Category Archives: Health care reform

OneCare: “Please make us too big to fail”

As VTDigger reported a few days ago, Vermont’s public sector unions are feeling a little dubious about turning over their health care benefits to OneCare Vermont, the accountable care organization that’s beginning to develop a record of scoring own goals. For instance, OneCare seems to be (inadvertently, one would hope) doing its best to validate the unions’ concerns.

OneCare is in the process of seeking a dominant position in Vermont’s health care marketplace, by signing up as many groups and individuals as possible to its model of paying providers for outcomes instead of services performed. It’s the current hot idea in health care, and many smart people see great promise in it.

Of course, go back eight years and a lot of smart people saw great promise in then-governor Shumlin’s single-payer idea. And we know how well that went.

A little more than a month ago, OneCare went before the Green Mountain Care Board with a request for a $1.36 billion budget — a whopping 33 percent increase over last year’s. See, it’s been losing money and failing to produce the cost savings it promised.

OneCare’s explanation: It’s not big enough. Digger:

“We can’t measure success without scale,” [OneCare] CEO Vicki Loner told the Green Mountain Care Board at its budget hearing last month. The more people who participate, the more effective the system will be, she said.

Yeah, well, that may be true. But it’s also an invitation to pour more money down what might turn out to be a rathole. Loner is essentially saying that OneCare has to become too big to fail, merely in order to adequately test its health care model.

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I don’t know why Doug Hoffer puts up with our bullshit

State Auditor Doug Hoffer is at it again, pointing out the turds in the carefully curated punchbowls of state government. This time, it’s OneCareVermont, the massive, publicly-funded and poorly-understood initiative that seeks to reinvent the economics of health care by paying providers per patient instead of per treatment. The idea is that providers will be incentivized to encourage health instead of waiting to treat disease. (Not that there’s any evidence whatsoever that doctors and nurses can effectively change lifelong behavioral patterns that lead to chronic conditions like obesity and diabetes, lookin’ in the mirror there.)

Of course, the entity seeking to reinvent health care is owned by the two dominant providers in the current system, University of Vermont Medical Center and Dartmouth-Hitchcock Medical Center. Kind of like the foxes guarding the henhouse, except they’re big ol’ grizzly bears.

Hoffer had the audacity to take a look at OneCare’s commitment to some creative community-based health programs, including efforts to encourage healthy food shopping and meal prep and providing palliative care. And he found — shocking, I know — that OneCare, having accepted millions in public dollars for those programs, had no evidence whatsoever that they had any effect. At all. (Link is to VTDigger’s story. You can read Hoffer’s memo here.)

In fact, the behemoth isn’t even pretending to try.

OneCare CEO Vicki Loner faulted Hoffer’s “expectation for documentation of every activity.” Instead, OneCare is evaluating the outcomes for the system as a whole.

Which, if true, is just fuckin’ dumb.

What kind of large-scale organization launches a series of initiatives with no intent to evaluate each one’s impact? If you’re evaluating the system as a whole, how do you figure out which parts of the system work and which are a waste of time and money? Do you think the good folks at Hannaford don’t bother to track sales and profit margins in each department (or in each individual store), as long as they’re getting good outcomes for their system as a whole?

Even worse, OneCare is taking public money for specific programs and refusing to be accountable for how effectively it’s being spent. Which is ironic, don’tcha think, for a so-called Accountable Care Organization?

But if you think Hoffer is getting a hero’s welcome for his work, then you haven’t been paying attention to his tenure as auditor. Because his reward never comes in the form of gratitude and promises to enact reforms. No, his work is greeted with deliberately misdirected criticism and claims that reforms are already in the works. And, as quickly as possible, his work is dumped in the circular file.

Like I said, I don’t know why he puts up with our bullshit.

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Do the Democrats want to beat Phil Scott?

Stupid question, right?

Ask any Democrat — well, almost any Democrat — and they’ll say of course they want to beat Phil Scott and put one of their own in the corner office.

But I’m not asking any of them.

Instead, I’m looking at their collective actions. And they tell a different story, one full of abject failure to mount competitive races, of convenient excuses for legislative inaction, of top-tier contenders avoiding a tough challenge.

Conventional wisdom says that Scott is a singularly popular Republican thanks to his plain ol’ working-man demeanor and his plausibly moderate stands on the issues. I mean, look: He’s never lost in his 20-year political career. That includes campaigns for state Senate, lieutenant governor and governor. Impressive.

But who has he beaten? How many difficult races has he had to run? How many times did he amble his way to victory?

Short answer: He’s had it about as easy as a politician could hope for.

Scott first ran for Senate in 2000, the year of the great conservative backlash over civil unions for same-sex couples. He secured one of Washington County’s three seats in a race that nearly produced a Republican sweep of the county. (Incumbent Democrat Ann Cummings barely edged out fourth-place Republican Paul Giuliani.)

After that, Scott’s fortunes were buoyed by the super-strong incumbent’s edge in state Senate races. He finished a strong third in 2002. 2004 was the closest call of his entire political career; he won the third seat by a margin of only 230 votes. 2006 and 2008 were easy wins for all three incumbents — Scott, Cummings, and the redoubtable Bill Doyle.

As a reasonably inoffensive Republican, Scott benefited from the good will of Democratic leadership. He served as vice chair of the Senate Transportation Committee and chair of  Senate Institutions, burnishing his reputation for working across the aisle.

In 2010, Scott ran for lieutenant governor and won, beating then-state representative Steve Howard by 49-42 percent.  That was the closest call he’s had in this entire decade.

As LG, Scott’s reputation for bipartisanship was given a boost by then-governor Peter Shumlin, who included Scott in his cabinet. Not the kind of move you make if you really wanted a fellow Democrat to take Scott’s place.

Unsurprisingly, the potential A-List or B-List candidates for Lite-Gov kept their distance, allowing relative unknowns Cassandra Gekas (2012) and Dean Corren (2014) to mount the altar as sacrificial lambs. Scott beat Gekas by 17 points and Corren by an astounding 26.

And that set the stage for Scott’s elevation to governor in 2016. His Democratic opponent Sue Minter was a former state representative and cabinet official, but she’d never run for statewide office and was little known outside of Montpelier and Waterbury. She lost by nine points. In 2018, the top tier of Democrats was nowhere to be seen; former utility executive Christine Hallquist made history by becoming the first openly transgender person to win a major party’s gubernatorial nomination, but she had no chance in November. Scott sailed to a 15-point victory.

Now, you tell me. Who’s more responsible for the remarkable political career of Phil Scott? The man himself — or the Democratic Party that has consistently failed to seriously challenge him, and the Democratic officeholders who’ve consistently given him a hand up?

That also goes for top Democrats who are more than happy to make public appearances with Scott, even during his 2018 re-election campaign. The governor could fill a thousand campaign brochures with photos of himself making nice with Democratic officeholders, from the legislature to statewide officials to members of our congressional delegation.

I know, we’re all proud of Vermont’s tradition of political comity. But at some point, don’t you have to be just a little bit partisan?

Now, let’s look at the Democrat-dominated legislature, where Scott provides a convenient excuse for not getting stuff done. Over and over again in the past three years, the Dems have failed to advance key bills because of the potential for a gubernatorial veto. Just as often, they’ve ended up negotiating against themselves — weakening legislation in hopes of winning the governor’s approval.

Y’know, if they had a progressive-minded Democratic governor, they’d have to actually try to craft effective legislation. This didn’t work out too well with Shumlin’s health care reform push, did it? Much safer to flail helplessly in the face of a Republican governor.

They’ve also reached a comfy non-confrontational position on taxes and spending. There was little dispute over the 2020 budget. There is no real effort to challenge Scott on taxes. VTGOP press releases will tell a different story, chronicling every tax or fee increase proposed by every single Dem or Progressive lawmaker — even though the vast majority were dead on arrival.

During the 2019 session, the Dems undermined much of their own agenda. They spent week after week trying to come up with weaker and weaker versions of key bills. In some cases, that effort prevented bills from gaining legislative approval at all. Scott didn’t have to veto a minimum wage increase, a paid family leave program or a commercial marketplace for cannabis — three high priority issues for the Dems. They also failed to confront the governor on other contentious issues, including legalization of personal possession of buprenorphine. They disappointed their liberal base by failing to seriously address climate change.

Point being, the fear of a veto was powerful juju, turning the Dem/Prog supermajority into so many zombies. And leaving potential 2020 gubernatorial candidates with precious little material to run on. For the sake of anyone willing to challenge Scott, the legislature had better come prepared next January to hold the governor’s feet to the fire. Force him to make difficult choices. Show that there’s a real difference between the Democrats and the Republican governor.

Or, well, just sit back, relax, let some schmo lose to Scott by double digits, and get back to the established routine of shadowboxing the big bad governor.

The Narrow Parameters of Acceptable Debate

So how many political parties do we have in Vermont? Two? Three? Umpteen, if you count Liberty Union and whatever Cris Ericson and Emily Peyton have going on and the Mad Hatter of #vtpoli, H. Brooke Paige?

(I know, he’s a Republican. But any day I can mention Mr. Paige is a good day.)

Well, looking at recent policy debates in the Statehouse, you might just conclude that we have a grand total of one: The Moosh Party. Because on a whole range of issues, there’s little disagreement on the fundamentals; the discussion is confined to the details. At a time when Vermont faces some huge challenges, there’s a complete lack of bold thinking in the executive and legislative branches. We’re All In The Box.

The most basic area of consensus is on state finances. There’s no serious talk of raising taxes, cutting taxes or even significantly reforming our tax system. There’s no serious talk of raising or cutting spending. Streamlining or reforming government seems as unattainable as ever.

(When Phil Scott was running for governor in 2016, he talked a lot about “Lean management” as a way to make government more efficient and free up money to pay for new programs without raising taxes. He rarely, if ever, brings up that idea anymore. His state website touts his PIVOT program (Program to Improve Vermont Outcomes Together, and someone was paid taxpayer dollars to come up with that pukey acronym) but — deep into the third year of the Scott Era — doesn’t cite any cost savings. It does boast of 44 PIVOT projects underway and the training of hundreds of state managers and employees in Lean practices. Which makes me suspect that spending on PIVOT has outweighed any actual savings.)

When times are good and the state is enjoying unexpected revenue, the broad consensus is that we shouldn’t spend it — or at least not very much of it. The Republican governor and the four Democratic money committee chairs are in agreement on that. Except perhaps at the margins.

There’s also broad agreement that the state shouldn’t be borrowing any more money. Remember Sen. Michael Sirotkin’s ill-fated proposal to launch another $35 million housing bond this year? He’s a powerful committee chair, and his idea went nowhere. One of the loudest voices in opposition: Democratic Treasurer Beth Pearce, who’s fiercely protective of the state’s bond rating.

All this broad consensus leaves room only for piecemeal action. Take, for example, the legislature finding $6 million in this year’s budget to boost child-care subsidies. Nothing to sneeze at, but advocates will tell you that it’s a drop in the bucket compared to the actual need — for parents trying to keep their jobs and for child-care workers trying to make a living.

And it’s one-time money. That’s what passes for significant accomplishment in 2019.

Here’s another. Universal broadband is widely seen as a necessity for rural Vermont to become economically competitive. This year, the state enacted Act 79, which produces $1.2-1.4 million per year for broadband grants and creates a revolving loan fund for existing and startup internet service providers. A nice step, but nothing like a game-changer.

Meanwhile, the overwhelmingly Democratic legislature whiffed on three signature issues: paid family leave, minimum wage and a tax-and-regulate system for cannabis. What’s notable about those three, besides the whiffing, is that none of them would have cost the state much money. Paid leave? A new tax. Minimum wage? Employers would foot the bill. Cannabis? Would have brought new revenue to state coffers.

Not even on the table: Climate change, housing, education, the tattered mental health system, economic development, seriously addressing income inequality and health care reform, among others. No effort, through increased state aid or some sort of student debt forgiveness, to confront our affordability crisis in higher education. Nothing to address Vermont’s demographic crisis — except for the Scott administration’s dink-and-doink grant programs that only benefit a handful of employers and workers. On climate change, leaders of both parties acknowledge the crisis and our lack of progress toward established climate goals. But propose or approve a truly game-changing agenda? Not on your life.

Literally.

For years, politicians on all sides have talked about ending our reliance on out-of-state prisons. But actually doing something about it? Spending money on facilities or enacting new programs to reduce the inmate population? Nah.

Any effort to close the ridiculously large and still growing wealth gap, either through boosting benefits or job training or education affordability — or through increasing taxes on top earners? All talk, no action.

Health care reform would seem to be a critical need, considering that the Green Mountain Care Board just approved whopping insurance-rate premiums. But do you hear anything besides the gentle shuff-shuff of hand-wringing? Nope. I think elected officials of all stripes are still scarred by then-governor Peter Shumlin’s disastrous reform efforts. Nobody wants to call that monster out from under the bed.

The biggest exception to this depressing parade of cromulence was Act 76, which establishes a revenue source and administrative structure for waterways cleanup. Nice. But it only came after years of ducking the issue as long as humanly possible — even as toxic algae blooms make an annual joke of our alleged commitment to environmental purity, not to mention killing dogs and maybe causing Lou Gehrig’s Disease.

And action only came under threat of federal intervention. Yep, we can thank the Trump EPA for forcing Vermont to clean up its water.

This around-the-middle consensus isn’t only frustrating for those on the left. It’s got to be just as galling for conservatives, who believe the answer to Vermont’s problems lies in cutting taxes, spending and regulation. You’re not getting any of that from Team Scott, much less the legislature.

It’s funny. Vermont is widely seen as bluer-than-blue Bernie Country. But our current crop of elected leaders is comfortably at home in a narrow band of non-threatening incrementalism.

 

 

Hey kids! It’s time for Uncle Phil’s Funny Math!!!

So far, our political media has seen fit to abdicate its responsibility to fact-check the gubernatorial campaign. Instead, it has simply reported without comment the cornucopia of questionable numbers endlessly repeated by Phil Scott.

I do give ‘em credit for reporting Scott’s frequent non-answers and failures to give specifics on his own damn policy proposals. But they need to go farther. Especially since the Scott campaign has apparently decided not to respond to my own inquiries for substantiation.

Some of Scott’s figgers need a better man than I to assess, me not being a budget expert. But others are so transparently phony that even a muggle like me can see through them.

In this post, I’ll sometimes stand on the shoulders of Vermont’s number-one budget expert, Private Citizen* Doug Hoffer. In the absence of any oversight by the media, Hoffer has begun a projected series of essays examining Phil Scott’s favorite numbers.

*He’s also State Auditor, but he’s writing these pieces outside the auspices of his elected position.

First, let’s take Phil Scott’s constant claim that taxes and fees have risen by $700 million during the past six years of Democratic governance. Team Scott has failed to provide any documentation, but there is a little something in his economic plan.

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On journalism and blogging

If you’re not following me on Twitter, you missed a downright Pharisaical disputation about journalism and blogging and bias, and what exactly it is that I do.

My end of the argument has been severely restricted by Twitter’s character limit, so I thought I’d address the question in greater length here.

The critics are, quelle surprise, Phil Scott fans. In fact, the most persistent was Hayden Dublois, a nice young man who’s a paid staffer on the Scott campaign.

His complaint, echoed by others, is that I’ve been unfair to Scott because I’ve frequently criticized him while never scrutinizing Sue Minter.

Which is, as a matter of fact, not true. I was sharply critical of her campaign in its first several months; I thought she was getting left in the dust by Matt Dunne. I’ve criticized her for too often following Dunne’s lead and for failing to articulate differences between herself and the Shumlin administration. I criticized her performance in the post-primary debate for missing opportunities to confront Scott and for appearing overly programmed.

It is accurate, however, to say that I’ve been far more critical of Phil Scott. So, why is that?

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The race for governor will offer a stark contrast

This year’s election will trigger a turnover at the top perhaps unprecedented in Vermont history. A new governor, lieutenant governor, attorney general, and new heads of the House and Senate will all be in place by next January. And heading into the campaign, Vermont’s two major parties are offering completely different visions of the state of our state and the mood of its people.

Republicans see Vermonters as tired of high taxes, government intrusion, and the restless reformism (as they see it) of the Shumlin administration.

You’d expect Democrats to be treading cautiously. They are in the tightrope position of simultaneously defending their tenure in power, and crafting a distinctive profile going forward. Not to mention its persistently strong incrementalist tendencies.

However. Driven by Bernie Sanders’ overwhelming success in our primary, the party is moving leftward. There is a sense that Vermonters are ready for even more decisive change, even more government, a more aggressive push to lift up the downtrodden and blunt the sharp edges of capitalism.

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