Devil’s in the Details in Vt. Health Care Reform

Valley News Staff Writer
Published: 10/1/2016 11:02:30 PM
Modified: 10/1/2016 11:35:41 PM

Manchester, Vt.— While the candidates for governor from Vermont’s two major parties are campaigning as supporters of health care reform — broadly defined — they disagree on some of the devilish details on how to rein in costs, improve services and make residents healthier.

At a Sept. 23 forum sponsored by the Vermont Association of Hospitals and Health Systems, Democrat Sue Minter, the former transportation secretary in Gov. Peter Shumlin’s administration, promised to tamp down health care costs that “are bankrupting our family budgets, our school budgets and driving our property taxes as well as our state budget.”

She highlighted health care services where providers respond to “incentives for more visits, more pills and more procedures” and stressed the need to “reform our payment system.”

Four days later, at an employee event at Dartmouth-Hitchcock Medical Center, Phil Scott, the Republican lieutenant governor, presented himself as a pragmatist determined “to make health care accessible and affordable to every Vermonter.”

Vermont residents “are not ideological,” he said at the hospital association forum. “They want to have health care when they need it at a price they can afford,” he added. “They don’t care what it’s called.”

Scott and Minter both prevailed in primary contests against opponents calling for more drastic changes in health care policies.

Those winnowed out included two Democrats who wanted to move aggressively toward a publicly financed universal health insurance (often labeled “single-payer”) and a Republican who had vowed to drive a figurative stake through the heart of single-payer.

This year’s debate also was influenced by someone who wasn’t a direct participant: Shumlin, who was elected in 2010 on a single-payer platform but announced in December 2014 that he was abandoning that quest rather than impose hundreds of millions of dollars in new taxes and fees to pay transition costs.

At the Sept. 23 forum in Manchester, Minter cautiously saluted the single-payer banner, which remains a priority with progressives inside and outside the Democratic Party. But Minter’s pledge evinced no inclination to charge up any hills behind that banner. “Let’s keep doing the thinking about how might we incrementally move in that direction,” she said.

At the same event, Scott declined to salute. “We went through some philosophical debate about single-payer that went on way too long,” he said. “It could have been solved in about a year, coming to the conclusion that we couldn’t afford it here in Vermont.”

The local retreat on single-payer got noticed nationally. “A lot of people looked to Vermont,” said Matthew Petty, executive director of Physicians for a National Health Program. Advocates wanted to see how the state would implement Act 48, a 2011 law that included a 2017 target to have a single-payer plan in place.

An active single-payer debate continues in a number of states including Colorado, where a ballot initiative will go before the voters in November, Petty said. Amendment 69 would create ColoradoCare, a payroll tax-funded universal health insurance system, according to the Ballotpedia website.

Advocates for what PNHP calls “Medicare for All” also got a boost from the unsuccessful but surprisingly strong bid for the Democratic presidential nomination by Sen. Bernie Sanders, a long-time supporter of single-payer, Petty said. The task now, he added, is to “focus that energy and make a real movement out of it.”

Single-payer advocates have remained in motion in Vermont, despite disagreements about where to go next. Some have advocated for expansion of Dr. Dynasaur, the state’s medical insurance program for children under 18 in low- and some medium-income families, to cover all Vermonters up to age 26, regardless of income. Others backed legislation that would provide $160 million of public financing to give all Vermonters access to free primary care.

Minter said at the forum that she is not ready to choose either path toward publicly financed universal health insurance: “I want to know what it costs (and) I want to know how we would pay for it well before I am willing to seize upon either of those two.”

Scott singled out for criticism the proposal to expand Dr. Dynasaur, arguing it would remove “the younger, healthier population” from the pool of those insured by other plans and raise the costs to those who remain. Scott’s opposition also stems from backers’ intention to use a payroll tax to fund the expansion, Ethan Latour, Scott’s press secretary, said later.

Both candidates voiced their displeasure with Vermont Health Connect, the website and backoffice operation set up by the Shumlin administration. It was built at a cost of about $300 for every resident of the state but failed to achieve its fundamental goal of automating insurance shopping and choices for individuals who do not have group coverage through employers or government programs like Medicare.

Minter acknowledged that the administration she was a member of “spent over $200 million on a system that, frankly, has failed Vermonters. This is a grave concern to me, not just because of the families that it serves, and mine is one of them, but because we have lost faith in government.”

But Minter said that there were questions to answer before deciding whether to keep Vermont Health Connect going or find an alternative, including “what’s the cost of changing?” and “what is the impact of people possibly losing their health care?”

Scott said he would have no qualms about shutting down the ill-starred website, which he said comes with $45 million a year in maintenance and operating costs. “We should have pulled the plug on Vermont Health Connect a couple of years ago,” he said. “This is really an embarrassment.”

Both candidates endorsed a continuing role for the Green Mountain Care Board, which oversees health insurance companies premiums and spending and reviews hospital budgets.

Scott said the panel had “done an effective job in trying to control the growth of hospital budgets.”

Minter said she would at least maintain the board in its current role because it has been effective and has led the state toward “beginning to think of a system of care.” Increasing the collaboration and cooperation among providers is important to efforts to “bring down costs, deliver better care and, most importantly, better outcomes,” she said.

But both candidates kept their distance from efforts by the board and the Shumlin administration to negotiate a deal with federal overseers of the Medicare program on a so-called “all-payer” model. All-payer would expand the use of capitation arrangements that pay doctors a set amount for each patient they care for and, advocates say, ease some of the perverse incentives in the current fee-for-service model that drive up health care costs.

On Wednesday, state officials released a 47-page summary of a preliminary agreement with federal regulators on the proposed all-payer model and announced a series of public hearings on the deal, including one in Norwich at the Montshire Museum on Monday from 5:30 to 7:30 p.m.

Both candidates expressed skepticism at the forum.

“I get the concept, but at the same time the devil is in the details,” Scott said. “What is it going to mean to each of us and how much is it going to cost and what are we going to get out of it?”

“This could be the best thing since sliced bread,” he added. “This could be the answer that we’re looking for. But I heard this before with single-payer not too many years ago, and I think that Vermonters are just a little bit gunshy at this point in terms of what it is that’s going to be coming next.”

Minter was a little more upbeat. “We have to try to do things differently,” she said. “There’s no question that the fee-for-service model isn’t helping us reduce costs.”

So it may make sense to push ahead, she said, adding a note of caution: “I believe there may be real incentives to us moving relatively quickly on this but I absolutely want to understand the system of governance for decision making, who and how decisions on budgeting will get made.”

Spokesmen for both candidates said that their positions on all-payer had not changed since last week’s announcement.

As they spoke to hospital executives and managers, neither candidate saw the need to close any of the state’s 16 hospitals.

“You all have done a good job of right-sizing what we have here in Vermont and I don’t see that we should be closing hospitals in Vermont,” Scott said.

Better system-wide thinking and planning is the real key to cutting costs, Minter said: “I don’t think it’s about closing hospitals.”

The candidates differed in their attitude toward Medicaid, the state-federal program that insures many low-income people, nursing home residents and persons with mental illness or addiction problems. “One-third of our population is enrolled in some form in Medicaid,” Scott said. “That’s nothing to celebrate,” he added. “Because what it points to is our economy is something that’s not working.”

Scott noted what he said had been a sharp increase in administrative costs and said he would like to see the program shrink: “It’s all about trying to decrease usage in the Medicaid program.”

Minter said that the low rates at which Medicaid reimburses health care providers were “a huge problem” but said the program had helped the state achieve a long-standing goal of reducing the number of uninsured residents.

In 2015, only 5 percent of Vermonters were uninsured, according to the Kaiser Family Foundation, a nonprofit health policy analyst. Only Massachusetts and the District of Columbia had lower rates. New Hampshire also had a 5 percent uninsured rate, while the nationwide rate was 9 percent.

The candidates also addressed mental health care in the aftermath of Tropical Storm Irene, which destroyed the state’s 50-bed mental hospital in Waterbury. Although a modern, 25-bed hospital in Berlin opened in 2014, during the first seven months of 2016 there were 168 instances when patients with serious mental illness were forced to wait in hospital emergency rooms because no space was available in the state’s high-level treatment facilities.

Scott said that meeting the treatment needs of people with severe mental illness in a growing population “may lead us to building another long-term facility,” even if it were expensive, and could require additional funding for community mental health agencies so that they could handle more acute problems.

Minter said that addressing the problem would require focuses on prevention and early intervention and improving “step-down” — the relocation of patients into intermediate facilities when a crisis passes.

Both candidates sounded personal notes at the forum. Scott presented himself as a sort of ad hoc avatar of greater personal responsibility by those with such chronic diseases as diabetes and heart ailments.

“Look at ourselves in the mirror,” he said. “We do it to ourselves and then we expect you and others to take care of us as a result.”

Minter talked of her family’s experience with hospice, the end-of-life program that aims to comfort patients who no longer receive curative care.

Hospice was not used in the death of her brother from cancer at the age of 48 but was used to help realize her elderly father’s wish to die at home. Vermont has a very low hospice utilization rate, she noted. “It’s about thinking differently about our medical model which, at the most expensive time, is driving us to keep (a patient) alive at all costs.”

Almost certainly, health care will continue to pose tough and mulit-faceted problems to Vermont’s leaders.

Even the relatively wide-ranging discussions in recent forums and candidates’ websites have ignored one contingency: the possibility that the national Republican Party might prevail in its persistent efforts to repeal the 2010 Affordable Care Act.

And even a conservative critic of the state’s recent reform efforts would like to see more creative thinking about to remake the system. John McLaughry, vice president of the Ethan Allen Institute, said it was disappointing but understandable that the candidates had not gone further in discussing ways to fundamentally change health care in Vermont: “It’s a minefield.”

Rick Jurgens can be reached at or 603-727-3229.
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