Bill Schubart: Let’s start the dialogue about a vision for Vermont health care

It will take vision, leadership and courage to rebuild Vermont’s health care system for the next decade. I can offer neither leadership nor courage, but can, with the help of wiser voices, presume to offer a possible vision to begin the discussion.

When I last wrote about health care, I painted a troubling picture of aggressive expansion at our dominant health care provider, the UVM Health Network.

I was challenged for doing so, but since my first of three columns appeared, the combined impacts of Covid, staff exhaustion and resignations, longer patient wait-times, and accelerating risk to Vermonters has only worsened and is now openly acknowledged by leadership.

Any future vision for health care must be viewed through the eyes of those who need it, use it and provide it, not solely through the eyes of those who administer it or profit from it.

As a nation, we’re an outlier in the international community, still debating whether health care is a human right or a business. Over 100 other countries have long since resolved that question, offering varying degrees of coverage, sometimes at a shared cost but in all cases more cost-effectively.

The unresolved nature of this question limits Vermont’s capacity to truly innovate because we’re integrated into a national health care economy that includes the lucrative Pharma, medical device, hospital and insurance industries. But we can do better with what we have.

The acuity of need should define a patient’s point-of-entry, from a visit to a local sole practitioner, group practice, or community health care center   ̶  federally qualified healthcare centers  ̶̶   to a regional “critical access” hospital emergency room, or to a tertiary-care hospital like UVM Health Network or Dartmouth Hitchcock.

Currently, UVM Health Network seems to want to be all things to all people, from primary care, physical therapy, home health, pharmacy, medical supply, urgent and emergent care and mental health provider to insurer and hospice provider. 

Now, by their own admission, the system is breaking down, although the messaging blames outside factors rather than inside ones. The sheer scale and complexity of trying to be all things to all people in a two-state region makes little sense. Most physical and mental health care is best provided locally, escalating to critical care or tertiary care hospitals only for serious medical conditions or interventions.

A different system is emerging. 

A recent locally produced film, Restoring Balance, provides a clear vision for how health care can best be provided at the community level. The Health Center in Plainfield is an federally qualified healthcare center, offering primary care to the surrounding community. As an integrated practice, it treats dental, physical, emotional and family well-being. 

Over two-thirds of Vermonters live in rural areas and the health center model depicted here and deployed across Vermont could well be the most cost-efficient and patient-effective vision for primary health care.

But to re-envision a patient-centered system of health care, we must resolve the conflict between monied interests and the socioeconomic well-being of our citizens.

Our current socioeconomic system does little to prevent physical and mental illness. 

We have no paid medical leave during which newborns might bond with their parents, or a family member might provide care for and say goodbye to a dying family member. 

We have no universal, affordable early education/child care system, and, of course, no national health care. The largely successful child tax credit is being phased out. 

Put simply, there’s too much money to be made repairing a steady stream of sick or injured people. Whereas investing in prevention and seeing to it that Vermonters lead healthy lives — health care vs. illness care — would be far more beneficial and cost-efficient.

We’re also coming to understand — and support with hard data — the fact that the prevalence and magnitude of chronic toxic stress (trauma) is driving much of the current cost of mental and physical health care, special ed, criminal justice and corrections. 

Research in adverse childhood experiences and their impacts on physical and mental health is making clear the intergenerational damage done to a family’s health by lack of identification, intervention and providing nurturing care to help the child and their family recover.

Our failure here has generated a mental health crisis among our young and is causing a bloom of diseases caused by toxic stress.  Low-grade inflammation caused by toxic stress can lead to heart disease, diabetes, neuropathy and mental illnesses such as anxiety, depression and substance abuse followed by self-harm, eating-disorders and suicide. Toxic stress also has long-lasting negative consequences for cognitive functioning, behavioral health and immune system function.

UVM Health Network has rolled out its UVM Health Advantage health insurance plan with all the potential for ethical conflict that that entails. As UVM Health Network becomes both provider and payer, how will it balance the competing interests now negotiated by “denial managers”? How does this contribute to the well-being of Vermonters?

Meanwhile, BlueCross BlueShield Vermont, now competing with its largest payee, is refocusing its strategy on access and affordability to accommodate independent primary care practices and more flexible care coverage for their patients. 

Current initiatives include collaborations with mental health providers to address the growing need for treatment options, and also redesigning its all-payer model for large employers, including those who self-insure.

Chittenden County is Vermont’s main economic driver, but its largest hospital will never be the point of entry for health care for a majority of Vermonters who live elsewhere in the state. The natural tension between payer and provider benefits Vermonters. Such an arms-length relationship would even benefit a government-operated single-payer system, should we ever have one.

I began this column by discussing vision, leadership and courage. But there’s a vacuum of leadership in Vermont. Effective leadership would — based on research, collective experience and data — lead us to a consensus on an appropriate model for health care delivery in our state.

Leaders for change would be clearly empowered by the legislative and executive branches to promulgate and regulate the development of such a model and not be deterred by the daunting strength of monetary interests (courage) that distort the whole system. 

According to the Journal of the American Medical Association, “From 1999 to 2018, the pharmaceutical and health product industry recorded $4.7 billion — an average of $233 million per year — in lobbying expenditures at the federal level, more than any other industry.”

As a state, we must find the will and leadership to derive a consensus on patient-centered, community-based health care delivery systems, with points of entry based on primary-care screening and acuity of presentation. 

This vision and mandate is provided in statute and once existed in the Department of Health: “Create a State Health Improvement Plan and facilitate local health improvement plans in order to encourage the design of healthy communities and to promote policy initiatives that contribute to community, school, and workplace wellness, which may include providing assistance to employers for wellness program grants, encouraging employers to promote employee engagement in healthy behaviors, and encouraging the appropriate use of the health care system.”

This function of the Department of Health was subsumed into Gov. Shumlin’s single-payer initiative and died with it. At the outset of his term in 2011, the Legislature passed Act 48, whose intent was to “create Green Mountain Care to contain costs and to provide, as a public good, comprehensive, affordable, high-quality, publicly financed health care coverage for all Vermont residents in a seamless manner regardless of income, assets, health status, or availability of other health coverage.” 

Where do we see that today?

No one today owns this vision for the well-being of Vermonters, certainly not the Green Mountain Care Board, which today is little more than a de facto financial regulator rather than a source of vision for the well-being of Vermonters.

Somebody or some body in Vermont must be authorized to revive Act 48 and bring it to life as it was once envisioned.

The good news is that we have an army of doctors and nurses who, day in and day out, provide professional, nurturing care. We just need an institutional and regulatory vision to support them.

And finally, Vermont politicians must have the courage to put the well-being of Vermonters over the substantial monied interests orbiting the health care universe.