Since the Shumlin administration took office a little over two years ago, its major single payer health care policy initiative has rolled steadily forward. The administration won approval for the foundational legislation it needed by a comfortable margin, and the follow-up legislation passed easily, as well.
Most important, Governor Shumlin put in place an excellent team to execute his plan. He has Mark Larson and Lindsey Tucker at the Human Services Agency to manage the insurance exchange that kicks off the reform effort starting in October; he has Robin Lunge and Administration Secretary Jeb Spaulding in his Pavilion office to manage the legislative process and wrestle with the issue of how to pay for the system.
The heart of the operation, however, is the Green Mountain Care Board, which has the job of getting health care costs under control, first by regulating the state’s hospital budgets, and, more critically, devising a new payment mechanism for health care services, and integrating the system sufficiently so that doctors and hospitals can take responsibility for the financial performance of the delivery system.
After two years of essentially preparatory work and just as the board is reaching the heavy-lifting phase of the reform effort, the Shumlin administration is losing its most important player. Anya Rader Wallack, the chair of the board, has resigned as of Sept. 1. She will be replaced by Al Gobeille, a member of the five-person board. But it is worth asking how this change in leadership will affect the trajectory of the Shumlin program.
The first point to make is that Wallack can’t be replaced by any single person: she has a unique set of qualifications. She is a national-class health policy expert, who has a doctorate and who has worked in the field, both in Vermont and other states, for 25 years. She also has a native’s understanding of Vermont, having grown up here and served in former Governor Howard Dean’s administration.
Finally, she has a finely honed political sense of the state: She got her start here in 1988 shortly after graduating from UVM running Paul Poirier’s quixotic campaign for the U.S. House. (Poirier beat two strong opponents in the Democratic primary before losing to Republican Peter Smith in the general election.)
So, there is no deprecating the loss. That does not mean, however, that the reform effort has been crippled. The main reason for that conclusion is the fact that Al Gobeille has turned out to be a very strong player on the board, in leadership terms, a de facto vice chair, though no such title exists.
For example, as the board has worked its way toward setting hospital budget targets for the next fiscal year, Gobeille, working closely with Wallack, has taken the lead on coming in on a target that has to be a major step toward cost containment. The iterations on the inflation number itself, as well as the board’s position on issues like how to deal with exemptions to the target and how to manage the purchase of physician practices by hospitals, have been drafted and pressed forward by Gobeille.
And his business acumen has been very important to the board. Hospitals, after all, are businesses before they are anything else and Gobeille knows business inside and out. Ask him what percentage of hospital costs consist of labor, and he has the answer on his tongue (59 percent). He’s at home with managers saying they can’t possibly function without more money, or this or that. His service on the Shelburne select board means that he is familiar with the town highway boss saying that the people of the town won’t stand for this or that cut in funding, whether the town has the money or not.
It is true that Gobeille does not have any direct experience inside the health care delivery system itself. He has not worked directly with hospitals, for example. Although Wallack doesn’t have much of that, either.
But anyone who tries to suggest that too much pressure on hospital costs could damage patient care, as the Vermont hospitals have tried to do, runs smack into board member Allan Ramsay, a former Fletcher Allen primary care physician with more than 30 years experience in the delivery system.
Ramsay regularly tells his board colleagues that the chief threat to health for Vermonters is that it costs too much. The board has a moral obligation to change that fact, he says. He suggests that a major stumbling block in achieving that goal is the fact that doctors and hospitals are doing all they can to ratchet up costs, not get them down.
Moreover, he tells his colleagues that he has talked to more than 1,000 physicians in the state over the past couple of years and that they tell him they are ready to change the way the system works.
This combination-Wallack’s health policy knowledge and political experience, Gobeille’s business and leadership skills, and Ramsay’s unparalleled knowledge of the medical system itself-have turned out to be core of the board’s strength. The other two members, Con Hogan and Dr. Karen Hein, make important contributions on various issues, but the key to health care reform is cost containment and the board will retain both the business and medical system dimensions of the problem.
It is true that Wallack’s health policy knowledge won’t be at the table after September, but there is an obvious fix for that. Governor Shumlin could retain her on a consulting contract to help Gobeille out on this front whenever he needs it. In fact, Shumlin himself, as well as the other players on the health care team, could benefit from Wallack’s political advice as the reform project moves forward.
The decision by Wallack to leave has given rise to some vague speculation about potential problems ahead for health care reform. One is that Gobeille, an owner of a chain of restaurants, can’t be qualified to lead a health care reform effort. No one who sits through a selection of the Green Mountain Care Board’s Thursday meetings will end up thinking that.
As for Wallack’s reason, she has always made it clear that it has nothing to do with dissatisfaction with Vermont or the health reform program and everything to do with the fact that her son and husband live in Rhode Island and that they want her back.