by Hamilton E. Davis

The Vermont health care reform project that was born in 1983 crested over the last six months and is now becalmed, ahead of any other state, but well short of the goal of a 21st century system that delivers high quality care at an affordable price. Nothing structural stands in the way of reaching the goal.

Unfortunately, however, all the major players and most of the minor ones are playing really badly, which means that Vermont could just drift for two, three or more years, wasting at least $300 million a year and putting up with dodgy quality across much of the system. We won’t see any real movement before the Green Mountain Care Board considers the Fiscal Year 2023 hospital budgets in September of this year and nothing in the record so far augers well for anything definitive then.

This seems like a good time, therefore, to sum over the reform issues as they evolved recently, especially because some of the most important have never surfaced in what now passes for a Vermont press corps. I lay each one of those out in detail over the next several weeks:

Reform Issues

A major complexity of the reform project is that the Green Mountain Care board has two responsibilities—one is as a conventional regulator of hospital spending; the other is as the point of the reform spear. The single most important action by the Green Mountain Care Board has been to drain the financial strength out of the UVM Medical Center in Burlington. The performance on the UVMMC budgets since 2017 indicts the Board for reckless incompetence. Two particulars before a full analysis of that question: UVMMC has the highest quality and the lowest per capita costs in the Vermont system; yet the Board regularly cuts UVM’s ability to recoup its costs. The Board has cut UVMMC’s requested increase in insurance payments in 5 of the last 6 years. There is no evidence that the Board set out to damage UVMMC’s ability to deliver necessary care, but that has been the result. By underfunding the state’s most important, and cost-effective hospital, it has rendered the reform effort more difficult, and may have doomed it altogether.
One of the most egregious failures in the whole reform experience has been the refusal of Governor Phil Scott to confront the whole reform head on. I asked the Governor about that in a private interview late last year and his response was that he didn’t think Vermont needed the Green Mountain Care Board at all. The current system, he said, was designed in 2012 to meet the requirements of former Gov. Peter Sumlin’s Single Payer reform model; and since that effort died in 2014, the whole exercise looks redundant.
Of course, the Scott administration couldn’t simply walk away, so Scott’s Agency of Human Services (AHS) has had to deal with a range of practical questions that arose from the reality that reform continued in the wake of the failure of Shumlin’s Single Payer project. That responsibility devolved to the various AHS secretaries—first, Al Gobeille, then Mike Smith, and in 2022, Jenny Samuelson. I’ll lay out that performance in a future post, along with a full account, including a transcript, of my interview with Governor Scott.

A major failure of the Green Mountain Care Board, along with the Scott administration, has been its refusal to act on its responsibility to reshape the rest of the delivery system financially and medically. That can probably be ascribed to sheer political terror. Vermont has 15 full-service hospitals (including Dartmouth-Hitchcock Medical Center in New Hampshire, which serves eastern and central Vermont) and it only needs four. The remainder should be clinics of varying sizes.
On Oct. 27 of last year, the Green Mountain Care Board received the reports of a squadron of health policy consultants who provided a wealth of data to support the above conclusion. A couple of examples: In the state’s 13 technically rural hospitals (UVMMC is urban) an average of 30 percent of its care was judged to be unnecessary. And several of those hospitals were doing some surgeries in numbers far below what’s necessary to ensure competence. It’s critical that the public weigh in on the question of whether they want to pay outrageous unit costs for questionable quality surgeries.

Of course, there are more players involved than the Green Mountain Care Board and the Scott administration. The Legislature is a huge player, though so far more potentially than actually. The state’s hospitals outside of the UVM health network are critical players; in fact, the interests of the UVM Network hospitals can and often do diverge from the rest of the hospitals. And, to date, the non-Network hospitals have functioned with far more political coherence than the UVMers. A third personification of the hospitals is OneCare Vermont, which nobody appears to understand. The Vermont Auditor and the Health Care Advocate have a voice, which to me seldom make sense. Of course, Vermont Blue Cross and Blue Shield has huge influence owing to their direct or indirect coverage of a third of the state’s residents.

Anomalies abound. The “press” writes extensively about some developments and events, and nothing about others. UVM’s Medical Center and its Network hospitals (which include Central Vermont Medical Center in Berlin and Porter Medical Center) routinely and unfairly get excoriated by other players, but have never been able to tell their own story adequately…

Hence the need for this overview, which I will complete by the end of April. Promise.