Twelve years ago, Vermont Democrats tried to make their state the first in the nation to have a single-payer government-financed healthcare system \u2014 a bold experiment to push the limits of American health coverage when Obamacare was just being launched.<\/p>\n
Their plan failed<\/a>, and rebooting it became politically impossible, even in Vermont: The Democrats lost the governorship to Republican Phil Scott for what turned out to be a decade.<\/p>\n This year, that could finally change. A progressive political newcomer named Amanda Janoo is taking on Scott in what polls show is a tight governor\u2019s race<\/a>.<\/p>\n And if she wins, the state could be poised to try a whole new national experiment: one of Janoo\u2019s central campaign promises is to create a pioneering health system where the state pays the full tab for primary and preventive care, while leaving the rest to the existing system.<\/p>\n Amanda Janoo, the Democratic nominee for governor of Vermont, wants to move primary and preventive healthcare to a single-payer system \u2014 where the state would pay providers for such care, make it free for patients, and cut insurers out.Previous attempts to pass or enact full single-payer systems have failed at the state level, including in Vermont in 2014.Janoo is trying to focus first on this one relatively smaller slice of the health system, but hopes it could be a starting point to full single-payer reform eventually.Yet even this more limited reform faces difficult political and practical challenges.<\/p>\n Janoo\u2019s candidacy is an example of the policy experiments that are becoming possible nationwide in a projected \u201cblue wave\u201d year, when Democrats could sweep into power in a number of states. But in the healthcare universe, her plan is also an example of how even progressive policy idealists are trying to learn from past failures and focus on what they think can actually be achieved.<\/p>\n Compared to the sweeping ambition of Vermont\u2019s 2014 effort, or Bernie Sanders\u2019s signature \u201cMedicare-for-All\u201d idea, Janoo\u2019s proposal for single-payer has very specific limits. Under Janoo\u2019s proposal for \u201cuniversal primary and preventive care\u201d (she typically avoids the term \u201csingle-payer\u201d), the state government would pay for Vermonters seeing primary care providers such as doctors and nurse practitioners. This government coverage would be universal and free for patients, and insurance companies would be cut out.<\/p>\n However, other parts of the health system \u2013 such as hospitals, specialists, and prescription drug companies \u2013 would remain under the existing insurance system, for now.<\/p>\n Every effort so far to enact full single-payer at the state level has failed \u2014 even in blue states<\/a>, bills and ballot initiatives have regularly gone down to defeat. Vermont\u2019s previous single-payer experiment made it the furthest \u2014 it was signed into law but abandoned before being implemented, when the governor concluded it was unworkable. Wherever it\u2019s gained steam, politicians and voters have blanched at the high costs of moving their health systems onto state budgets, and the high taxes that would be necessary to fund them.<\/p>\n Now, Janoo is making an attempt to refurbish single-payer as something more achievable, by cutting off a smaller slice of it.<\/p>\n \u201cI think it\u2019s clear at this point that a profit-oriented healthcare system is a terrible idea,\u201d Janoo told me in an interview Monday. But after assessing that the state budget made it \u201cunrealistic\u201d to do single-payer immediately, she concluded, \u201cwe could do universal primary and preventive care,\u201d financed by a tax on the wealthiest.<\/p>\n Indeed, single-payer for primary care seems more achievable precisely because primary care is a relatively less expensive part of the healthcare system. But Janoo hopes it will pay major dividends \u2014 that better preventive care will improve Vermonters\u2019 health, reducing costs elsewhere in the system by, for instance, making some hospital visits unnecessary.<\/p>\n In speaking to health policy experts about this idea, I heard much sympathy for the goal of universal primary care, but many questions about the details. Would Janoo\u2019s plan be sufficient to bring more primary care doctors to Vermont \u2014 and, not unrelatedly, would it pay them more? Would her hoped-for cost savings from preventive care actually materialize? Is picking up the tab for a relatively less expensive part of the healthcare system the best use of sparse state funding?<\/p>\n These questions are becoming national ones, as healthcare gains traction as a political issue again. It isn\u2019t just Vermont where primary care reform ideas are gaining steam: Democrats in Minnesota<\/a>, Washington<\/a> state, and elsewhere have discussed them. \u201cThere is growing interest in a number of states across the country in doing a universal primary care for all program,\u201d Kevin Grumbach, a family physician and a professor of family and community medicine at the University of California San Francisco, told me. Even Gov. Scott, Janoo\u2019s opponent, signed a law calling for a study of universal primary care<\/a>.<\/p>\n One dividing line emerging, though, is whether to keep insurers involved, or to clear them out with a single-payer system, as Janoo wants. Insurers are unpopular with the public, but they can be a formidable political opponent when they argue that the benefits voters currently enjoy might be lost. Scott has said<\/a> that the idea of universal primary care is appealing \u2014 but that if universal is \u201cjust code for single payer, I\u2019m not interested. We\u2019ve already been through that.\u201d<\/p>\n Yet Janoo is hoping that single-payer for primary care will be a stepping stone \u2013 a trial run for eventually making the rest of the state\u2019s health system single-payer down the road.<\/p>\n \u201cI think about this often,\u201d Janoo told me. \u201cHow do you build the new system as you transition the old \u2014 or hospice the old?\u201d<\/p>\n Amanda Janoo is tired of \u201ccorporate neoliberal bullshit\u201d<\/p>\n Janoo has long been an unorthodox economic policy thinker. Her rise is part of a broader trend in which progressives and leftists are winning primaries and gaining influence in the Democratic Party \u2013 but she doesn\u2019t fit the prototype of the democratic socialist candidates<\/a> in New York City<\/a>, Colorado<\/a> and elsewhere who\u2019ve gotten much attention this year. Instead, she comes from a different strand of the left, a movement based on a dissident strain of economics and openly skeptical of the benefits of economic growth.<\/p>\n Dating back to when she graduated from college in 2010, in the aftermath of the financial crisis, she was part of a younger cohort rebelling against what seemed the glaring failures of the economic establishment. \u201cThe one thing coming out of university I was clear on was that neoliberalism was the worst,\u201d Janoo said<\/a> on a podcast last year. \u201cThis whole idea that governments should just take a hands-off approach to the economy and trust in sort of the disciplinary powers of the global free market to lead them to infinite growth seemed highly problematic and very anti-democratic.\u201d<\/p>\n So for graduate school, Janoo attended Cambridge to study development economics under the \u201cheterodox\u201d economist Ha-Joon Chang<\/a>. She then spent several years working abroad in international development for the United Nations and other organizations, before moving back to Vermont and working as an economic policy consultant.<\/p>\n In recent years, Janoo became deeply involved with the \u201cwell-being economy<\/a>\u201d movement: an international group of advocates, academics, and experts who criticize what they deem modern capitalism\u2019s obsession with economic growth, and say the \u201cwell-being\u201d of humans and the environment should be prioritized instead. They overlap with the \u201cdegrowth<\/a>\u201d movement, which outright argues economic growth should be reduced; last year, Janoo led a workshop<\/a> at a DeGrowth Institute event on \u201cDegrowth Policy Design.\u201d<\/p>\n Trump\u2019s return to power horrified Janoo. \u201cI\u2019m feeling angry about the rise of fascism and the growing threat of world war, because I feel like we don\u2019t have time for this shit,\u201d she said in a speech<\/a> at an environmental event last year. \u201dThe planet is on fire and ecosystems are collapsing, and that should really be the focus of all of our attention.\u201d But, she said, \u201cI believe I was born in this moment of history for a reason\u201d and vowed \u201cto fight for democracy \u2013 for life.\u201d<\/p>\n So Janoo decided to jump in the race for governor of Vermont. While she is not running on a degrowth platform, her campaign is deeply informed by aspects of the movement\u2019s thought: skepticism about growth\u2019s benefits, a sense that untrammeled capitalism is leading the world to disaster, and that localism provides a better way. For instance, candidates for governor typically pledge that they\u2019d help bring business investment in, but Janoo said in a July debate<\/a>: \u201cA lot of the problems we\u2019re facing is because we focus so much on attracting external business.\u201d<\/p>\n \u201cOur economy is not super-diversified, and it is not really centered in the most essential kinds of goods and services you want to make sure people have access to no matter what happens \u2014 because honestly, things are bad now and they\u2019re going to get worse,\u201d Janoo told me. \u201cI feel a little bit like a collective prepper right now. My motto is, protect what we love, produce what we need.\u201d<\/p>\n In the Democratic primary, Janoo\u2019s opponent, Aly Richards, had closer ties to the party establishment and led in fundraising. But Janoo ran as a progressive outsider; she promised<\/a> to advance a \u201cmore economically populist vision\u201d instead of \u201ccorporate neoliberal bullshit.\u201d Her health plan became a point of contrast with Richards, who said she wouldn\u2019t run on \u201cmagical thinking<\/a>,\u201d and that she wanted a version of universal primary care that would keep insurance companies involved. Janoo won the primary by 2.5 percentage points.<\/p>\n