On Sept.
But Brumsted, who oversees half of Vermont’s health care system, wasn’t alone in his rebuke.
Around the same time, members of the public also lambasted the board for raising insurance rates.
Residents say health care is too costly; hospitals argue the process is too administratively burdensome; lawmakers say the regulators should be doing more to advance the state’s all-payer health care system.
Vermont ranked fifth in the country in its per capita health care costs, which were $8,853 per person in 2018, according to the Bureau of Economic Analysis.
“It hasn’t been doing its job, and in some ways, its job is impossible,” said former Gov.
“The Green Mountain Care Board has been trying to do the right thing,” said Shap Smith, who served as speaker of the Vermont House when the board was created.
The five-member Green Mountain Care Board, one of the most powerful in Vermont, is often overlooked due to the sheer monotony of its work and the convoluted bureaucracy in which it operates.
Its members — who currently include a former BlackRock accountant, an ex-legislator, a Middlebury economics professor and longtime Vermont bureaucrats — have the power to regulate health insurance rates, approve and adjust hospital budgets, oversee the state’s health care claims database, and regulate certificates of need, which are required to develop a new surgical center or even purchase new MRI machines.
The board was given a lengthy list of obligations: improving the health of Vermonters and the quality of health care, reducing the growth in health care costs, recruiting more doctors, and reducing administrative burden.
That spring, Shumlin appointed its first members — among them Rader Wallack, who had advised both Shumlin and Dean on health policy.
The staff includes the five board members, an executive director, data and analytics staff, a legal team, and financial analysts.
Shumlin abandoned the single-payer effort in late 2014. By 2016, he had embraced a new alternative — all-payer.
It was also given control of the state health information exchange, which aggregates and shares patient data.
“The Legislature placed greater and greater responsibilities on it, more than anything that had been on the health care administration,” said Rep.
With more competition, consumers will choose the lower-priced health care options, the argument goes, incentivizing hospitals to keep costs down.
Vermont has based its top-down regulatory approach on an alternative hypothesis: Hospital patients don’t actually opt for cheaper services because they’re difficult to research and because those with health insurance don’t actually save money when costs are lower.
Kevin Mullin, who chairs the Green Mountain Care Board, pointed to its responsibility to ensure that insurance companies remain solvent as they decide whether to cut their rates.
In his letter in the fall, Brumsted threatened to cut staff at the UVM Health Network or close money-losing services if the board reduced its budget.
Even if hospital cuts make economic sense, staff and community members will inevitably object, said Smith, the former House speaker.
Experts disagree on whether Vermont’s higher costs have led to better outcomes and the state’s high quality and health rankings.
Neither lawmakers, state officials nor regulators want to choose decisively between them, he said.
During meetings, Mullin regularly highlights the fact that hospital budgets have increased at lower rates since the board was created.
The percentage the state spends on health care overall also continues to rise, but it has leveled off, Mullin said.
Costs have continued to rise over that period, but without the board’s intervention, insurers would have increased rates even more, “increasing consumer premium cost,” the report concluded.
The board doesn’t have much power to increase access to medical care or allow more people to get health insurance, which would likely require action from the state Legislature or the federal government.
Even in the best of times, seeing systemic change in a monolithic system such as health care takes time, said Feder, the Georgetown professor.
In 1992, the state instituted a three-member Health Care Authority to oversee hospital budgets.
Later, when the Legislature hoped to consolidate oversight, the Department of Banking, Insurance, Securities and Health Care Administration took over regulation.
Hospitals and programs must submit an application to renovate, add new equipment or build new facilities, ranging from drug treatment to surgeries centers.
“There’s no one with the wherewithal, the resources, the legal expertise — the Green Mountain Care Board has to be that entity on their own,” he said.
Dean said he would do away with the board entirely, citing the rate of the state’s health care inflation.
“The regulatory system has been built in a piecemeal way, not necessarily for this model,” he said.
Others maintain the board should simply do more or just wait for its work to bear results.
The state has made progress on reducing costs and improving care, but it’s a challenging task, said Rader Wallack, the first board chair.
She has freelanced and interned for half a dozen news organizations, including Vermont Public Radio, the Valley News, Northern Woodlands, Eating Well magazine and the Herald of Randolph.