This commentary is by Matt Swenson, who is the founder of Omnidex Solutions, a risk diagnostics company. He lives in Vermont.
Vermont’s healthcare debate has spent a decade stuck on the wrong question. The political class argues about who should pay the bill. Patients are asking something simpler: Can I actually see a doctor?
Insurance is not care. Coverage is not capacity. A promise from the government does not create a primary care appointment, a hospital bed, a nurse or an operating room. Yet Montpelier keeps tightening its grip on the money while patients have fewer real options every year.
Call it what it is. The Green Mountain Care Board is a rationing authority, whether or not anyone in Montpelier has the nerve to use the word. It sets hospital budgets, caps revenue and increasingly dictates what hospitals can build and offer. For fiscal year 2026, the board denied $94.5 million in revenue Vermont hospitals had proposed, most of it aimed at the University of Vermont Medical Center.
The board has its defense. Regulators accused the UVM Health network of shipping Vermont healthcare dollars to New York to cover losses at its New York hospitals and said the network should cut administration, executive pay and traveling staff before touching patient services. Fine. Hospital executives have earned that scrutiny. But look at the arrangement: Regulators choke the money, administrators pick where the cuts land, and patients absorb whatever falls out of the fight. Nobody voted for that outcome, and nobody answers for it.
The pattern is already on the ground. In 2024, UVM Medical Center shelved a planned $130 million outpatient surgical center after the board approved a fraction of the revenue growth it requested — a facility meant to replace aging operating rooms and expand the exact surgical capacity Vermonters are waiting on. Vermont did not reduce the need for surgery that year. It reduced the ability to perform it.
That is rationing by spreadsheet, and Act 68 is about to make it law, pushing Vermont toward global hospital budgets: fixed annual spending targets, first for the larger hospitals, eventually for all of them. Global budgets look tidy because the numbers are set in advance. Illness doesn’t care what the number is. When demand outruns the approved figure, you get closed beds, dropped service lines, out-of-state transfers and longer waits.
There’s a quieter cost. Squeeze a hospital hard enough, and it stops practicing medicine and starts managing throughput. Patients get sent home minutes after surgery ends, nowhere near a safe margin for anesthesia recovery, because the bed has a quota. Surgery becomes drive-through. Recovery becomes your problem, at home. That is the Walmart model of healthcare: high volume, standardized product, minimum staffing, everybody processed on the average and nobody treated as a person. At least McDonald’s is honest about what it’s selling.
Vermont is building the machinery of single-payer without the payer: centralized financial control, politically set spending caps and the delusion that squeezing payment produces affordability without destroying access.
Canada is the warning label. Its system guarantees public coverage for medically necessary care, and Canadians wait anyway. In 2024, only 68% of hip replacements and 61% of knee replacements happened within the recommended six-month window, and only 69% of cataract surgeries within the recommended 16 weeks — even as Canada performed record surgical volumes. The clinicians are not the problem. Scarcity is. When government dominates payment and constrains capacity, rationing doesn’t go away. It moves from price to queue.
The asymmetric patient pays first — the patient whose illness refuses to match the average the budget was built on. Several interacting conditions, a strange diagnosis, a failed prior treatment, a need for one particular surgeon. Standardized pathways were never built for that person, and a budget-driven system has every incentive to push them aside. The asymmetric patient waits the longest, gets transferred the farthest and takes whatever the system has left over.
Better models exist. Switzerland covers everyone without a government payment monopoly: regulated basic insurance for all, subsidies for those who can’t pay. It’s expensive, but it proves the point Montpelier refuses to hear: Universal coverage does not require running every dollar through one public spigot. Kaiser Permanente proves the delivery lesson: Tying insurers, physicians, hospitals and records into one system genuinely cuts waste. But Kaiser also shows the trap. A closed network works right up until you need something it doesn’t have. Then coordination becomes confinement.
Take the coordination, refuse the captivity. Vermonters should hold enforceable rights to outside referrals and second opinions whenever timely care isn’t available in network. Take Switzerland’s regulated competition, refuse Canada’s payment monopoly.
And measure reform by access, not enrollment. How long for a primary care appointment? How many specialists take new patients? How many surgeries slipped? How many Vermonters had to leave the state for treatment?
Montpelier keeps mistaking control for reform. Past a point, controlling budgets controls care — and when the state caps capacity and patients have nowhere else to go, cost containment stops being accounting. It becomes rationing with better manners.
An insurance card is not an appointment. A balanced spreadsheet is not a cured patient.
