WASHINGTON, D.C. - For almost three decades, thousands of ailing and aching folks in the Northeast Kingdom, many of them without health insurance, have had their throats checked, their prescriptions filled, their broken legs set and their teeth fixed thanks to an idea - or an obsession - that David Reynolds developed in the 1970s.

Now Reynolds has a new assignment: Do the same thing for the whole country.

Well, that's not the official job description. But when Reynolds says his new boss told him he "wants nothing less than reform of the entire health-care system," he's only half joking. So was the new boss.

Reynolds' new job, according to an official press release, is "Chief Health Care Policy Director" for Vermont's new senator, Independent Bernard Sanders. But the job description itself is one that Sanders created. Senators, even the ones on the Health, Education, Labor and Pensions Committee, don't automatically get health-care policy directors, with or without the capital letters.

Both the appointment and the credentials of the appointee provide strong evidence that Sanders is not going to let his rookie status discourage him from making as much noise as he can about the health-care system until everyone is covered and prescription drugs are cheaper. It's a tall order, but one that Northern Counties Health Care, established by Reynolds in 1976, has come close to fulfilling on a local level.

"It was me and a secretary with a $30,000 government grant for planning," Reynolds says, recalling the early days of his organization. "This was an area where people had no access to care whether they had money or not. We met with community people. Each community donated a center. They were fixed up with sweat equity. It was exciting."

Northern Counties is now a $14-million-a-year operation; its six community health centers in St. Johnsbury, Danville, Concord, Hardwick and Island Pond provide medical and dental services to some 20,000 people. Only 11 percent of its budget comes from federal grants, Reynolds says. Otherwise, the services are financed in the same way as most health enterprises, by payments from Medicare, Medicaid and private insurance.

In a place such as Essex County, where Northern Counties provides all local health services, meeting that kind of demand is a lot harder to do than say.

"It's amazing what it takes to recruit and sustain providers in rural areas," says Jeanne Keller, of the Burlington health-care consulting firm Keller and Fuller. "It's like recruiting a star athlete. You have to be able to give the spouse a job. You have to keep changing reimbursements according to what works and what doesn't. The Northeast Kingdom is the area of the state with very high levels of the uninsured. It's hard to keep the fiscal balance with all those people walking in the door without insurance."

Keller says Reynolds is so highly regarded by health professionals in the state that some of them wonder how Northern Counties will fare without him. While Reynolds finds such talk "very flattering," he offers assurance that his organization is strong. "I wouldn't have done very much if it couldn't continue without me," he says.

A Connecticut native with degrees in health administration from the University of Michigan, Reynolds will work out of a Montpelier office, closer to his St. Johnsbury home than to Washington, D.C. While he won't be able to avoid frequent trips to the larger capital, he says he hopes to bring a beyond-the-Beltway perspective to the discussions there.

The appointment indicates Sanders' pragmatism as much as it does his commitment to universal health care, which has been plain for years. Sanders has made it clear that, essentially, he wants Medicare for everyone - one single, universal, government-paid arrangement. To implement that, he won't need an expert, just the votes.

But it's equally clear that the necessary votes aren't available. In creating this new position and appointing Reynolds to fill it, Sanders is effectively conceding that health coverage will have to be expanded in steps, not all at once. A possible first step might be covering more children.

Reynolds seems to understand. "We tend to do best in this country when we do [things] incrementally, rather than try radical change," he says. But he leaves little doubt that he, too, will look carefully at using an expanded Medicare system as the foundation for broader coverage.

"We really have a system to build on," Reynolds explains. "Medicare has one of the lowest administrative structures. It pays in a timely way. It seems to be a well-run program."

He'll get quite an argument on that from most Republicans, and some Democrats, in his new job. "I think I have the ability to negotiate with folks," Reynolds says. He's chosen to put that ability to a stern test.