Studies find better primary care improves health but doesn’t reliably lower total spending. State reports on the idea are due in January.
Amanda Janoo, the Democratic nominee for governor, says making primary care free for every Vermonter would save the state an estimated $300 million a year. Her campaign platform says the savings would come from fewer emergency room visits, hospital stays and specialist bills.
That savings figure is larger than the state’s own 2015 estimate of what the whole program would cost each year: $281.9 million, projected for 2017.
A major 2025 review of federal primary care programs found better care and fewer hospital visits, but higher total spending. Meanwhile, the Legislature has already declared its intent to build universal primary care, in a law Gov. Phil Scott signed in June. The first state reports on how to do it are due Jan. 15.
What Janoo Is Proposing
Janoo’s platform calls for free primary and preventive care for every Vermonter. It would:
- End copays and deductibles for primary care visits.
- Put a community health team in every town: primary care providers, nurses, mental health workers and local pharmacies. The model is the town-run community nurse programs in Upper Valley towns such as Thetford, Tunbridge and Norwich.
- Stop paying primary care by the visit or test, known as fee-for-service, and fund practices directly instead.
- Serve as a first step toward universal health coverage, possibly in partnership with neighboring states.
She would pay for it with what she calls a Fair Share Tax on the wealthiest Vermonters. Janoo told VTDigger her cost and revenue figures are a “sense check” that the plan could be paid for.
Janoo has used $300 million two ways. Her platform calls it the program’s yearly savings. In July, she put the program’s yearly cost at more than $300 million, Vermont Public reported. Neither figure comes with published calculations.
Molly Gray, the Democratic candidate for lieutenant governor, made the same promise in the Oct. 6 debate, Compass reported.
What the Research Shows
Better primary care improves health and cuts some hospital use. Whether it lowers total health spending is much less certain.
- Federal programs, 2010-2021. A November 2025 review in JAMA Health Forum looked at major federal primary care programs. It found better care, more engaged patients and modest drops in hospital and ER use, but net increases in spending.
- Medicare. A 2024 analysis of Medicare primary care redesign found an average effect of $26 per patient per year, too small to tell apart from zero.
- Private insurance. A 2025 review found only seven studies that met its standards. Some targeted programs cut avoidable ER visits and hospital stays, but very few found ways for clinics to lower total costs. The authors said that may be because few clinics are held responsible for those costs.
- Vermont’s own review. A 2016 state report found no studies that directly measured savings from universal primary care. It did find many studies showing savings from parts of primary care, including four on Vermont’s Blueprint for Health, the state program that pays practices extra to coordinate patients’ care.
None of these studies tested a statewide program like Janoo’s, so none can confirm or rule out a $300 million figure.
Who Would Get the Savings
Janoo’s platform counts the $300 million as savings for the state. But when a patient avoids a hospital stay, the money saved goes to whoever would have paid that bill:
- Medicare, the federal program for Vermonters 65 and older and some people with disabilities.
- Medicaid, which the state shares with the federal government. Washington pays about 58 cents of each regular Medicaid dollar.
- Private insurers, and the employers and families who pay their premiums.
- Patients, through lower deductibles and copays.
Only part of that would reach the state budget, unless a program is built to capture more of it. The state’s 2015 study assumed a federal Medicaid waiver, a special permission to redirect federal Medicaid money into a new program. Janoo has said she’d avoid seeking one for now, VTDigger reported.
Compass asked the Janoo campaign what its $300 million estimate is based on, and how much of it would go to the state.
The campaign did not respond by Compass’s deadline.
What Vermont Found When It Priced This in 2015
The state’s 2015 cost study is the most recent official estimate Vermont has.
Most of that money pays for care Vermonters already get, through premiums, Medicaid, Medicare and their own pockets. Dropping copays and deductibles added about $60 million a year, roughly $97 per Vermonter.
The Legislature’s Joint Fiscal Office reviewed the study. It put the new public money needed at $113 million to $175 million a year after what Medicaid already pays, plus $12 million to $35 million to run the program. Paying primary care providers more would push the total as high as $415 million a year, Vermont Public reported.
Those are 2017 figures, and health costs have risen since. The state has not updated them.
How It Would Be Paid For, and Who Pays
A household earning under $250,000 would pay no new income tax under any version of Janoo’s plan, and would stop paying copays and deductibles for primary care. Whether its insurance premiums would go down is an open question.
Janoo would fund the program with a Fair Share Tax, a surcharge, or extra tax, on top earners’ income. The Fair Share for Vermont coalition behind the idea supports three versions:
All three estimates come from the proposal’s backers, mainly the Montpelier think tank Public Assets Institute, not from the Legislature’s fiscal office. The estimates for Plan 1 have varied: nearly $100 million in 2023, VTDigger reported, over $74 million in the coalition’s 2025 fact sheet, and $114 million now.
Plan 1 falls short of the state’s 2015 estimate of new spending plus administration. Plans 2 and 3 would cover that estimate, before adjusting for a decade of rising health costs.
What each plan would add to a household’s state income tax, roughly:
These figures apply each rate to income above its threshold. The bills define taxable income in more detail, so actual amounts would differ.
Which plan Janoo backs is not clear. Her platform says the tax would ask the wealthiest Vermonters to pay the equivalent of their recent federal tax cuts. That wording matches Plan 2, which the coalition says would take back about all of the federal cut for the top 1% of earners and about 10% of it for the next 4%.
But in July, Vermont Public reported that her proposal relied on Plan 3’s rates: 2% on income over $250,000 and 8% on income over $500,000. Plan 3 is also the version in Rep. Kate Logan’s bill, H.794. In October, Janoo told VTDigger she is open to other ways of paying for the program.
Compass asked the campaign which plan Janoo supports, and how much of its revenue would go to primary care.
The campaign did not answer that question by the deadline either.
What Scott Already Signed
Scott signed Act 173 on June 18. It states the Legislature’s intent to create universal primary care, and orders the groundwork. It does not make care free, end copays or raise taxes.
In plain English, the law:
- Requires health insurers, starting in 2027, to pay the Blueprint for Health at least as much as Medicaid does.
- Orders a count, due Jan. 15, of what Vermont now spends on primary care per person each month, overall and by who pays.
- Orders the Blueprint’s director to report by Jan. 15 on paying practices for patients’ routine primary care, instead of visit by visit.
- Asks the Agency of Human Services and the Tax Department to recommend funding the Blueprint through the health care claims tax, a tax on what insurers pay out in claims.
- Directs the state treasurer to explore a regional universal primary care program with other Northeastern states, and report by Jan. 15.
- Requires the state to set a target for primary care spending per person, and a schedule for raising it, by Jan. 1, 2028.
The regional option is close to the partnership with neighboring states that Janoo’s platform describes.
Scott’s campaign says he supports the concept of universal access to primary care and will study the reports. “There is no such thing as ‘free’ healthcare,” campaign representative Emma Shouldice told VTDigger.
The January reports land in the first weeks of the next governor’s term, whoever wins Nov. 3.