by Hamilton E. Davis
The Vermont healthcare reform project is about to enter its 13th year, shrouded in a miasma of uncertainty, fear, misinformation, sheer incompetence across the playing field, and risk to both the hospital system and the state’s economy itself. It is a panorama of paradox: there has been considerable progress made, more than in any other state. Yet every player is playing badly—the Governor is not involved; the Green Mountain Care Board is deeper in the weeds than it has ever been; the Legislature is deeply concerned, but has no trajectory; the press is clueless.
That bleak prospect does not mean that the issue is hopeless, only that getting the project on track will be very hard. Many of the issues will have to be resolved this fall, and it is possible, even likely, that the only player that can right the ship will be the Legislature, which could be in the reform crosshairs when it reconvenes in January. The Green Mountain Care Board itself is embarking on what it describes as a broad-gauge effort to develop a “sustainable” system, in which each of the state’s 14 hospitals will offer an array of services that make sense medically and financially.
Vermonters should applaud that effort, but it will be hideously difficult because imposing a rational template on a massively over-bedded system would be a political tsunami. We now waste $300 to $500 million a year on our horse and buggy system, but clawing even some of that back would require dipping into local pockets across the state. And the Board’s performance so far has been simply atrocious. Moreover, the deep medical expertise necessary to move from the mess we have now to a viable 21st-century model exists only at the academic medical center level. And ours, the UVM Network, is itself a huge problem. The medical expertise is still there, but the whole contraption has proven, so far, to lack the ability to navigate its own environment politically.
So, what should my tiny corps of brilliant readers think about this? Herewith my suggestions about how to squeeze the whole nettle:
From the outset of reform, when Peter Shumlin ascended to the Governor’s office in 2011, there has been a lack of clarity about what healthcare reform actually means—what it would look like and how would it work. I will deal with that issue in a short post in the next day or two.
As I indicated above, there are many players and issues involved. I will deal with each one separately. First will be Governor Shumlin, and then his successor, Phil Scott.
Then the Green Mountain Care Board. There have been three iterations of that, each of which has been markedly different from its predecessor.
The senior management of the University of Vermont Health, especially the flagship Medical Center Hospital in Burlington. The lines trying to get treatment at the Burlington Medical Center are out the door, down the street, around the block, and headed now for another area code…without a credible word about a solution. And the senior management appears to have no ability to cope with the political whitewater it has to navigate.
The legislature is concerned about reform, but has no clear idea, at least so far, how to approach it. Paying for primary care has some support, but the money there would be a killer. Primary care amounts to just five percent of the nearly four-billion dollar annual health care bill, but do the math.
The hospital industry machinery, in the “person” of VAHHS—the Vermont Association of Hospitals and Health Systems—has been focused entirely on protecting all 14 hospitals as full-service providers in a state that needs, at most, three for four. The costs of that are hundreds of millions of dollars wasted each, year, not to mention fronting for significant volumes of low-quality medicine. The obvious answer—step down the majority of full-service facilities to clinics that meet local needs—scares everybody.
The press is clueless, so the public has no grasp of an issue that concerns everybody.
The minor players, like the State Auditor and the Health Care Advocate make some noise occasionally, but their contribution to debate has been minimal. And the performance of the non-player peanut gallery has ranged mostly from irrelevant to just strange.
In addition to the players, there are a number of gnarly issues that overarch the reform space. How do you measure the quality of care, for example? What effect is the Canadian experience having on reform? What influence does national policy have on the Vermont system?
There are a couple of potential paths forward, but they are problematic. There is a movement in the state to press for a breakthrough, but nowhere near a critical mass yet. Hope for the best, but the odds at this point favor stasis, and in the case of healthcare reform, stasis means decline.
So, fasten your seat belt.
A note to my tiny corps:
In a shift from past practice, these posts will be much shorter, and will include just the evidence necessary to make a given point.