Vermont’s primary care system is under enormous strain, with physician shortages, rising insurance premiums, and patients struggling to get timely appointments. Lawmakers are right to look for solutions. But the proposal currently moving through the Legislature, S. 197, risks making things worse.
Across the country, one promising approach is gaining traction: Direct Primary Care (DPC). In this model, patients pay a simple monthly membership fee directly to their doctor instead of going through insurance for every routine visit. That fee (often around $50 to $100 per month) covers most primary care services like office visits, basic labs, and preventive care. Because doctors don’t have to bill insurance for every appointment, they spend far less time on paperwork and much more time with patients.
The difference can be dramatic. Traditional primary care doctors often manage 2,000 to 3,000 patients in their practice. Direct Primary Care doctors typically limit their panels to 300 to 600 patients, which allows longer visits and often same- or next-day appointments. For patients, that means better access and time to form a real relationship with their doctor. For physicians, it means less burnout and more time practicing medicine. Recognizing these benefits, more than 30 states have passed laws making it easier for Direct Primary Care practices to operate by clarifying that these agreements are not insurance products.
Florida offers a good example of how these reforms can work. In 2018, Florida passed legislation confirming that Direct Primary Care agreements are not insurance, allowing doctors and patients to contract directly for care. Since then, the model has expanded as both patients and physicians look for alternatives to the paperwork-heavy insurance system. Doctors in DPC practices can often spend 30 to 60 minutes with patients instead of the typical 10 to 15 minutes in traditional clinics, allowing more time for prevention and chronic disease management. Research shows physicians are increasingly interested in the model because it reduces administrative burden and improves patient care.
Unfortunately, Vermont appears to be moving in the opposite direction. S. 197, a bill to establish “a primary care payment reform program,” passed out of the Senate and is currently being considered by the House. Instead of empowering DPC providers, it would create a centralized system for paying primary care doctors through a state-managed payment program. Under this proposal, insurance companies and public programs would pay into a pooled system, and the Green Mountain Care Board (GMCB) would help determine how that money gets distributed to primary care practices. For years, the GMCB has overseen Vermont’s healthcare prices, including hospital budgets and insurance premiums, yet costs have continued to rise, and Vermonters face some of the highest health insurance premiums in the country.
If strict regulation has not slowed the growth of healthcare costs in the past, why would forcing insurers and primary care practices to operate under a state-controlled payment system suddenly make prices go down? It won’t. Policies that eliminate copays at the doctor’s office often sound appealing, but the money still has to come from somewhere. In many cases, those costs lead to higher insurance premiums instead of lowering overall healthcare spending.
Vermont’s insurance market is already extremely small and fragile. At the moment, only two insurers offer plans on Vermont’s individual and small-group markets. If insurers are required to operate under a structure where payment levels and funding pools are tightly managed, it could make the Vermont market even less attractive.
Direct Primary Care works because it bypasses insurance billing and administrative mandates, allowing physicians to operate smaller, independent practices that focus on preventive care and patient relationships. Bringing these practices into an insurance-centered payment system that could eventually require them to participate in statewide payment arrangements, defeats the whole purpose.
Instead of adding complexity to an already complicated healthcare system, lawmakers should focus on reforms that expand consumer choice and support new care models:
- Clarifying that Direct Primary Care agreements are not insurance
- Allowing Health Savings Accounts to be used for DPC memberships
- Removing regulatory barriers for independent primary care practices.
If Vermont truly wants to strengthen primary care, why make it harder for models like this to grow? Encouraging innovation and giving patients and doctors more freedom to work together is one of the most practical ways to improve healthcare access in our state, and all it requires of the government is for it to get out of the way.
