A retired physician, a public health academic, and a psychiatrist who practices in New Zealand walk into a bar. They want to redesign your doctor’s practice.
This isn’t a joke. It’s a Press Herald op-ed from May, and it deserves a response from someone who actually sees patients in Maine.
The piece, written by the co-chairs of Maine AllCare, makes a genuinely interesting argument: Maine already passed a universal healthcare law in 2021. We just forgot to turn it on. (Read it here) The 130th Legislature enacted something called the Maine Health Care Plan — a framework for state-based universal coverage — but buried a trigger clause inside it requiring federal legislation to pass first. Since Congress hasn’t done that (and under the current federal government, isn’t going to), the law just sits there, loaded but uncocked.
Maine AllCare’s proposal: remove the federal trigger. Activate the board. Let Maine be Maine.
It sounds simple. It isn’t. And before I explain why, let me say something clearly: the Maine healthcare system is broken. Premiums are catastrophic. Rural access is collapsing. The uninsured get squeezed out, the insured get surprised billed, and physicians spend half their working hours fighting insurance companies instead of seeing patients. I left that system in 2014 because I couldn’t tolerate it. Maine AllCare is not wrong about the problem.
They’re wrong about the solution. And the proof is sitting in the actual text of the legislation they want to build on.
Vermont Called. They Want Their Cautionary Tale Back.
Before we get to Maine’s specific bill, let’s spend a moment in Vermont, because single-payer advocates are going to make you forget this happened.
In 2011, Vermont passed Green Mountain Care — the nation’s first state-level single-payer framework. Governor Peter Shumlin signed it. Democrats celebrated. Single-payer advocates declared victory.
Then someone actually ran the numbers.
Green Mountain Care would have cost $4.3 billion in its first year. Vermont’s entire state budget at the time was $5.01 billion. Funding it would have required an 11.5% payroll tax on businesses and a new income tax of up to 9.5% on workers — a 151% increase in total state taxes. In December 2014, Shumlin killed it before it ever launched.
Single-payer advocates will correctly point out that the plan never failed in operation — it was killed before implementation, so you can’t technically call it a failed system. Fair enough. But here’s what you can say: Vermont built the framework first and figured out how to pay for it later. The legislature punted the financing question from 2011 to 2012 to 2013 to 2014, and nobody was willing to actually vote for the taxes required to make the math work. When the bill finally came due, they folded.
What came after isn’t inspiring either. The Green Mountain Care Board survived but pivoted to a modest multi-payer ACO pilot — years of political capital spent, the single-payer plan dead, and what emerged from the wreckage was incrementalism with better branding.
Maine is smaller than Vermont. Our tax base is older, more rural, and lower-income. The math will not be more favorable. But Maine AllCare wants to build the framework first and figure out how to pay for it later.
If that strategy sounds familiar, it should.
The “Board Will Fix It” Problem
Here’s what the Maine AllCare op-ed proposes: activate the Maine Health Care Board, let them design a plan, study the economics, seek federal waivers, and bring it back to the Legislature. Sounds reasonable. Democratic, even.
Except the board’s composition tells you everything you need to know about whose interests will shape whatever comes out of it.
Under LD 1883 — the most detailed Maine single-payer proposal, which Maine AllCare backed in 2025 — the 20-member board would include four patient representatives, three employers, one attorney, one health economist, one public health expert, and ten “provider” seats. Of those ten “provider” seats: one goes to hospitals. Three go to physicians, “at least one of whom must be a primary care provider.”
Note that word carefully: not “physician.” Provider. Maine AllCare knows the difference between a physician and a “provider.” If they meant physician, they would have written physician. They’ve been in this fight since 2010. The word choice is not an accident.
Under this bill, the primary care seat on the board that sets your reimbursement rates could be filled by a nurse practitioner, a physician assistant, or — for all the bill specifies — a CNA from a nursing home. Anyone the governor decides qualifies as a primary care “provider” checks the box. One seat. Possibly not a physician. On the body making every consequential decision about how medicine gets practiced and paid for in Maine.
This is the same move hospital systems have been running for years: blur the credential, flatten the hierarchy, treat a clinician with 600 hours of training and a physician with a decade of it as interchangeable “providers” — because interchangeability is cheaper and easier to staff. The bill doesn’t fix that dynamic. It builds it into the governing structure.
One primary care “provider” seat. On the body that sets your reimbursement rates, defines covered services, and — more on this in a moment — decides what you’re legally allowed to do outside the system.
Meanwhile, MaineHealth and Northern Light Health — the two systems that have used Certificate of Need legislation to prevent competition, that have closed rural services while posting operating losses and paying executives accordingly — get their interests represented through a hospital seat on that board, through the attorney seat, through the employers, and through every informal conversation with every governor’s appointee between now and the day the plan launches.
The board doesn’t write the plan in a vacuum. It writes the plan in Augusta.
“May Participate” Is Not What It Sounds Like
Let me show you something from the actual bill text. Section 7809 of LD 1883, on “provider” participation:
“All health care providers licensed to practice in this State… may participate in the All Maine Health Plan.”
May. Not shall. Participation is voluntary. The advocates will tell you this is physician freedom.
Read the next sentence.
“Providers who accept any payment from the All Maine Health Plan for a covered health care service may not bill the patient for the covered health care service.”
And the private insurance provision:
“An eligible individual may purchase an insurance policy to provide coverage for services not covered under this chapter.”
Here’s the problem: the plan covers everything. Inpatient, outpatient, diagnostics, drugs, dental, vision, mental health, substance use, chiropractic, acupuncture — it’s all in there. Private insurance is technically permitted, but only for services the plan doesn’t cover. Since the plan covers essentially all of medicine, private insurance becomes legally vestigial. There’s nothing left to insure.
So participation is “voluntary” in the same way that opting out of Medicare is voluntary. You can do it. But you’ll do it alone, in a state where every patient you see is enrolled in a system you’ve rejected, and where the payer landscape has been absorbed entirely into a single government fund.
Here’s what that means in practice — not for me, but for my patients.
I practice Direct Primary Care in rural Maine. My patients pay me directly, monthly, with no insurance involved. No billing department. No prior authorization. No middleman between physician and patient. The majority of my panel is uninsured — people who, under the old model, had no real access to a primary care physician at all. Under DPC, they do. That’s not a side effect of the model. That’s the point.
LD 1883 has no lane for those patients. The entire framework presumes insurance as the background condition, with the state replacing private insurers as the single payer. A model that works precisely because it removes insurance from the equation doesn’t fit the architecture. The patients currently being served by that model — the ones everyone in this debate claims to be fighting for — lose access to it the moment this system absorbs the entire payer landscape.
Nobody in the Maine AllCare proposal addresses that. Not as a problem to solve. Not at all.
The Ambiguity Is the Point
Here’s the part that should make every independent physician in Maine uncomfortable.
Section 7810 of LD 1883 gives the board authority to establish conflict-of-interest standards “prohibiting providers from any financial benefit from their medical decisions outside of board reimbursement.”
That sentence is ambiguous. Deliberately so, I’d argue.
Does “financial benefit outside of board reimbursement” include a monthly DPC membership fee? A direct-pay urgent care visit? A cash-pay procedure? The bill doesn’t say. Maybe they meant to target kickbacks and self-referral — that would be a reasonable reading. But that’s not what they wrote. What they wrote is broad enough to cover any financial arrangement outside the plan, and the board decides what it means. In rulemaking. Later. With one primary care seat out of twenty at the table.
In administrative law, ambiguity isn’t a drafting error. It’s a grant of authority. You write the broad mandate into statute — the legislature debates it, passes it, signs it into law — and then the board fills in the definitions quietly, through rule-making, with far less public scrutiny than a legislative hearing ever provides. By the time you find out what “outside of board reimbursement” means for your practice, you’re already out of compliance.
They wrote the ambiguity. They own what it becomes.
Nobody Is Asking the Right Question
Here’s what nobody in this debate seems willing to say out loud: changing the payer doesn’t fix the delivery system.
Every single-payer proposal assumes insurance companies are the problem. Replace them with a government fund, eliminate administrative overhead, cover everyone — done. And yes, the administrative waste is real. Yes, prior authorization is a catastrophe. Yes, insurers deny care for profit and call it utilization management.
But the delivery system underneath all of that — fee-for-service medicine, RVU-based productivity, hospital consolidation, the systematic undervaluation of primary care — that’s still there. You haven’t touched it. You’ve just changed who writes the check.
Consider what Maine is actually working with. There were 630 family medicine physicians in Maine in 2024 — down from 710 in 2019. Maine is projected to be short 120 primary care physicians by 2030. Nearly a third of the primary care doctors we have now are over 60. In the most rural counties — Oxford, Somerset, Washington — the physician-to-patient ratio is less than a third of what it is in Portland. Maine has no MD-granting medical school. Only 35 primary care residency slots per year, and nearly half of those residents leave the state.
Single-payer doesn’t fix any of that. It changes who pays the physicians we don’t have. You can’t insure your way out of a workforce crisis, and you can’t legislate physicians into existence. If Maine builds a universal payment system on top of a primary care desert, you get universal coverage and nobody to call. The waiting room gets bigger. The wait gets longer. The physicians who are left burn out faster, because the structural conditions that drove burnout — the administrative burden, the RVU treadmill, the moral injury of practicing inside a system that doesn’t value primary care — those conditions don’t change when you swap the payer.
My practice exists because I decided, in 2014, that I wasn’t going to wait for a board to fix it. No insurance billing. No prior authorization. No middleman. Direct access to a physician, for a flat monthly fee, for patients who under the old model had no real access to primary care at all.
That model — Direct Primary Care — which the AAFP’s own data shows delivers 94% physician satisfaction while restoring real access to a doctor, doesn’t appear anywhere in the Maine AllCare proposal. Not as a complement to the system they want to build. Not as a model worth preserving. Not at all.
If Maine wants to actually move the needle on access, the path isn’t a new government board with a blank mandate and an ambiguous conflict-of-interest clause. It’s investing in primary care infrastructure — more residency slots, loan forgiveness tied to rural practice, CON reform to break hospital monopolies on outpatient services, and preservation of practice models that are already working. DPC alone can’t solve the access crisis. But a universal payment system built on a collapsing primary care workforce won’t either. You need both the payer reform and the delivery reform, and right now Maine is only talking about one of them.
A Word About Who’s Driving This Bus
The May op-ed was written by Tom Sterne, MD — a retired primary care physician from Bridgton — and David Jolly, DrPH, a public health academic who spent his career in HIV/AIDS work and university education. They’re co-chairs of Maine AllCare.
Maine AllCare’s co-founder and most prominent physician voice is Dr. Julie Pease, a psychiatrist who practiced in Maine for over 25 years. She currently practices part-time in New Zealand, a country that has had single-payer universal healthcare since 1948.
I want to be fair here. These are not bad people. They are not wrong about the problem. The Maine healthcare system is expensive, inaccessible, and getting worse. The instinct to fix it is correct.
But the people designing the framework for Maine’s healthcare future are a retired physician, a public health academic, and a psychiatrist who practices under the very system she wants Maine to adopt — in another country. None of them are currently practicing primary care in rural Maine. None of them are seeing the patients who would live inside whatever gets built.
I am. And what I can tell you, from the exam room rather than the op-ed page, is that the plan Maine AllCare is proposing would replace one set of administrative masters with another, hand the rate-setting authority to a board where primary care has one seat out of twenty, and leave the structural undervaluation of primary care exactly where it was — while eliminating the only practice model that’s actually working for the patients everyone says they’re trying to help.
Fix the payer if you want. But if you build a new payment system on the same broken foundation, you haven’t fixed anything. You’ve just handed a different set of people the keys to the same car — and asked the physicians to keep driving it off the same cliff, for rates to be negotiated later, by a board, on a Tuesday.
I’ll pass.
