – at the beginning of pain, illness, have questions about a strange mole or whether or not a sore throat is just that or on its way to a serious illness.
    The method for delivering the funds is also unique in following the theory behind ACOs – a capitated payment system which allows for flexibility of care and reduces administrative billing cost for providers. New young doctors will be eager to work in this environment of primary care eliminating lots of administrative burdens.

  • John Wagner

    Superb column, Deb. I will try to email it to the candidates for governor, although I doubt that Lisman, and especially, Phill Scott will listen. They think health care is for those who can afford it and — for all their yapping about efficient use of tax dollars — they won’t listen to the wisdom of investing $48/person to save that state thousands/perosn later on, because denying health care is for them an ideology. Still, I really liked your analysis.

    • Walter Carpenter

      “They think health care is for those who can afford it”

      And for those who make money off of it to the detriment of others.

      • Randy Jorgensen

        “And for those who make money off of it to the detriment of others.”

        Like Doctors? Come on Walter, it sounds like you dislike pretty much anyone that actually makes money.

        Are you okay with doctors making 6, even 7 figure salaries?

  • Dr. Richter’s commentary is a most rational response to an irrational and cumbersome health care system that in many cases denies access to primary care due to artificial barriers.

  • Art Bell

    You always have the good, consistent, important and evan vital message Deb, unfortunately health care has left the building. Thank you Peter Shumlin…not likely to return any time soon.

  • Lee Russ

    It’s a better option than we have now. And better than any option than leaving health care to the “free market.” For people who want to quibble with the idea of the care being “free,” obviously the concept refers to not paying at the time you receive care. Of course the care needs to be paid for, and of course taxes are the mechanism. The fact that “other countries” with this kind of system have higher taxes is only a small part of the story. They also have lower health care costs, far fewer people who can’t get care, and, by and large, happier patient & happier doctors.

  • How can employers work with Accountable Care Organizations (ACOs)? See new report, “Introduction to shared savings arrangements and ACOs,” here:

  • sandra bettis

    I had a friend who recently had to make 10 phone calls to get a bill straightened out – just think of the time wasted by the ins cos and drs on these calls. If we had single payer, there would be no bills – no wonder they say we’d save 50% in health care.

  • sandra bettis

    When health care is pd thru your taxes, you know how much you are spending – there are no surprises – no worrying – no wonder Europeans live longer.