Vermont’s healthcare debate often centers on premiums, hospital budgets, reimbursement rates, and workforce shortages. Those are real and urgent issues. But, beneath them lies a quieter truth. In rural communities especially, preventable suffering and fiscal instability are symptoms of the same structural misalignment. Healthcare-related spending, driven largely by Medicaid, represents one of the largest components of Vermont’s state budget and a major driver of its growth, according to the Vermont Joint Fiscal Office. Yet hospitals are strained, families struggle with affordability, and too many Vermonters still face barriers that have little to do with clinical care, such as:
● Transportation gaps
● Housing instability
● Behavioral health access delays
● Workforce scarcity
● Fragmented navigation across systems
● Childcare shortages (although better than they used to be due to recent legislation).
These are not side issues. They are infrastructure. And, when we underinvest upstream, we pay downstream in emergency utilization, increased cost of delayed treatment, clinician burnout, and rising public costs. Preventable suffering is expensive.
Rural Reality Is Different
In Vermont, healthcare institutions do more than deliver services. They anchor local economies, employ neighbors, and stabilize communities.
But, rural systems operate on thin margins and serve older, often sicker populations. As noted in the Oliver Wyman report entitled Act 167 Community Engagement: Recommendations, dated Aug 2024 and updated 1/30/25 (the “Oliver Wyman Report”), nine of Vermont’s fourteen hospitals reported operating losses in 2023, with projections worsening in the years ahead. That financial strain is not abstract. It affects workforce stability, service availability, and long-term access.
When a patient misses follow-up care because transportation isn’t reliable, outcomes worsen and costs increase. When housing instability exacerbates chronic conditions, utilization rises. When behavioral health access is delayed, crises escalate. These are human stories. They are also budget stories.
We often debate reimbursement formulas and hospital consolidation. But, unless we address the social and structural drivers of health, we are designing around the problem rather than solving it.
Care Is Not the Same as Health
Vermont has long worked to expand access to care. But, today, long wait times, workforce shortages, and uneven geographic coverage make clear that access remains fragile, especially in rural communities. And, access to appointments is not the same as access to stability.
While we reimburse visits and procedures, we do not consistently reimburse housing stabilization, transportation access, preventive coordination, or community-based supports — even though those investments often reduce downstream costs.
Lawmakers have spent the past two legislative sessions focused heavily on housing affordability and supply — and rightly so. Healthcare sustainability has also been a sustained focus in Montpelier, with ongoing debate around payment reform, system structure, and proposals such as universal primary care.
The Green Mountain Care Board’s relatively recent independent assessment by Oliver Wyman reinforces the urgency of these debates. The Oliver Wyman Report identifies three imperatives for transformation, beginning with building housing capacity and fixing transportation infrastructure, alongside payment reform and shifting care out of hospitals. It also documents significant levels of avoidable emergency department use and preventable inpatient admissions, underscoring how upstream gaps translate directly into system strain.
That analysis provides an important framework. The opportunity now is ensuring that reform efforts, whether in payment design, primary care expansion, or workforce planning remain structurally aligned with the upstream conditions that drive utilization in the first place.
Fiscal sustainability and human outcomes are not competing priorities. They are interdependent. If we want to slow cost growth in a meaningful way, we have to address the drivers of utilization before someone reaches a crisis point.
We can’t communicate our way out of structural gaps
As someone who has worked alongside rural healthcare marketing and communication leaders in Vermont and elsewhere, I’ve seen how often institutions are asked to manage structural constraints through communication alone. Granted, clear and transparent messaging matters on myriad levels. But, no campaign can compensate for misaligned incentives. No branding effort can fix transportation gaps. No outreach strategy can replace behavioral health infrastructure.
Healthcare reform in Vermont must widen its lens. This is not, however, a call for sweeping ideology. It is a call for alignment. Alignment between:
● Incentives and outcomes
● Community realities and funding structures
● Prevention and reimbursement
● Fiscal prudence and human dignity.
We simply cannot continue asking hospitals, taxpayers, and families to absorb costs that originate upstream.
A Vermont path forward
Vermont has long valued pragmatic problem-solving and community-rooted leadership. Healthcare reform should reflect that same mindset.
Upstream investments in housing stability, transportation access, behavioral health integration, and preventive infrastructure are not peripheral to healthcare sustainability. They are central to it.
Addressing social determinants of health is often framed as a moral argument. It is that, but it is also a fiscal argument. When we reduce preventable crises, we reduce high-cost utilization. When we stabilize housing, we stabilize health. When we align incentives with prevention, we ease long-term budget pressure.
In rural communities especially, preventable suffering and fiscal strain are inseparable. They are products of the same design. If we are serious about healthcare sustainability in Vermont, the debate cannot stop at hospital budgets or premium rates. It must include the conditions that shape health before someone walks through a clinic door.
This is not a partisan issue. It is a design issue. And, it deserves a broader, sustained conversation among healthcare leaders, policymakers, employers, community organizations, and taxpayers alike.
Because in the end, preventable suffering is expensive, and sustainable systems are built upstream.
Related perspectives on Vermont healthcare transformation
Transforming Rural Healthcare Means Transforming the Conversation
How Will We Know if Vermont’s Healthcare Reforms Are Working?
Mark Crow is President of Tenth Crow Creative, a brand strategy, design, and marketing agency serving health and wellness organizations, with a particular focus on rural and small healthcare systems. We help these organizations clarify who they are, align their messaging, and communicate with confidence and purpose. Through strategic branding and messaging, thoughtful design, and integrated marketing, we strengthen external presence and internal clarity. The result: stronger connections with the communities these organizations serve and greater momentum behind their missions.