by Hamilton E. Davis
One of the knottier problems in assessing health care reform in Vermont is figuring out the role played by Governor Phil Scott. Since coming to office in 2017, Scott has come in and out of focus, staying hands off, then engaging in a sort of positive way, then shifting from warm to cold and back again.
That all sounds kind of mysterious, of course, but given that the reform project now is more political than policy-driven, Scott’s posture over the next six months could be decisive, either to leave reform in limbo or to break through to a sustainable delivery system that would be a model for the country. It is pretty easy to follow the meandering track Scott has left so far, but impossible to predict where he goes next. The Scott posture is worth examining, however, because it could affect the other key players, like the Legislature, the Public, the Green Mountain Care Board, and the healthcare industry itself. Let’s give it a try.
The reason why Scott is Governor in the first place is the health care reform project. The father of the effort was former Governor Peter Shumlin. Shumlin ran for office in 2010 and won a very close race against several credible opponents on the strength of his advocacy of a Single Payer system for Vermont’s doctors and hospitals. He steered his plan through the legislature in 2011 and got off to a good start. In 2012, he won a second term decisively and picked up momentum to the point that there was speculation that he might be a Democratic candidate for President. Health care reform is a long-term effort, of course, but Shumlin appeared set for an extended tenure, like Howard Dean who served for 12 years, and Jim Douglas, his immediate successor, who spent eight.
It all went south for Shumlin in 2014. He botched the opening of a federal subsidy for health insurance and then failed to figure out how to finance a full-on Single Payer plan, in which state government would pick up the private sector’s share of the cost of the acute care system. His political credibility gone, Shumlin barely won reelection to a third term against a marginal candidate and retired from politics before the 2016 election.
Shumlin’s Lieutenant Governor was Phil Scott, a Republican from Barre, a tall, regular guy, a formidable race car driver at Thunder Road, and the operator of a small construction company. He wasn’t a public policy maven, but he was respected and everybody liked him, including Shumlin. So, when Shumlin blew up, the one left standing was Scott, who ran in 2016, and won solidly.
When Scott took office in January of 2017, the world thought that reform had died in Vermont, which it hadn’t. Shumlin was gone, and so was the Single Payer idea, but the reform launched in 2011 was still alive. Both Scott and his new chief of staff, Jason Gibbs, however, wanted nothing to do with it. They understood perfectly that healthcare reform had wrecked Shumlin’s career; whatever the implications of that, a project like Vermont’s reform was anathema to Gibbs, a combative conservative. So, Gibbs and Scott did what they had to do: they named a new Green Mountain Care Board chair, and a couple of new members, and otherwise ignored the whole process.
The AHS Conundrum
It is important at this point to look at a sort of kink in Vermont state government that has become an important factor in the reform project. Governor Scott and his staff run state government from Montpelier, but his Agency of Human Services operates out of a sprawling complex of buildings in nearby Waterbury. Moreover, the reform structure gives an outsized role to the Secretary of AHS; that person, for example, is a signatory to the reform arrangements with the federal government…We can fast forward here by saying that the Scotties have had three AHS secretaries under Scott, all of them with dramatically different approaches.
The present incumbent is Jenny Samuelson, who took the AHS helm early in 2022. Samuelson is intense, aggressive, and committed to health care reform, but with some important differences with her predecessors, particularly in their relations with the Governor’s office. Samuelson understands clearly that she works directly for Gibbs, who has been almost completely detached from the reform project, but who has retained some important powers, such as naming new members to the Green Mountain Care Board. Asked about her role in that issue, Samuelson said she had no involvement at all.
She does manage all the details in the day-to-day processes, and they are extremely complex, but our focus today is on where Scott stands on reform.
As I’ve said, his involvement has varied over time, with much of the progress reflecting the postures of the AHS secretaries. That all changed dramatically, however, on June 1 of last year. On that day, Scott wrote a letter to the Green Mountain Care Board ripping its performance to date, promising to “hold the Board accountable” for getting better results for Vermonters, and to drive all that home, announced that he would create a committee of senior healthcare experts to provide advice on how to accomplish that. The leader of that effort, Scott said, would be Samuelson; the process would be fully transparent, and the results would be announced to the public. Well, that was quite a shift in direction from the first four years of Scott’s tenure. The questions for today are: what led to the pivot, what has the advisory group accomplished, and where do we stand today?
What led to the change in direction? I cannot be sure exactly, since getting information out of government has become difficult. My sense, however, is a major factor was the drumbeat of criticism of the Board’s performance from the hospital industry, especially in the period when Covid dominated our community life. Jeff Tieman, then chairman of the hospital association, hammered the Board for putting his members under unnecessary pressures when they were struggling to cope with the virus. I think another factor was that Dr. John Brumsted, the CEO of the UVM Health Network, had convinced Scott that his organization was being so starved for revenue that its mission was in danger, that without a change in the Board’s attitude toward 60 percent of the state’s delivery system, the UVM Network could be forced to close some vital services, which would have to be obtained out of state, at enormous additional cost.
Whatever the reasoning process, the operations of the advisory group got underway last July, and significant chunks of Scott’s plan didn’t survive the political reality on the ground. The original scheme called for there to be eight to ten members, with important leadership from Doctor Brumsted, by far the most credentialed medical and corporate leader in the state. Well, Brumsted agreed to serve, but every healthcare interest group and lobby clamored to be allowed onboard. Result, 26 members, not eight or ten.
The second Scott assurance didn’t last either. The idea of just any old person attending the meetings of the august group spooked the Scotties, so no actual transparency. The meetings would be closed to the public, but Samuelson’s staff would provide regular notes on the content of the meetings.
That also turned out to be a chimera. The “notes” were just a few snippets, with no information about the author of the snippet nor any context anyone could use to discern the development of policy. And Samuelson, who was willing to discuss the reform issues at length shortly after she took office, will no longer return my calls. What I can discover indirectly is that Samuelson is heavily focused on the operations of the Designated Agencies, the ones that combine some medical issues in conjunction with other concerns like poverty and homelessness.
A second area of focus for the AHS Secretary has been on how to maximize the revenue available from federal Medicare officials to support the delivery of acute care; that would be of great benefit to the UVM Network, especially because of its status as an academic medical center. But the size of those revenue flows, and whether they are an adequate replacement for ordinary revenues in hospital businesses is unclear at this point.
So, whither Phil Scott today? The only thing I have any confidence in is what Scott told me in a one-on-one interview in November of 2021. I have not published this before, but I checked recently with Jason Maulucci, Scott’s press secretary, who told me the Governor’s views haven’t changed. I’m paraphrasing here, but this is what he said:
I don’t see any reason why we need a Green Mountain Care Board at all. We designed the Board to regulate a Single Payer system, and Single Payer is gone. So, why do we need it?
Given that position, will the Scotties try to get rid of the Board? Well, Scott didn’t say, and it doesn’t really matter because as things stand now, there is no chance the Legislature would buy into such a proposition. Democrats have veto-proof majorities in both chambers, and the Board has been popular there.
The only break from the current stasis can arise from sentiment in the Legislature itself. Is that likely? Not now. Is it possible? Yes, but that is an issue we’ll look at in a forthcoming article.