Vermont ended a nearly decade-long experiment in health care payment reform when 2025 closed out, and the state is now grappling with what nearly $100 million and eight years of effort actually bought.
The “all-payer model” launched in 2018 under an agreement between Vermont and the federal Centers for Medicare and Medicaid Services. The idea was straightforward, at least on paper: align insurers and providers around a shared goal of preventive care, and move away from the fee-for-service model that rewards volume over outcomes. OneCare Vermont, an accountable care organization, sat at the center of the effort.
The gap between that vision and what the model delivered grew steadily over the years. By the time the agreement expired at the end of 2025, OneCare Vermont had been reduced to a skeletal operation, and the state is now searching for a path forward in health care reform.
For public health advocates and students watching closely, the experiment raises urgent questions. What does it mean when a state invests heavily in a structural health reform model and it still falls short? And what do communities, especially those with the least access to care, lose in the process?
Tom Borys, OneCare’s CEO, appeared before the Senate Health and Welfare Committee in late January to offer some answers. He urged lawmakers to carry forward what the organization learned, particularly from its Comprehensive Payment Reform program, nicknamed CPR. That program rethought how primary care physicians get paid, shifting away from per-service billing toward a fixed monthly payment. The goal was to encourage providers to focus on keeping patients healthy rather than waiting until those patients were sick enough to require expensive treatment.
S.197, a bill currently working through the Vermont Legislature, proposes a similar approach. Participating primary care providers would receive a fixed monthly sum rather than individual service payments. The structure attempts to reorient financial incentives toward population health, a shift that public health researchers have long argued is necessary for any meaningful reform.
Borys was supportive but measured in his testimony. He acknowledged the CPR program did meaningful things for independent primary care practices. He also warned lawmakers not to underestimate the administrative demands the approach requires. That administrative weight was one of the persistent challenges OneCare faced throughout its existence.
The stakes here go beyond Vermont’s policy debates. Fee-for-service medicine has driven American health care costs upward for decades while producing uneven outcomes. Communities of color, rural populations, and low-income patients consistently bear the consequences of a system that profits more from treating illness than preventing it. Vermont’s model tried to change that calculus at a systems level. The fact that it struggled does not make the goal wrong. It makes the design questions more urgent.
Primary care is the foundation of any functioning health system. When people can see a doctor regularly, catch conditions early, and manage chronic illness before it becomes a crisis, they live longer and healthier lives. The all-payer model understood that. The challenge was translating that understanding into a payment structure that providers, insurers, and the federal government could sustain together.
S.197 draws from those lessons. Whether Vermont’s legislature can build something more durable than its predecessor depends on how seriously lawmakers engage with both the promise and the friction of the earlier model. Borys offered a realistic picture of both. The administrative burden alone requires honest planning, not just optimism.
For those of us tracking health equity, the story of Vermont’s all-payer model is a case study in the distance between policy ambition and community impact. The model aimed at systemic change. It ran into systemic resistance, from administrative complexity to the structural weight of a fee-for-service culture that does not give up ground easily.
Vermont now has a chance to try again, this time with the benefit of a hard-won record. If S.197 moves forward with clear eyes about what failed and why, it could represent genuine progress. The communities who rely on accessible primary care cannot afford another experiment that runs out of steam before it reaches them.
