The two leading Democrats running for governor have different ideas about how to drive down the state’s health care costs. 

Former education secretary Rebecca Holcombe wants to continue to expand the state’s all-payer health care system, a reform that began in 2016 and aims to change the way doctors and hospitals are reimbursed. 

Lt. Gov. David Zuckerman believes that the state should move in “the direction” of a single-payer health care system. He says he would support a publicly funded universal primary care system. 

During a press conference on health care policy this week, Holcombe said her focus would be expanding the state’s all-payer health care system.  

Vermont began rolling out its all-payer system in 2016, in the wake of Democratic Gov. Peter Shumlin’s failed effort to enact a statewide single-payer health care system. 

Under the system, health care providers don’t receive payments for individual procedures or services. 

Instead, a for-profit accountable care organization, OneCare, gives them flat monthly payments per patient. 

The goal of the reform is to drive down health care costs and encourage doctors to keep people healthy by creating an incentive for preventive care. 

“Unfortunately, our current healthcare model rewards people and compensates doctors if they provide expensive service,” Holcombe said. 

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“The problem is we don’t reward doctors and our hospitals for keeping people healthy in the first place. Payment reform makes that difference,” she said. 

So far, 268,000 Vermonters are receiving health care through the all-payer system, according to the Green Mountain Care Board, the state’s health care regulator .

But last year, the care board estimated many more people — a total of about 530,000 — could be eligible to receive care through the system. Doctors and hospitals have been slow to opt in to the model, wondering if participation is worth the increased cost and paperwork. 

The teacher’s union and the Vermont State Employees Association decided not to participate in January. 

Holcombe says Gov. Phil Scott, the Republican incumbent, has had an “arm’s length relationship to payment reform” and has failed to take advantage of federal dollars that could have moved the state’s health care reform ahead more quickly. 

She says she would work to get more providers—particularly primary care doctors outside of hospital systems— involved in the all-payer model. 

She would expand the state’s health care workforce by expanding loan forgiveness programs for primary care doctors, and policies to help more Vermonters become nurses.

She advocates forming a “regional purchasing consortia” with neighboring states to bring down the cost of pharmaceutical drugs. 

Holcombe doesn’t think state policymakers should try to enact a single- payer health care system again. Shumlin, who had made single-payer a campaign pledge for years, backed off after concluding it would be too expensive.

However, Holcombe says she would support a publicly-funded health care system at the federal level

“I think if you look at other industrialized nations it both improves care, keeps people healthier and is less expensive,” she said. 

Zuckerman said the biggest difference with Holcombe is her proposals “still incorporate for-profit insurance companies.” 

“As long as we have the idea of insurance profits as a part of the healthcare system, I think we are on an unsustainable path,” Zuckerman said. 

Zuckerman, a Progressive Democrat, says that he wouldn’t close the door on discussions about single-payer health care in Vermont. 

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“Healthcare costs are crippling Vermonters and Vermont businesses. There’s an incredible opportunity if we could do it right, to actually promote entrepreneurialism and attract young families to Vermont,” he said. 

“So we have to keep the door open on that conversation, and see what the possibilities are,” he said. 

To start, Zuckerman said he would consider enacting a publicly funded universal primary care system. 

In 2018, some Vermont senators tried to pass legislation for a taxpayer funded universal primary care system by 2022. 

But Senate leaders watered down the bill, instead agreeing to study how such a system could be implemented. The measure never passed the House. 

Zuckerman, who is in favor of raising taxes on the wealthy to fund various initiatives, said he doesn’t know how much a universal primary care system in Vermont would cost. 

But he said it could be funded by patients paying a “premium” to the state, instead of insurance companies, which he believes could bring those costs down. 

Zuckerman expressed some concerns with the state’s all-payer system. He pointed to a report published by Vermont State Auditor Doug Hoffer earlier this month which called for greater transparency and accountability in the system. 

In the report, Hoffer said that the Green Mountain Care Board “has not developed a methodology to determine whether OneCare’s operating costs will be greater or less than the benefits of the ACO model.” 

This year, the administrative costs were $19 million of a total budget of $1.43 billion. 

“We have to evaluate after a few years, and tens of millions of dollars, is that model effectively working?” Zuckerman said. 

Zuckerman says he would also support legislation to prevent drug companies from “price gouging” prescription insulin, ensure steady Medicaid funding, and work with the state’s congressional delegation to expand the services offered through Federally Qualified Health Centers.

Gov. Phil Scott has not proposed significant reforms. He agreed that Shumlin was right to withdraw single payer in 2014. Last year, he raised the the idea of lowering health care costs, including a scenario in which insurance premiums might be based partly on age in an effort to reduce prices for younger people.

The third candidate running in the Democratic primary, attorney Patrick Winburn, has called opioid addiction the biggest problem facing Vermont. He believes universal health care coverage — including mental health treatment — is an important part of helping Vermonters recover. He said the financing for expanded health coverage could come from a range of sources: a slight increase to the sales tax, higher taxes on the rich, and perhaps some of the marijuana sales tax revenue. 

Katie Jickling contributed reporting.