Vermont’s Future: Green Mountain Care

The Vermont governor, Peter Shumlin (D), has signed a bill, which proposes to set forth a strategic plan for creating a single-payer and unified health system for Vermont. (

For a pdf of the bill use the following link:

In this post, I am going to discuss a couple of the eleven Principles, which are the framework for reforming health care in Vermont. They are recorded as Sec. 1. on pages 2 & 3 of the 213 page pdf of the bill. I will give the number of the principle and place the exact words in italics, and then my comments will follow as non-italicized text.

Principle (3) The health care system must be transparent in design, efficient in operation, and accountable to the people it serves. The state must ensure public participation in the design, implementation, evaluation, and accountability mechanisms of the health care system. If the legislators really mean this, such that the general public really understands what is being done for (to) them and such that the general public has an important, deciding voice in the design and implementation etc., then I applaud them. Do you think the legislators really mean this? I will hold my applause for now.

Principle (4) Primary care must be preserved and enhanced so that Vermonters have care available to them, preferably within their own communities. WATCH OUT ! We are getting into medical rhetoric land. Why is the distinction made for primary care. What about specialty care? Is it possible that they are trying to create primary care holding pens with the aim of reducing specialty referral, i.e., the concept of medical homes? Why are specialists not the first point of medical contact for patients? If that were the case, there would be an expanded knowledge base at the point of first contact and one less layer of referral for the patient should he/she need that type of specialty care. Why should patients have to go through the process of a referral, when they often know the type of specialist they need and/or want to see? The medical specialists such as cardiologists, lung doctors, gastrointestinal doctors etc. have to undergo general medical training prior to specialty training. They are capable of providing “primary” care but the reverse is not correct. I am wary when legislators start differentiating about the types of medical care patients should receive. How do they know?

Principle (5) Every Vermonter should be able to choose his or her primary care provider. Again, no mention of the specialists. And why does this principle use the word provider and not doctor? Oh, of course, we have to include nurse practitioners and physician assistants, who follow all the appropriate protocols. I wonder who writes up all those protocols; what is the basis of knowledge that supports those protocols; who pays the salary of the protocol writers; and who funds the institutions, which pay those salaries and provide that basis of knowledge.

Principle (7) The health care system must recognize the primacy of the patient-provider relationship, respecting the professional judgment of providers and the informed decisions of patients. Oh, so politically correct and inclusive. The essence of medicine is the doctorpatient relationship, and the distinction I make is a whole lot more than splitting hairs. The primacy of the doctorpatient relationship, the medicine of medicine, should be served by the entire system. The dollar bill, currently the primary endpoint for the business of medicine, needs to be designated as the servant of the doctorpatient relationship, which is the exact opposite of the current state of affairs. Moreover, careless terminology, such as patient-provider, designed to lessen the importance of the doctorpatient relationship and elevate the importance of legislators, legislation, and the business of medicine within our healthcare system, should be understood for exactly what it is: Deceptive, undermining propaganda. Other questions: Who is it that pays the providers’, doctors or others, salaries? For whom do they work? Are these providers independent, meaning that the patient is the employer? Or do they work for hospitals, integrated health systems, or health management plans, which, because they pay the salary, can interfere with medical decision making?

Principle (1) (last sentence) All Vermonters must receive affordable and appropriate health care at the appropriate time in the appropriate setting, and health care costs must be contained over time. Wow! Just, who is it that defines appropriate? Do you think that the governor and the legislators are going to go see a provider for their illnesses, or do you think they are going to obtain, for themselves, immediate appointments with real doctors, who will often be specialists?

Good luck Vermonters! I can tell by the smoke and mirrors of this politically correct, official, altruistic sounding rhetoric that you are going to need it.

R. Garth Kirkwood, MD


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